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NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE SNiDiasw do Aavaan ivnoiivn 3NiDia3w do Aavaan tvnoiivn snidiosw do Aavaan tvnoiivn o NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 3Nma3w do Aavaan tvnoiivn 3nidiq3w do Aavaan tvnoiivn 3nidiq3w do Aavaan tvnoiivn v ' | Xf NATIONAL LIBRARY QF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 1 NATIONAL LIBRARY OF MEDICINE V\ i j^y * ^ 3NiDia3w do Aavaan tvnoiivn 3nidiq3w do Aavaan tvnoiivn SNioiasw do Aavaan tvnoiivn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE \r\ - r%S 1 \./^x - >^P\ , iNiDiasw do Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn ^'\ ! ,/xf& ? $&fy- V.2. Entered, according to Act of Congress, in the year 1845, by LEA AND BLANCHARD, in the clerk's office of the District Court of the United States for the Eastern District of Pennsylvania. FAGAN, STEREOTYPER. COLLINS, PRINTER CONTENTS OE THE SECOND VOLUME. Contributors. Page Emphysema.......... Dr. Townsend .... 9 Emphysema of the Lungs Townsend.... 17 Empyema............ Townsend.... 21 Hancock...... 39 Stokes .... Endemic Diseases Enteritis. 46 Dunglison Todd........ 62 Hancock...... 64 Cheyne...... 75 Ephelis............ Epidemics......... Epilepsy........... Epistaxis............ Kerr.........91 Erejhismus Mercurialis Burder.......96 Erysipelas........... Tweedie...... 96 Erythema............ Joy..........105 Eutrophic............ Dunglison .... Ill Exanthemata........., Tweedie......112 Expectorants......... A. T. Thomson 112 Expectoration Favus, Feigned Diseases .. Fever Continued..... Typhus ....... Epidemic Gastric Intermittent..... Remittent...... Malignant Remit- tent ......... Dunglison.... 223 Williams......119 A. T. Thomson 123 Scott.......~) Forbes.....Cl23 Marshall ...J Tweedie......147 Tweedie......153 Tweedie......162 Cheyne......201 Brown.......205 Brown.......219 " Infantile Remittent » Hectic....... " Puerperal.... " Yellow...... Fungus Hamatodes. Galvanism........ Joy..........224 Brown.......229 Lee..........231 Gillkrest.....247 Kerr.........280 Apjohn ....?285 Gastritis........... Gastrodynia........ Gastro-enteritis...... Glanders ............ Dunglison Glossitis............. Kerr .... Dunglison.. 3 Stokes.......298 Barlow.......307 Stokes........314 323 325 Glottis, Spasm of the . Gout............... Joy..........329 Barlow......332 85 391 391 Contributors. Page Hsematemesis........Dr. Goldie.......357 Haemoptysis.......... Law.........362 Headach............ Burder.......371 Heart, Diseases of the.. Hope.........377 « Dilatation of the.. Hope.........379 " Displacement of the.......... Townsend .. " Fatty and greasy de- generations of the Hope...... " Hypertrophy of the Hope..... " Malformations of the........... Williams.....404 « Polypus of the .. Dunglison ... .409 " Rupture of the .. Townsend ... .410 << Diseases of the valves of the ... Hope.........414 Hemorrhage.......... Watson.......430 Hemorrhoids .....'.... Burns ...... 438 Hereditary Transmission of Disease......... Brown.......443 Herpes.............. A.T. Thomson 445 Hiccup.............. Ash.........450 Hooping-Cough....... Johnson......453 Hydatids............ Kerr.........459 Hydrocephalus........ Joy..........476 Hydropericardium..... Darwall......502 Hydrophobia......... Bardsley.....506 Hydrothorax......... Darwall......538 Hyperesthesia........ Dunglison---543 Hypertrophy......... Townsend___543 Hypochondriasis...... Prichard.....554 Hysteria............. Conolly......562 Ichthyosis............ A.T. Thomson 589 Identity.............. Montgomery ..591 Impetigo............. A.T. Thomson 594 Impotence............ Beatty.......597 Incubus Indigestion ... Induration .. Infanticide... Infection Inflammation Williams.....606 Todd........608 Carswell......666 Arrowsmith... 677 Brown.......693 Crawford. Tweedie. (5) B 694 CYCLOPAEDIA OP PRACTICAL MEDICINE. EMPHYSEMA. —This term, derived from the Greek verb ijifvadui, to inflate, is used in medical language to signify the presence of air in the cellular tissue. The portion of the cellular tissue which is most frequently affected with emphysema is the subcu- taneous ; but as all the prolongations of this tissue throughout the body are directly continuous, and communicate freely by their areola structure, the air in emphysema, when once effused in any part of it, may extend wherever cellular tissue exists. Frank remarks that thin persons are more liable to emphysema than those whose cellular tissue is loaded with fat; and it is matter of common ob- servation, that those parts of the body where the cellular tissue is lax and free from fat are most easily affected with this disease. Thus, the eye- lids, scrotum, neck, and sides of the thorax, yield readily to the admission of air, while the buttocks and thighs, the arms and legs are much more slowly distended. The dense cellular tissue which lines the serous and mucous membranes yields with still more difficulty to emphysema, and the palms of the hands and soles of the feet are among the last parts to become so affected. There are two modes in which emphysema may be produced: 1. by the introduction of atmospheric air into the cellular tissue through a solution of its continuity ; or, 2. by the develop- ment of gas within the cells of the part. The former is termed traumatic, the latter idiopathic or spontaneous emphysema. Traumatic emphysema is of much more fre- quent occurrence than the idiopathic species. It may succeed to any wound of the integuments which allows the external air to get into the sub- jacent cellular tissue; but in a great majority of cases, (amounting to ninety-nine out of the hun- dred,) it arises from the introduction of air into the common cellular tissue through a communi- cation formed more or less directly with the organs of respiration. The following are the principal ways in which this communication may be estab- lished. 1. By wounds or ulcers communicating with the interior of the mouth or nares. 2. By perforation of the larynx or trachea. 3. By rup- ture of theair-cells and interlobular cellular tis- sue, the investing membrane or pleura remaining uninjured, and the air escaping through the roots of the lungs and mediastinum into the general cellular tissue. 4. By perforation of the lung, pleura pulmonalis, and pleura costalis. 5. By Vol. II. —2 penetrating wounds of the chest, the lung and its investing membrane remaining uninjured. 1. Wounds or ulcers communicating with the interior of the mouth or nares.—Frank states that emphysema is not unfrequently produced in per- sons learning to play on the flute, or other wind instruments, in consequence of the air being forced into the parietes of the cheek through any wound or small ulcer which may happen to exist on its internal surface, (De curand. hom. morbis: Art. Pneumatosis.) And M. Rullier informs us that the prisoners in the Bicetre at Paris, when they wished to be transferred to the infirmary, were in the habit of producing an artificial emphysema of the face and throat, by puncturing the inside of the cheek with a pin, and then forcing the breath through the puncture, (Diet, de Medecine, Art. Emphyseme.) In wounds of the under-eye- lid communicating with the lachrymal sac, em- physema is not a very uncommon occurrence, the air passing from the nares, through the duct, into the sac, and thence finding its way into the lax cellular tissue in the neighbourhood : in like man- ner emphysema of the head and face has been observed to take place in cases of fracture of the frontal bone communicating with the interior of the nares. 2. Perforation of the larynx o. trachea.—In wounds of the larynx or trachea, part of the air which is expelled from the lungs at each expira- tion, instead of passing through the glottis, escapes through the wound ; but if its free exit is opposed by the narrowness or obliquity of the external orifice, instead of passing out directly, it insinu- ates itself into the areolae of the cellular tissue, forming an emphysematous swelling round the wound, and from thence extending all over the body. Instances have also occurred, where, from a severe blow, some of the rings of the trachea have been ruptured ; and the same effect has been said to arise from coughing. We are not acquaint ed with the records of any case in which perto rating ulcers of the larynx or trachea have led to the formation of emphysema ; a fact which is pro- bably to be accounted for by the air being pre- vented from entering the cellular tissue by the adhesive inflammation which usually precedes! and limits the ulcerative process. 3. Rupture of the air-cells and interlobular eel lular tissue, the investing membrane or pleuia remaining uninjured, and the air escaping through the roots of the lung and mediastinum into the '9) 10 EMPHYSEMA. general cellular tissue. The rupture of the pari- etes of the air-cells formed by the ultimate rami- fications of the bronchi is by no means an un- common occurrence; (see Emphysema of the Lungs ;) but so long as the cellular tissue which invests each lobule, and isolates it from those ad- joining, remains uninjured, the extravasated air is prevented from escaping beyond the lobule in which the ruptured air-cells are situated. When, however, the cellular tissue which invests each lobule, and which is in fact a prolongation or pro- cess of the general cellular tissue, of the body, is likewise lacerated, the air is then at liberty to en- ter the cells of that tissue which communicate one with another throughout the lung, and through the root of the lung and mediastinum, with the cellular tissue of the throat; so that having once found its way from the ruptured air-cells into the interlobular cellular tissue, it passes uninterrupt- edly from cell to cell, (when urged forward by a sufficient force,) until it reaches the cellular tissue of the throat, where it makes its appearance in the form of an elastic crepitating tumour over one or both clavicles, and soon becomes diffused over the face and trunk. This variety of emphysema may be produced by violent fits of straining, coughing, or crying, or any other exertion of the respiratory organs, sufficiently powerful to rupture the air-cells and interlobular cellular tissue; but it has been ob- served to occur most frequently in women during parturition, and in children severely affected with the hooping-cough. Dr. A. Hamilton, of Edin- burgh, observed a case of emphysema produced in this way by the efforts which a young woman made to conceal the pains of labour. She sud- denly lost her voice, and her face became swelled in a wonderful manner ; her respiration, too, be- came quick and laborious, and her pulse full and rapid. However, by rubbing the tumid parts twice in the day with camphorated oil, and tak- ing away a considerable quantity of blood from the arm, together with the use of laxative medi- cines, and an opiate at bed-time, the swelling be- gan to give way in the course of a week; and in proportion as the emphysema disappeared, she recovered her voice. (Halliday on Emphysema.) Dr. Johnson, the learned professor of Midwife- ry in the Royal College of Surgeons of Dublin, informs us that six cases of this accident have occurred in his practice. In general the emphy- sematous swelling is confined to the neighbour- hood of the throat, where it first makes its appear- ance ; but in some cases it extends with a fright- ful rapidity, and involves the entire surface of the body. In one case it extended to the very tips of the fingers. This form of emphysema is likewise occasionally produced by violent paroxysms of the hooping-cough. Dr. Johnson has known it to occur in three cases of this disease j and Dr. Mackintosh of Edinburgh, and the late Dr. Beat- tie of Dublin, mentioned to us similar cases that had fallen under their observation. An interest- ing case of this form of emphysema is also record- ed by Dr. Ireland, in the third volume of the Dublin Transactions.—« A child nine years old was attacked with pneumonia. Under appropri- ate treatment the inflammatory symptoms seemed to subside, but a severe cough remained behind, during a violent fit of which a colourless crepitat- ing swelling was observed to form above the cla- vicles, and extended rapidly until it spread over th* whole body. The child died, apparently of suffocation, on the fifth day after the appearance of the emphysema." A case of emphysema of this kind is related by Louis, (Mem. de 1'Acad. de Chir. t. iv,) which was produced by the efforts made to expel a bean that had fallen into the larynx. We have, however, had opportunities of observing that a fatal suffocation may be caused by the presence of a foreign body in the air-tubes, without necessarily producing this symp- tom. It is probable that many cases of emphysema supposed to be spontaneous are really produced in this manner. Thus, the emphysema which some- times appears on the sides of the thorax when much force is employed to reduce a dislocation of the humerus, probably arises from the escape of air in the manner we have described, through a rupture of the air-cells caused by the violent efforts which the patient makes to hold in his breath during the reduction of the dislocation. In like manner the emphysematous swellings which have been noticed by Frank, Cullen, and other practical writers, as occasionally occurring during the paroxysms of hysteria, may proceed from the air being forced through the cellular tis- sue of the lung and mediastinum, by the violent efforts at expiration which are made during the paroxysm, while the aperture of the glottis is kept spasmodically constricted. The great difficulty of breathing which occurs in this form of emphysema is sufficiently account- ed for by the distension of the lung, from the in- filtration of its interlobular tissue with air, and by the emphysematous swelling of the mediastinum. 4. Perforation of the lung, pleura pulmonalis, and pleura costalis. This triple lesion may be produced—1. by fracture of the ribs; 2. by pene- trating wounds of the chest and lungs; 3. by ul- ceration. As the emphysema which arises from the first two of these causes belongs more particu- larly to the province of surgery, we shall notice it very briefly, and refer the reader, who wishes for further details, to the works of surgical writers. There is no accident which so frequently gives rise to emphysema as fracture of the ribs; for when the sharp ends of the fractured bones pro- trude through the pleurae and lacerate the paren- chyma of the lung, the air passes freely through the bronchi into the sac of the pleura, and thence through the breach in the costal pleura into the subcutaneous cellular tissue, from whence it be- comes diffused all over the body, as there is no opening in the integuments through which it can escape externally. At each dilatation of the chest the air is sucked into the thorax through the la- cerated air-cells, and diffused uniformly over the surface of the lung, (supposing that no adhesions exist,) while at each effort of expiration the stra- tum of air contained within the pleura, being compressed by the contraction of the thoracic pa- rietes against the entire pulmonary surface, is pre- vented returning by the wound through which it had previously entered; in this way the air con- tinues to accumulate within the sac of the pleura until it becomes so condensed, especially during EMPHYSEMA 11 the efforts of expiration, as to exert a very con- siderable degree of pressure on the parietes of the chest, and the important organs contained within it. The air then forces its way through the breach in the costal pleura made by the protru- sion of the fractured bone, and escapes into the cellular tissue on the outside of the thorax, whence it is rapidly diffused all over the body, a fresh supply of air being forced out at each expi- ration, so long as the wound in the lung con- tinues permeable. From this view of the mechanism by which emphysema is produced in the case of a fractured rib, it is evident that the escape of air into the cellular tissue, which has commonly been looked upon as the most dangerous part of the disease, should with more propriety be regarded as a fa- vourable circumstance, inasmuch as the air which escapes in this way would, if confined within the pleura, oppress not only the lung of that side where it is contained, but, by hindering the play of the diaphragm, and thrusting the mediastinum over into the opposite side, oppress the other lung also, and so produce great difficulty of breathing, or even a fatal suffocation. In the greater number of cases of emphysema arising from fracture of the ribs, the wound of the lung is soon closed by the effusion of blood, or by adhesive inflammation ; after which the further escape of air into the pleura ceases ; that already effused is promptly absorbed; the respiration is no longer laborious ; the subcutaneous emphyse- ma ceases to extend, and in the course of a few days is removed by absorption. But in more severe cases the wound of the lung remains unclosed, and a fresh supply of air is pumped into the cellular tissue at each expiration, until the whole body becomes so distended as scarcely to retain a semblance of the human form. The following " History of an Emphysema," from the pen of Dr. William Hunter, is exceedingly characteristic of the appearances produced by ex- cessive distension of the subcutaneous cellular tissue, and of the peculiar difficulty of breathing caused by the pressure of the air accumulated within the sac of the pleura:—" The patient had received a considerable hurt in his side by a fall from his horse. When first seen by Dr. Hunter (twenty-nine hours after the accident,) he was in bed, panting for breath; his form was that of a human skin stuffed. The inflation was great and universal, except in his hands and feet, where it was very inconsiderable. The skin was every- where shining, as it is when much extended by any kind of swelling. The air could easily be pressed out from any part, but it immediately re- turned upon taking off the hand. When struck, his body sounded like a wet drum; and when pressed, the air could be felt, and its sound dis- tinctly heard. The cellular membrane was less inflated, and the skin less distended upon his ex- tremities, in proportion nearly to the distance of the part from his chest. Those parts on the sur- face of the body which have a more loose and yielding cellular membrane were proportionably more swelled; thence his eyelids were so fixed by their own bulk that he had not been able to see light from a few hours after the accident happen- ed. The penis and scrotum were as much dis- tended as in the worst anasarca. It is impossible to convey a more accurate de- scription of the appearance which this disease presents in its most aggravated form. Dr. Hun- ter's description of the difficulty of breathing pro- duced by the air accumulated within the sac of the pleura, is equally characteristic : " His breath- ing was very laborious, and rather frequent, in the following manner: — his inspiration was so short as to be almost instantaneous, and ended with that catch in the throat which is produced by shutting the glottis; after this he strained to expire without any noise ; then suddenly opening the glottis, he forced out his breath with a sort of inward groan, and in a hurry, and then quickly inspired again; so that his endeavour seemed to be to keep his lungs always full. Inspiration succeeded expiration as fast as possible. From the small quantity that was inspired and expired at a time, it was plain that he either had not room for a greater quantity, or could not bear a greater expansion of the chest." (Med. Obs. and Inqui- ries, vol. ii.) When the surface of the lung is attached by adhesions to the costal pleura, the air which escapes from the wounded lung cannot accumu- late within the chest, but passes directly through the corresponding wound of the costal pleura into the cellular tissue on the outside of the thorax; in which case there is no pneumo-thorax, and the difficulty of breathing is consequently much less. Emphysema may likewise be produced in this way by penetrating wounds of the chest and lungs. It has, however, been observed that these wounds are not as constantly followed by emphy- sema as fracture of the ribs is. The mechanism by which the emphysema is produced is the same in both cases, the air first escaping through the wounded lung into the sac of the pleura, and thence through the wound of the costal pleura into the subcutaneous cellular tissue. When the wound of the integuments is large, and directly parallel to its internal orifice, the air has an open and unobstructed issue, through which it passes; but when the external wound is narrower than its internal orifice, or only communicates with it ob- liquely, the air which is forced out may then in- sinuate itself into the areolae of the cellular tissue, and thus produce emphysema. Mr. Hewson endeavoured to produce artificial emphysema by cutting and wounding the lungs of rabbits and dogs in various ways; but all his experiments were unsuccessful: no air was effused either into the cavity of the thorax, or into the cellular membrane. From these experiments he concluded that a puncture or incision of the lungs would seldom produce emphysema, on account of the effusion of blood from the divided vessels, and that the escape of air is more apt to follow a super- ficial abrasion or laceration of the part, such as is produced by the extremity of a fractured rib; and experience has fully confirmed the accuracy of these conclusions. (See Hennen's Principles of Military Surgery, J. Bell on Wounds, and Baron Larrey's Memoires de Chir. Militaire.) M. Littre has published a case of emphysema 12 EMPHYSEMA. produced by the thrust of a small sword, which is remarkable on account of the enormous distension of the cellular tissue that took place. The emphy- sema commenced soon after the accident, and the patient died in two days. On examination after death, the emphysematous swelling on the chest measured eleven inches thick, on the belly nine, on the neck six, and four on the other parts of the body ; the wound in the lungs was seven or eight lines long, one and a half broad, and one deep. (Mem. de l'Academie Royale des Sciences, for 1713.) Ulceration of the lung, pleura pulmonalis, and pleura costalis, is the last mode we have enumer- ated in which a communication may be formed between the interior of the lung and the cellular tissue on the trunk. In some cases a direct com- munication is thus formed, as when a circum- scribed empyema that points externally between the ribs, or an abscess primarily formed in the parietes of the chest, bursts internally into the bronchi, and thus forms a direct communication between the air-passages and the abscess on the thorax. In such cases the pus is evacuated by the bronchi, and its place is supplied with air, which may either infiltrate the cellular tissue of the trunk, producing general emphysema, or, if the walls of the abscess have been rendered im- permeable by adhesive inflammation, may be pre- vented from escaping further, and thus produce a circumscribed emphysematous tumour, bearing the same relation to diffuse emphysema that phleg- monous abscess does to common cellular inflam- mation. A remarkable case of this kind in which several emphysematous tumours were formed in succession over the surface of the chest and neck, is recorded by Dr. Duncan, in the first volume of the Medico-Chirurgical Transactions of Edin- burgh. This communication may likewise take place indirectly, the air first escaping through an ulcer on the surface of the lungs into the sac of the pleura, producing pneumothorax, and thence, through an ulcer of the costal pleura, into the cel- lular tissue of the trunk. A remarkable instance of this kind is related by Dr. Halliday. The patient had felt unwell for some days, and on the evening before his admission into hospital was seized with rigors and severe headach; he had also a slight cough, which excited some pain about the superior part of the sternum. Early the next morning he began to complain of great difficulty in respiring; at twelve o'clock the breathing had become more severe, his face was turgid, and his lips quite livid; there was also at this time an unusual fulness of the neck and breast, which, when pressed, yielded an evident crackling noise. In about half an hour after, this fulness was be- come not only more evident, but was diffused all over the chest, and down both arms ; he had now the greatest difficulty in respiring at all, and before one o'clock every part of the surface of his body was become emphysematous, except the palms of his hands and the soles of his feet. On inspection after death, the right lung was found to contain, in its upper lobe, a vomica of about three inches in circumference, from which it appeared that nbout four ounces of pus had very lately escaped i'ii- the sac of the pleura, through an opening which would scarcely admit the head of a probe : upon blowing into the trachea it was observed that the air passed freely through this opening into the sac of the pleura. On searching for the opening through which the air had escaped from the cavity of the thorax, a small part of the pleura costalis, between the sixth and eighth ribs, was discovered with the appearance of being more inflamed than any other part; and nearly in the centre of this small spot an opening was detected, through which the pleura and cellular membrane were easily inflated. (Op. cit.) 5. Emphysema may likewise be produced by penetrating wounds of the chest, even though the lung and pulmonary pleura remain uninjured. The formation of emphysema in such cases may be explained as follows. In all wounds of the chest where the air is admitted into contact with the pulmonary pleura, the lung generally collapses, when not prevented from so doing by emphysema of its tissue, or by old adhesions: a sort of false v respiration is then established, air being inspired into the chest through the wound at each dilata- tion of the thorax, and alternately expired through the same orifice at each contraction of the thoracic parietes. But when, as not unfrequently happens, the wound remains direct and unobstructed during inspiration, but becomes oblique or even closed by the alteration in the relative position of the integu- ments and ribs during expiration, it follows that the air having a free ingress into the thorax during inspiration, and not having as free an egress during expiration, must suffer such a degree of pressure from the contraction of the chest as to be forced into the subcutaneous tissue, and so produce general emphysema. The last variety of traumatic emphysema we shall notice is that produced by the escape of air from the alimentary canal, through a rupture of its parietes. It appears from an interesting work, published by MM. Chabert and Huzard, entitled, " Observations sur les Animaux Domestiques," that this accident is not of unfrequent occurrence in ruminating animals, in consequence of their food fermenting and generating such a quantity of gas as ruptures the internal tunic of the intestines, insinuates itself into the subserous cellular tissue, and thence extends all over the body. Haller mentions a case of emphysema produced in this way in a female, whose intestines were so over- distended by the quantity of gas they contained, that they at last gave way and allowed the air to escape into the cellular tissue. (Opusc. Pathol. Obs. xxxi. torn, iii.) In the eleventh volume of the Archives Gene- rales de Medecine there is a very interesting case of an extensive emphysema produced in this way by a violent contusion on the abdomen. We have now enumerated the principal varieties of traumatic emphysema, and described the me- chanism of their formation ; but we have yet to consider another form of this disease, in which the air is not introduced from without, but is formed within the cellular tissue of the part, and which, as arising from no very evident cause, has received' the denomination of idiopathic or spontaneous. The air or gaseous product which is formed' in spontaneous emphysema may be produced either by putrefactive decomposition or by secretion. EMPHYSEMA. in 1. Spontaneous emphysema caused by the ex- trication of gas from a putrefactive decomposition. The living body is composed of various elements, which are only prevented from decomposing and entering into new combinations by the powers of life, which, by a counteracting influence, prevent the chemical affinities of these elements from coming into full operation; but no sooner do those powers cease to act, than the body begins to decompose under the influence of the chemical and physical laws which govern all inert matter. One of the most constant phenomena of this putrefactive decomposition is the disengagement of various gases; hence it is that dead bodies become emphysematous during putrefaction, and that the bodies of drowned men are after some days buoyed up and float on the surface of the water. The extrication of gas from the death and de- composition of a part may likewise occur during life, as in the case of gangrene. Indeed this is by no means a rare occurrence, particularly when the gangrene is of the humid species. " I took particular notice (says Dr. Hunter) of the em- physema in a case of mortification from an internal cause, which began upon the ankle, and thence marched upwards upon the limb till it came to the groin, when the patient died. The cellular mem- brane under the skin was very sensibly inflated every where, to some distance from the mortified part, and I could as easily mark the progress of the mortification from day to day by the emphyse- ma as by the change of colour in the integuments." (Medical Observations and Inquiries, vol. ii.) Practical writers have remarked that gangrene, when accompanied with emphysema, has a re- markable disposition to spread. (James on Inflam- mation, p. 96.) The period at which the putrefactive decompo- sition commences after death depends in a great measure on external circumstances, such as heat, oioisture, &c.; but it is also materially influenced by the condition of the fluids, which in some cases have a much greater tendency to putrescency than in others; as is proved by the well-known fact that some bodies will remain for several days without exhibiting any sign of decomposition, while others from the state of the fluids swell up and run into putrefaction immediately after death. In the typhous fever that raged in the south of Ireland during the year 1817, it was found neces- sary to bury the bodies of those that died within a few hours after death, and to fill up the graves with lime. The same tendency to putrescence is some- times observed during life, in certain morbid con- ditions of the economy, which have hence obtain- ed the name of putrid or malignant diseases. We know, from direct experiment, that the intro- duction of certain deleterious substances into the blood, such as pus, putrid animal matter, and cer- tain poisons from the animal, vegetable, or mine- ral kingdom, produces certain alterations in it, by which it loses its power of coagulating, and ac- quires a tendency to rapid decomposition. Similar alterations are likewise produced in the blood by the sting or bite of certain animals, especially those of the serpent tribe ; and are also observed in the spasmodic cholera, the plague, and other diseases of a malignant nature, as it is termed; in all which some of the most constant phenomena are a sudden prostration of strength, a constant tendency to hemorrhage, and a remarkable dispo- sition to mortification wherever congestions are formed, (Andral's Pathol. Anat.) In such cases the vis vitse is actually diminished throughout the whole system, and the laws which govern all in- organic matter begin to exert their influence over the body while yet alive, producing, amongst other symptoms of decomposition, spontaneous emphysema. " A full-bodied middle-aged sailor was seized with a putrid fever and sore throat; he was bled at the beginning, but his blood appearing in a loose dissolving state, he was bled no more: about the seventh or eighth day of his disease, an em- physematous swelling appeared in his face, neck, and all over his breast, especially on the right side; the swelling was fomented with sharp vine- gar and camphorated spirit of wine, and under this treatment totally vanished in two or three days, and he soon recovered from the fever; but he continued very weak for a long time, and re- mained very scorbutic as he was before the fever, his gums being very spongy and bleeding on the slightest touch. In this case the emphysema was generated merely by the putrescence of the hu- mours, as is frequently observed in a less degree in and about the incipient gangrene of the limbs ; and I am persuaded that this more frequently hap- pens in putrid malignant fevers than is commonly imagined, (Huxham. Medical Observations and Inquiries, vol. iii. p. 33.) Frank states that the epidemic fever which raged at Bobbio, a small town in Italy, in 1789, frequently terminated in general emphysema; and that a similar epidemic had previously occur- red in Germany in 1772, during which emphy- sematous swellings suddenly appeared on the face and neck, and sometimes extended all over the body, (De Curandis Hominum Morbis, torn. iv. Pt. I. Pneumatosis?) Neither is this development of gas from the decomposition of the fluids peculiar to man. Dr. William Hunter has transmitted to us the history of an epidemical distemper prevalent among the black cattle in the neighbourhood of London, in which it was observed. At first, almost all died that were taken ill of it; most of the diseased were emphysematous all over their body ; and on dissection the emphysema was found to be uni- versal upon all the internal parts, as well as under the skin, (Op. cit. vol. ii.) Frank likewise alludes to an epidemic dysentery among the black cattle, during the progress of which the loins and back were frequently observed to become emphysema- tous. The last illustration which we shall adduce is one lately exhibited in Paris, at the Hopital Co- chin, an account of which was read by M. Bally at the Academie Royale de Medecine. A man, twenty-five years of age, who had been ill for fif- teen days, was admitted into the hospital with symptoms of typhous fever; he also complained of pain in the left thigh; and, whilst he was in a state of delirium, said he had been bitten on the knee by a dog. The limb was most attentively examined, but not the slightest trace of such an accident could be discovered. The thigh and 14 EMPHYSEMA. scrotum were much swollen. He died the follow- ing day. On dissection, eight hours after death, the surface of the body was found soiled by blood, which had transuded through the integuments; and some blood had also been discharged from the nose. The whole body was emphysematous, but the left inferior extremity was so to a very high degree. It was double its natural size, of a brown colour, ar_d covered with numerous phlyctense— some black, of great extent, and collected in clus- ters, from which escaped a reddish serous fluid mingled with a quantity of gas; others white, from which nothing but air escaped. When the limb was pressed with the hand, crepitation was distinctly heard ; the abdomen was much distend- ed with gas; and in the intestines were observed those alterations that are so common in cases of typhous fever. Bubbles of air filled the vessels of the pia mater, and the left vena saphena. The lymphatic ganglions of the mesentery were en- • larged and contained gas, which took fire from the flame of a taper, and produced an explosion; the same phenomenon also followed the exit of the air which was contained in the legs, thighs, and scrotum. A puncture was made into the abdomen, and the gas which escaped also took fire and burned for some time, the flame being blue at its base, and white at its summit: the combustion extended to the puncture which had been made with a trochar; the edges of this aper- ture became black, and were consumed, and the aperture itself was enlarged to double its original size. The gas which was contained in the sub- cutaneous cellular tissue was equally inflamma- ble, (London Medical and Physical Journal, for June, 1831.) This case is peculiarly interesting in conse- quence of the light it throws on the etiology of spontaneous combustion. On referring to the article on this subject it will be found that, in all those cases of spontaneous combustion of which we have an authentic history, the flame was com- municated by the contact of a body in a state of ignition, and it is reasonable to suppose that the combustion was likewise supported by an inflam- mable gas generated within the body, as in the present instance. Some doubt may be entertained whether this inflammable gas should be considered as the pro- duct of a putrescent decomposition formed by the ordinary laws of chemical attraction; or as a morbid secretion, the product of a vital action, and regulated by the same vital laws as other secretions. On this subject much yet remains to be dis- covered, as our present knowledge only amounts to this, that collections of air are sometimes found in the living body, under circumstances where there is no appearance of their having been gene- rated by fermentation or putrefaction; and that both in man and other animals, certain tissues possess the power of secreting gas, as, for instance, the swimming bladder in fish, the mucous mem- brane of the stomach and intestines in man, and the mucous membrane of the air-passages, which, as the accurate experiments of Dr. Edwards clearly prove, secretes a variable quantity of carbonic acid and azotic gases. The fact of a gaseous secretion being formed by certain tissues in the healthy state being established, we are authorized by ana- logy to conclude that a secretion of gas may, like other secretions, take place as a morbid phenome- non in parts where no such secretion naturally occurs, more especially as we possess several well- authenticated cases in which it is impossible to account for the presence of the gas in any other way. It must, however, be confessed that we are completely ignorant of the causes that influence the production of gaseous secretions, and of the condition of the solids or fluids most favourable to their development: if they are preceded or accom- panied by any alterations of texture, they are such as entirely to escape our notice. The chemical composition of these secretions is also a desidera- tum. Such being the state of our knowledge, we shall not enter into the consideration of any of the hypotheses which have been formed on this subject, but merely notice the fact, generally ad- mitted by pathologists, that spontaneous emphy- sema is occasionally produced by a secretion of gas within the areola? of the cellular tissue. Dr. Baillie has recorded a very remarkable case of this kind, in which the emphysema was so extensive as to affect the alimentary canal and the mesentery, as well as the whole of the subcuta- neous tissue ; yet in which there was no solution of continuity through which the air could have been introduced, and no appearance of any putre- factive decomposition, by which it could have been generated. Frank likewise relates several cases of spontaneous emphysema, which it is difficult to account for on any other supposition than that of their being a product of morbid secretion ; such, for instance, is the case of a young lady at Vienna, who became generally emphysematous during every paroxysm of a tertian fever, the emphysema disappearing as the paroxysm subsided. Many other curious instances of this disease are to be found in the chapter on Pneumatosis, in the 8th volume of this author's work " De Curandis Hominum Morbis." The diagnosis of emphysema seldom presents any difficulty when the disease affects the subcu- taneous tissue, as it then produces an uniform swelling, sufficiently characterized by its lightness and elasticity, and by the peculiar crepitating sound and feel it yields under the finger, from the displacement of the air from one cell into another. The prognosis must be regulated more by the cause of the emphysema, and the state of the respiratory organs, than by the extent of the em physematous swelling. The emphysematous dis- tension of the integuments is much more formida- ble in appearance than in reality, and, when unconnected with any lesion of the organs of respiration, may be very extensively diffused without producing any injurious consequences. Aristotle says that it was a common practice in his time to inflate the subcutaneous tissue of ani- mals in order to make them fatten more readily afterwards: this practice is also alluded to by Pliny; and Schulze states that the only effect it produces on horned cattle is to render them dull and heavy for two or three days, after which time the emphysema gradually disappears, they recover their spirits and appetite, and in the course of six weeks become quite fat. (Dictionnaire des Sci- ences Medicates. Art. Emphyseme.) Haller and EMPHYSEMA. Soemmering likewise attest the truth of these observations, which at least serve to prove that the effusion of air into the cellular tissue is not in itself productive of much injury, and that the sense of suffocation, and other formidable symp- toms which so often accompany the progress of this affection, depend more on the diseases with which the emphysema is complicated than on the emphysema itself. This conclusion is further confirmed by the result of those cases of emphy- sema that have been observed in the human subject, uncomplicated with any lesion of the organs of respiration. Sauvages mentions the case of a soldier, who was found asleep in a cave by some persons, who inflated his body through a quill until it scarcely retained a vestige of the human form, — all the lines of demarcation between the face, throat, and trunk, being com- pletely destroyed. In this case, which may be regarded as a rare example of general and exten- sive emphysema unconnected with any lesion of the respiratory organs, the principal symptoms observed were pain and stiffness from the over- distension of the integuments, and difficulty of breathing from the impeded motion of the thorax, and the congestion of the lungs, arising from the pressure which the superficial blood-vessels sus- tained ; these symptoms disappeared as the air was evacuated through several scarifications which the patient had given himself with a knife, and his recovery was rapid and complete. We may, therefore, conclude that the extreme difficulty of breathing, which so frequently ac- companies traumatic emphysema, and which is in almost every instance the immediate cause of death in those cases that prove fatal, is in reality produced, not by the emphysematous distension of the integuments, but by the air effused into the sac of the pleura, or into the interlobular tissue of the lung. Treatment. — The practice in emphysema must be regulated in a great measure by the cause of the affection, the extent of the emphysematous swellings, and the state of the respiration: the general indications of cure may, however, be ar- ranged under three heads : 1. to arrest the pro- gress of the emphysema, by preventing a further effusion of air into the cellular tissue; 2. to re- move the air already effused; and, 3. to relieve the disordered state of the respiration. The means employed for the fulfilment of the first indication must be regulated by the cause of the emphy- sema. In spontaneous emphysema, the only effectual method of arresting the further progress of the disease is, to correct the morbid state of the sys- tem on which the development of the gas depends, and of which it is merely a symptom. As it generally occurs during the progress of asthenic or typhoid diseases, aromatic and stimulating lini- ments should be applied externally, in order to promote the action of the capillaries, while the proper remedies adapted to the disease are admin- istered internally. Should the emphysema spread extensively, it may be proper to relieve the disten- sion of the swollen parts by puncturing them with the point of a lancet. In traumatic emphysema, arising from wounds of the larynx or trachea, the further effusion of air into the cellular tissue may be prevented by enlarging the external orifice of the wound, so as to make a direct passage for the exit of the air during expiration ; the same practice should also be adopted when the emphysema arises from penetrating wounds of the chest, after which the wound should be closed with adhesive plaster. When the emphysema arises from a fractured rib, the further effusion of air into the cellular tissue may be prevented by applying a tight roller round the chest, or by making a small puncture through the integuments over the seat of the frac- ture. When the breathing is not much oppressed, the application of a bandage may be employed with safety and advantage. But as (supposing that the surface of the lung is not adherent) the air is effused from the wounded lung into the sac of the pleura, before it escapes into the cellular tissue, it is plain that by applying a bandage round the chest, in order to prevent the further progress of the emphysema, we only confine the air within the pleura, where if it continues to accumulate, its presence must give rise to all the distressing symptoms of pneumothorax, as it not only com- presses the wounded lung, but, by its pressure on the mediastinum and diaphragm, obstructs the dilatation of the other lung also : under such cir- cumstances every facility for the enlargement of the chest becomes necessary, in order to admit as much air as possible into the lung, which still ex- ecutes its functions; but the effect of the bandage is to diminish the dilatation of the sound side as well as that of the diseased, and, consequently, to increase still farther the embarrassment of the re- spiration. For these reasons, it is much safer, where the breathing is at all embarrassed, to let the air escape by making several punctures or small incisions over the broken rib, than to confine it with a band- age, though the latter practice may be employed with advantage in those cases where the quantity of air effused into the chest is not sufficient to produce much dyspnoea or oppression. Lastly, in the cases of emphysema arising from over-distension and rupture of the air-cells, and the escape of air into the interlobular tissue of the lungs, and thence through the mediastinum into the common cellular tissue, the only method of arresting the further effusion of air is by employ- ing such means as are calculated to diminish the violence of the respiratory efforts by which the air is forced, at each respiration, into the medias- tinum. WTith this view copious venesection should be employed, for the double purpose of relieving the pulmonary congestion, and of diminishing the mass of the circulating fluid; for, by lessening the quantity of blood to be aerated, we also lessen the necessity for taking in so large a supply of air for its aeration, and in the same proportion dimin- ish the efforts made by the muscles of respiration to dilate and contract the thorax. Opiates should likewise be employed with the same intent, to diminish, as Laennec expresses it, " le besoin de respirer:" rest and silence should be enjoined, and the antiphlogistic regimen strictly enforced. We next come to consider the means of remo^. ing the air already effused into the cellular tissHe. In the slighter cases of emphysema, where tha 16 EMPHYSEMA. breathing is not much oppressed, and the quan- tity of air effused is not very great, the power of the absorbents will generally be found sufficient for its removal, and it will only be necessary to employ friction over the tumid parts with cam- phorated liniment, or some other stimulating em- brocation, for the purpose of accelerating the pro- cess of absorption : but when the quantity of air effused into the cellular tissue is so great as to produce considerable distension of the integuments, it will be advisable to make several punctures, with the point of a lancet, through the skin where it is most distended, in order to evacuate the air contained underneath. These punctures or sca- rifications should be made sufficiently deep to divide the cellular tissue, in order to make a free exit for the air from the deep-seated as well as from the superficial cells. If the air should have spread extensively over the body, it will be more advisable to puncture the skin wherever the parts are much inflated, than to press it along under the skin to the punctures which may have been made in a distant part. This practice should be adopted in all cases of extensive emphysema, from what- ever cause i* may have arisen; as it is perfectly free from danger, and affords immediate relief to the suffering arising from over-distension of the swollen parts, and likewise obviates the danger of the air forcing its way into the cellular tissue of the internal organs. We have already seen that in the great majo- rity of the cases of traumatic emphysema, the or- gans of respiration are more or less injured, and that it is from the injury which they sustain that the most distressing and dangerous symptoms in- variably arise. To them, therefore, our principal attention should always be directed, as the most important object of our treatment. In all cases of extensive emphysema the breathing is more or less oppressed, in consequence of the diminished mobility of the thorax, and the congested state of the lungs caused by the increased quantity of blood thrown on them from the surface of the body. In such cases, therefore, it will be proper to relieve the internal congestions by copious bloodletting, and to remove the pressure which impedes the motion of the thorax, by evacuating the air confined under the integuments, as al- ready directed. Venesection is also useful in such cases, as the most powerful means we possess of anticipating or arresting the development of in- flammation. Should these measures prove insufficient for the relief of the breathing, we may then infer, (espe- cially when the sense of oppression and suffoca- tion continues progressively increasing, and other symptoms indicate the existence of pneumothorax,) that air is accumulating within the chest, so as to oppress not the wounded lung only, which was collapsed and useless from the first, but the dia- phragm and mediastinum, and through them the opposite lung also. A freer incision should then be made through the integuments .over the seat of the injury, and if this does not afford sufficient vent to the air confined within, the incision should be continued through the intercostal muscles, and a small puncture cautiously made into the pleura. Mr Hewson, who has written an excellent paper on this subject, in the third volume of the Medi- cal Observations and Inquiries, recommends that the operation should be performed, as in cases of emphysema, on the fore part of the chest, between the fifth and sixth ribs at the right side, as there the integuments are thin, and in the case of air no depending drain is required ; but if the disease is on the left side, he considers it more advisable to make the opening between the seventh and eighth, or eighth and ninth ribs, in order that we may be sure of avoiding the pericardium. The perforation of the pleura will be immediately fol- lowed by the escape of the condensed air, the pressure of which being removed, the mediasti- num and diaphragm will regain their natural po- sition, and the opposite lung will thus be enabled to resume the free and unobstructed discharge of its functions; after which the wound should im- mediately be closed with adhesive plaster, in order to prevent the alternate ingress and egress of air during the dilatations and contractions of the tho- rax. Should the symptoms of oppression and suf- focation again return, the wound may be opened as occasion requires, and the accumulated air suf- fered to escape. It sometimes happens that the necessity of per- forming the operation of paracentesis is apparent from the oppressed state of the breathing, and other urgent symptoms of pneumothorax, but that from the nature of the accident, and the extreme distension of the integuments, it is difficult to as- certain at which side the operation should be per- formed ;—a point in reference to which an error may be attended with the most fatal consequences, as actually occurred in a case recorded by Dr. Halliday. " The operation of paracentesis was resolved on in consultation, and an incision was accordingly made between the sixth and seventh ribs on the left side of the thorax. As soon as the opening was made into the cavity of the chest, every distressing symptom became more severe, and the patient scarcely survived a quarter of ar. hour." On dissection, it was discovered that the operation had been performed on the sound side. (Op. cit.) In order to avoid the possibility of committing so fatal a mistake, the existence of pneumothorax, and its precise seat, should always be clearly ascer- tained by the physical signs of this disease fur- nished by auscultation and percussion (see Pneu- mothorax) before the operation is undertaken; and should the emphysematous state of the inte- guments prevent their employment, or obscure the indications which they afford, several punctures should be made over the chest, and the air pressed towards them, until the emphysematous swellings are reduced ; after which, the precise extent and seat of the pneumothorax may be ascertained with that degree of accuracy which the labours of Laennec have rendered so characteristic of this department of medical science. Some writers use the term emphysema in a more extended signification than that which has been assigned to it in this article, and apply it to all preternatural accumulations of air, in whatever part of the body they are situated. But, as these collections of air have each received distinct names, according to the cavities or organs in which they are situated, such as pneumothorax, tympanitis, physometra, &c, their description will EMPHYSEMA OF THE LUNGS. 17 find a more appropriate place in the articles re- spectively allotted to these subjects. Emphysema of the lungs alone forms an exception, and will therefore be treated of in the next article. R. Townsend. EMPHYSEMA OF THE LUNGS. —The morbid appearances presented by this disease have been noticed by Bonetus, Morgagni, Van Swieten, Storck, and other anatomists. In this country we have a very correct account of an emphysematous lung from the pen of Sir John Floyer; and Dr. Baillie's work on Morbid Anatomy contains an accurate description of the three principal circum- stances which characterize this lesion, namely, the great size of the lungs, the dilatation of the cells, and the vesicles formed by extravasation of air under the pleura. The discovery of its fre- quent occurrence as a disease, of its etiology, and diagnosis, was, however, reserved for the patholo- gical researches of M. Laennec. [An excellent essay on the subject has been published by M. Louis (translated by Dr. T. Stewardson of Phi- ladelphia, in Dunglison's Medical Library for 1838.) In order to render the following observa- tions intelligible, it will be necessary to premise a few observations on the anatomical structure of the pulmonary parenchyma, as the emphysematous condition of this viscus is, in many cases, merely an exaggeration of its natural or healthy struc- ture. If we examine in a good light the surface of a sound lung, we can ascertain by the naked eye, through the transparent pleura, that its paren- chyma is formed by the aggregation of a multitude of small vesicles of an irregularly spheroid or ovoid figure, full of air, and separated from each other by opaque white partitions. These vesicles, which on the surface of the lungs have the ap- pearance of small transparent points, are not of an uniform size ; the largest are equal to the third or fourth part of a millet-seed. They are grouped in masses or lobules, divided from each other by par- titions of closely condensed cellular membrane, very thin, yet thicker and more opaque than the partitions between the individual cells. These partitions traverse the pulmonary substance in all directions, and crossing each other under various angles, form figures of different shapes, such as lozenges, squares, trapeziums, or irregular trian- gles, the bounding lines of which are rendered still more defined by the black pulmonary matter that is deposited along them. (Forbes's Transla- tion of Laennec.) If we analyze this structure, we find that it is composed, 1st, of the minuter ramifications of the bronchi, which go on subdividing and diminishing in caliber until they terminate each in a cul-de-sac or air-cell, as it is commonly termed, of extreme delicacy and minuteness, on the parietes of which the pulmonary vessels ramify in an extreme state of fineness, (Reisseisen, De Structura Pulmo- num;) and 2dly, of the common cellular mem- brane which serves to connect these air-cells together, and which likewise forms several mem- branous partitions that divide each lobe into a number of distinct lobules, and is hence termed the interlobular cellular tissue, each lobule being as perfectly isolated from those adjoining it by Vol. II___3 b* this partition, as each lobe is by its investiture of pleura. Each of these textures is liable to emphysema, and hence we have two varieties of this disease in the lung: 1. the vesicular or true pulmonary emphysema, (as it is somewhat arbitrarily termed by Laennec,) formed by the dilatation of the minute bronchi and air-cells, or by the rupture of their parietes, by which several contiguous cells are thrown into one ; 2. the interlobular emphy- sema, formed by the infiltration of air into the interlobular cellular tissue. The former usually occurs as a chronic disease, while the latter as generally assumes the character of an acute affec- tion. I. Pulmonary or Vesicular Emphysema.— In pulmonary emphysema, the size of the air-cells is much increased and is less uniform. The greatei number equal or exceed the size of a millet-seed, while some attain the magnitude of hemp-seed, cherry-stones, or even French beans. (Laennec.) We are disposed to think, however, that cavities of such a size are rarely formed by the dilatation of individual cells, as in more than one hundred dissections which we have made of pulmonary emphysema, we never except in one instance saw the air-cells dilated to the size of a garden-pea ; in the great majority of cases the cavities of this size, or even of a less diameter, are formed by several cells being thrown into one, in consequence of their delicate partitions being overstrained and ruptured. In some cases, the walls of the cells disappear from one entire lobule, leaving only some lacerated filaments traversing its cavity from one interlobular partition to another, and in some instances these partitions are also lacerated, and their respective lobules are thus thrown into one large cavity, which usually reaches the surface of the lung, and forms a projection under the pleura. In order to see these alterations of structure, it is necessary to inflate the lung and dry it previous to examination, as without this precaution the cells collapse immediately when cut into, and all appearance of emphysema is consequently lost. "Emphysema may affect both lungs at the same time, one only, or a part of one, or both: in the latter case, and, indeed, in any case, as long as the disease is confined to a simple dilata- tion of the cells, or to the rupture of a few of their partitions, and does not form vesicles of any con- siderable size on the surface of the lung, it may be easily overlooked in the dead body ; for this reason, the disease, which is really one of the most constant morbid appearances in all cases of protracted dyspnoea, has been as constantly over- looked, and in this way the lungs of asthmatic patients have been regarded as healthy when they are in reality emphysematous, and cases of dys- pnoea set down as nervous or idiopathic, for which anatomy has now discovered an organic cause. « When the disease exists in a very high de- gree, we cannot help being struck with the ap- pearance of the parts. The lungs seem as if confined within their natural cavity, and when exposed, instead of collapsing as usual, they rise in some degree, and project beyond the borders of the thorax. If we examine them in this state, they feel firmer than natural, and it is more than usually difficult to flatten them. The crepitation 18 EMPHYSEMA OF THE LUNGS. they yield on pressure, or being cut into, is less, and of a kind somewhat different; it is more like the sound produced by the slow escape of air from a pair of bellows, and the air makes its escape from the cells much slower than in a healthy state of the organ. When we detach the lung, the crepitation is found to be still less perceptible, and the sensation conveyed by pressing the parts is very like that produced by handling a pillow of down. On placing an emphysematous lung in a vessel of water, it sinks much less than a healthy lung, and sometimes it floats on the surface with scarcely any obvious immersion. The pulmona- ry tissue is drier in a lung affected with emphyse- ma than in a healthy one, and it is unusual to find even towards the roots of the lungs any trace of the common serous or sanguineous infiltrations usually found after death." (Forbes's translation of Laennec.) In some cases, however, especially when the heart is diseased, and the pulmonary circulation much obstructed, the emphysematous lung becomes red and congested. It seldom happens that emphysema exists to the extent so admirably described in the preced- ing paragraph, without occasioning the rupture of several of the dilated cells, and it is by no means uncommon to find one or more large vesi- cular cavities formed, each by the re-union of all the air-cells of one entire lobule, and bounded by its interlobular partitions, which often remain un- injured when the texture of the air-cells which they enclose is completely destroyed ; in extreme cases these interlobular partitions give way like- wise, and several lobules are then thrown into one large vesicular cavity, resembling more a bladder filled with air, or the vesicular lung of a frog, than the parenchymatous texture of the human lung. These alterations are most frequently observed at the margin of the lung or at its base where it re- poses on the diaphragm. From these observations it results that emphy- sema of the lung esssentially consists in the rare- faction of its parenchyma, produced either by the dilatation of its cells, or the rupture of their pa- rietes. These lesions may be referred to three principal causes: 1. hypertrophy; 2. atrophy; 3. over-distension of the air-cells. 1. Hypertrophy.—Laennec has remarked that in several cases where the lung has been render- ed incapable of performing its functions, the other, having double duty to perform, acquires'an in- crease of volume proportionate to its increased ac- tivity of function. This increase of size appears to result from an increase in the capacity of the capillary bronchi and air-cells, at the same time that their parietes are increased in thickness; in- deed, this is rendered very evident by inflating and drying the lung, for when after this process it is cut into slices, we at once perceive some cells much larger than in the natural state, and likewise their parietes much thicker than they usually are. The state of the air-cells in this form of emphysema may be considered as anala- gous to the hypertrophy with dilatation of the heart and other hollow muscles. 2. Atrophy of the Lung.—Whenever any cause continues for a certain length of time to im- pede the free entrance of air into the pulmonary cells, those cells diminish in number, and the pa- renchyma of the lung falls into a state of atrophy. Accordingly we find this atrophy invariably taking place in lungs which have been compressed by pleuritic effusions of long standing, or when the principal bronchial tube is compressed by external tumours. In old age, likewise, the lungs some- times undergo so considerable a degree of atrophy that the chest is visibly contracted in consequence; and in such persons they are small, contain very little blood, are remarkably light, and their whole texture appears rarefied. If we inflate and dry a lung in this state, we perceive a remarkable altera- tion in the disposition of the ultimate bronchial ramifications, and of the air-cells in which they terminate; they no longer form distinct cavities, separated from each other by complete septa: at first these septa are only reduced to a state of ex- treme tenuity, but at a later period some of them appear perforated in one or more points, while others seem ruptured and irregularly torn. In some cases the walls of the cells disappear altoge- ther, and we only find in their stead some delicate filaments traversing in different directions cavities of various sizes. In the parts of the lung where these alterations exist, there are no longer to be found either bronchial ramifications, or air-cells, properly so called, but merely vesicles of greater or less diameter, divided into compartments by imperfect septa or irregular lamina?, bearing a perfect resemblance to the lungs of cold-blooded animals. (Andral's Pathological Anatomy.) Thus we see how lesions the most opposite in their characters, hypertrophy and atrophy, may alike produce this disease. But in the case of hypertrophy there is only dilatation of the cells without laceration of their parietes, unless as an accidental occurrence ; whereas, in atrophy of the lung, large cavities are formed by several cells be- ing thrown into one by the extenuation and rup- ture of their walls. Hence arises this important difference, that in the first case the number of sur- faces on which the blood is exposed to the action of the air remains the same, while in the second the number of these surfaces is considerably di- minished. It is easy to see that the respiration will not be equally affected in these two cases, and that the dyspnoea must necessarily be more considerable in the latter. There is, however, one circumstance that occurs in old age (at which pe- riod this alteration, as already stated, most gene- rally occurs,) which prevents the respiration from being as much embarrassed as we might a priori have expected,—namely, the diminution that takes place in the quantity of the blood, or (what comes to the same thing) the diminution in the rapidity of the circulation. For this reason atrophy of the lung, when occurring in old age, should rather be regarded as a natural phenomenon resulting from the fulfilment of a law in the animal econo- my which establishes a constant proportion be- tween the quantity of blood to be aerated in a given time, and the extent of surface on which this aeration is to be accomplished. Thus we find that the lung has its maximum of density in in- fants, and m those animals that have either a very rapid circulation or a very large supply of blood and that, on the contrary, the density of the lung is at its minimum in old persons, and in such ani- mals as receive into their lungs, at each round of EMPHYSEMA OF THE LUNGS. 19 the circulation, only a small proportion of the blood contained in their circulating system, (An- dral, Op. cit.) Besides these, which may be considered as the physiological causes of pulmonary emphysema, there are others which produce a similar condi- tion of the organ in a manner purely mechanical, by keeping the air-cells in a state of over-disten- sion. Amongst these may be enumerated violent efforts of any kind (especially if often renewed) which cause the long-continued retention of the breath; repeated attacks of catarrh, bronchitis, asthma, or other diseases of the lungs or air-tubes, attended with difficulty of breathing, or distress- ing paroxysms of coughing. The mechanism of the over-distension and rup- ture of the air-cells in these cases may be explain- ed by the efforts which are constantly made by the powerful muscles of inspiration to introduce a fresh supply of air into the air-cells, while that which they contain is prevented from escaping by pellets of viscid mucus, spasmodic stricture of the bronchi, or turgescence of the bronchial mem- brane, according to the nature of the disease which produced the dyspnoea. In this way, the air-cells are kept in a state of over-distension which the efforts that are made to evacuate them only tend to confirm and increase ; and provided the obstruction is of some continuance, the dilated condition of the cells will be rendered permanent, or else their parietes will give way, and allow sev- eral cells to be thrown into one. From this view of the matter, it will readily be understood why all diseases accompanied by pro- tracted attacks of dyspnoea, or violent and often repeated paroxysms of coughing, are so constantly followed by emphysema, especially when occur- ring in persons advanced in life, in whom, as we have already explained, the lungs are peculiarly predisposed to this disease by the atrophy which their parenchymatous texture naturally undergoes at this period of life. But though the over-dis- tension and rupture of the air-cells is in general a slow process produced by long-repeated efforts to overcome an obstruction to the free exit of their contents, and is consequently the result, in most cases, of some chronic affections of the bronchial tubes, such as dry catarrh, asthma, or the congest- ed state of the mucous membrane, so frequently produced by organic lesions of the heart; it may likewise be produced in a very short space of time, when the efforts made by the muscles of respira- tion are violent and constantly repeated. We have frequently found the lungs emphysematous in children dying of hooping-cough; and in one instance, where the hooping-cough had not last- ed longer than three weeks, we saw several cells dilated to the size of garden-peas, of a globular form, and with their parietes evidently hypertro- phied. [The disease is considered by some to be the result of bronchitis—the mucous secretion of which cannot readily be expectorated, and there- fore dilates the vesicles; but this is denied by M. Louis, because, in the cases which he observed, the emphysema was rarely preceded by bronchi- tis, and the bronchial tubes, in the vicinity of the dilated vesicles, were found empty, containing neither mucus nor false membrane. A recent writer, Dr. G. Budd, ascribes it to a want of elas- ticity of the lung, or, in other words, to absence of its natural tendency to collapse. The power ful muscles of inspiration are continually acting to dilate the chest, and thence, by virtue of-atmos- pheric pressure, the air-cells. This agency is not counteracted, as it should be, by the natural elas- ticity of the lung, and the air-cells, as well as the cavity of the chest, are, in consequence, perma- nently dilated. The question as to its hereditary nature was closely and ably investigated by the late Dr. J. Jackson, Jun., of Boston, who attained the fol- lowing results. First. Of twenty-eight patients, affected with pulmonary emphysema, eighteen were the offspring of parents, one of whom had been attacked with the same affection, and several of whom had died in the course of it. In some cases, the same was true of the brothers and sis- ters. Secondly. Of fifty individuals, not affected with emphysema, three only were descended of parents who laboured under the disease; whence it would follow, that emphysema is frequently an hereditary affection. It would appear, too, that hereditary influence is much more marked, where the emphysema dates from early infancy, than in those in whom it commences immediately before, or subsequently to the age of twenty.] From whatever cause the emphysema proceeds, its constant effect is to render the portion of lung affected incapable of performing its respiratory functions, as is evident from the absence of respi- ratory murmur in the part during life, and the difficulty with which the air escapes from the overstrained or ruptured cells, even after the lung has been removed from the body. Moreover, as the emphysema is in almost every instance origin- ally produced by turgescence of the bronchial membrane, or spasm of the circular fibres, so from an effect it generally becomes a cause, and main- tains the disease by which it was originally ex- cited. Accordingly we find that persons labour- ing under emphysema of the lung are particularly liable to attacks of asthma and bronchitis, and, as a consequence of the latter, and of the efforts made during respiration, to hypertrophy or dilata- tion of the heart. These intercurrent diseases usually occur only after long intervals during the first years of the disease ; but when the complaint is of long standing, and the patient is far advanc- ed in life, the paroxysms become more frequent and more severe, each succeeding attack increases the extent of the organic lesions and rupture of the pulmonary tissues, and sometimes interlobular emphysema then ensues. From these observations it may be concluded that pulmonary emphysema in a moderate degree is not a disease of great severity, and that the principal danger is to be apprehended from the repeated attacks of bronchial disease by which the emphysematous condition of the lung was origi- nally produced, and to which, in its turn, it seems to act as a predisposing cause. From the pathology of emphysema, its diag- nosis and treatment may be easily deduced. The dyspnoea, which is its most constant symptom, depends in a great measure on the extent of the disease, and the age and constitution of the indi- vidual. When the emphysema is rapidly formed. 20 EMPHYSEMA OF THE LUNGS. occupies an extensive portion of the lung, and occurs in a young plethoric subject, through whose lungs a large quantity of blood is constant- ly in circulation, the dyspnoea which ensues may be so great as to terminate rapidly in asphyxia. But when, as is much more frequently the case, the emphysema commences slowly and proceeds gradually, the disease is in itself seldom attended with any immediate danger, although it renders the organ obnoxious to serious or even fatal ef- fects from contingent pulmonary disease, which in a healthy lung might be borne with comparative impunity. The difficulty of breathing which accompanies this disease is constant, but is aggravated by pa- roxysms, which are irregular both in the period of their return and their duration; it is likewise increased by all causes which usually increase dyspnoea from whatever source arising, such as the action of digestion, flatulence in the stomach or bowels, anxiety, living in elevated situations, strong exercise, running, or ascending a height, and above all by the supervention of an acute catarrh, to which, as already stated, persons af- fected with emphysema are peculiarly liable. Be- tween the paroxysms there is no fever, and the pulse is generally regular. In slight cases the complexion and habit of body are little altered; but when the affection is more considerable, the skin usually assumes a dull earthy hue, with a slight shade of blue interspersed, and the lips be- come violet, thick, and swollen; there is likewise more or less of cough usually present, though it is sometimes so slight as to escape the notice of the patient : the expectoration generally consists of a greyish viscid mucus. These symptoms may, however, be considered as appertaining more pro- perly to the disease of the bronchi with which the emphysema is complicated, than to the emphy- sema itself. When the emphysema is confined to one lung, or is much greater in one than in the other, the side most affected is perceptibly larger than the other, its intercostal spaces are wider, and it yields a clearer sound on percussion. If both sides are affected equally, the whole chest yields a very distinct sound, and, instead of its natural com- pressed shape, exhibits an almost round or globu- lar outline, swelling out both before and behind : this conformation of the chest is sometimes so re- markable as to render the existence of the disease evident from simple inspection. (Laennec, Op. cit.) The pathognomonic signs of this disease are furnished by a comparison of the indications fur- nished by percussion and auscultation; for while the sound elicited by percussing the chest over the part affected is perfectly clear, or even tympanitic, the respiratory murmur is extremely indistinct, or even completely extinct, and in its place a slight sibilous rale only is heard even during the forced inspirations that precede the act of coughing. These inspirations will be confirmed by the long continuance of the disorder, and the existence of an habitual dyspnoea, occasionally aggravated by asthmatic paroxysms. When the disease is so far advanced as to form large vesicular cavities under the pleura, its pre- sence may be recognised by a sound heard during inspiration or coughing, which is quite pathogno- monic, and described by Laennec under the appro- priate name of the crepitous ride with large bub- bles. The sound of this rile he compares to that which would be produced by blowing into half- dried cellular membrane. We have repeatedly verified the accuracy of this comparison, and have uniformlv found on dissection that the sound in question'was produced either by an extreme state of vesicular emphysema, or by the interlobular form of the disease; we have often found these alterations on dissection in cases where this pre- monitory sound was never discovered. There is another stethoscopic sound which Laennec describes as belonging exclusively to in- terlobular emphysema, but which we have heard on more than one occasion, in cases of vesicular emphysema, where the ruptured air-cells projected above the surface of the lung. We allude to the "friction of ascent and descent," as Laennec terms it, which is a sensation of sound of one or more bodies rubbing against the ribs, and rising and falling during the alternate movements of inspiration and expiration. The friction of ascent takes place during inspiration, the friction of de- scent accompanies expiration, and is much more constantly audible than the other sound. Most commonly the friction seems to take place against the costal pleura; at other times it appears to hava its site against the diaphragm or mediastinum, or between the lobes of the lungs. These sounds are sometimes accompanied by a crepitation per- ceptible to the hand. Treatment. — As pulmonary emphysema must, in almost every instance, be regarded as an accident caused by some prior disease of the lung, the first indication should obviously be to remove the original disease, as the most effectual means of removing its effect, or, at least, of preventing its farther extension. This is perhaps as much as we can reasonably hope to accomplish in this case, as it is difficult to conceive how any method of treatment should restore that portion of lung which has once become emphysematous to its origi- nal healthy condition. M." Laennec, however, is of opinion that this affection should not be consi- dered as altogether incurable; and that, if we can diminish the intensity of the cause which keeps up the habitual distension of the cells, we may in the end hope that these will be actually lessened in volume. With this view the cause of the em- physema should be combated by prompt and ac- tive treatment, and the patient should be made to abstain from all the ordinary exciting causes of dyspnoea, as they not only produce present dis- tress, but likewise keep up the over-distension of the cells, and consequently increase the extent of the emphysema. It has already been stated that emphysema in a moderate degree is not a disease of great severity, and it is from the supervention of attacks of asthma or bronchitis that the principal distress and danger are to be apprehended. Every precaution shouid therefore be adopted to remove these affections and prevent their recurrence. To detail the treatment of these diseases here would be to repeat what has been stated in other parts of this work: we therefore refer the reader to the articles of Asthma, Bronchitis, and Ca EMPHYSEMA OF THE LUNGS —EMPYEMA. 21 tahrh, for all the information that can be obtained on the subject in the present state of our expe- rience. Laennec recommends frictions with oil as useful in diminishing the susceptibility to be affected with catarrh ; but a more effectual method of accomplishing this object is by sponging the chest every morning with vinegar and water, and after- wards dry-rubbing the part with flannel or a flesh- brush, as recommended in Asthma. In the case of pallid cachectic patients, the subcarbonate of iron has occasionally seemed to have a similar effect, and to tend at the same time to diminish the congestion of the mucous membrane, and also the spasmodic stricture of the bronchi. It is also of importance to attend to the state of the digestive organs, as experience has fully proved that irri- tation of the bronchial membrane is very often a sympathetic affection depending upon irritation of the stomach. Whatever, therefore, is improper for a dyspeptic patient should be avoided by those who labour under emphysema of the lungs. Warm clothing in all cases of delicate mucous membranes is particularly necessary, and flannel should be worn next the skin during the day, the lower ex- tremities should be kept especially warm, and other necessary precautions adopted to guard against the cold of the winter months. We have known many persons affected with emphysema of the lungs, and that to a very considerable extent, whose breathing was quite good during the sum- mer months, but who dreaded the approach of winter as the never-failing harbinger of their suf- ferings. For such cases the only alternative is to spend the winter in a more congenial climate. Indeed there is, perhaps, no class of complaints in which the beneficial effects of change of air and climate are more decidedly manifested than in those chronic cases of pulmonary emphysema complicated with great susceptibility of irritation in the mucous membranes of the air-passages.— (See Climate.) II. Interlobular Emphtsema.—This, as its name implies, consists in an effusion of air into the cellular tissue, which intersects the pulmonary parenchyma, and divides each lobe into a number of distinct lobules. This form of pulmonary em- physema may be easily recognised in the dead body, by the transparency of the interlobular par- titions, which contrast strongly with the denser structure of the intervening portions of parenchyma. Instead of the scarcely perceptible thinness which they exhibit in the natural state, these partitions, in a state of emphysema, are distended to the breadth of two or three lines, or even of an inch in some cases. They are generally widest at the surface of the lung, where the distension of their delicate cells bears an apt resemblance to a string of glass beads. Sometimes the emphysema is con- fined to two or three interlobular partitions, which run parallel to each other from the margin of the lung; in some cases these parallel bands are inter- sected by transverse partitions likewise in a state of emphysema, and the lobules intercepted between these intersecting partitions are thus completely insulated, being surrounded on all sides by trans- parent cellular tissue in a state of emphysema. When the disease continues to extend, the air passes from one interlobular partition to another, until it reaches the root of the lung, from whence it soon extends to the mediastinum, and thence spreads all over the cellular tissue of the trunk.— (See the preceding article.) It sometimes happens in this form of the disease that the air escapes into the cellular tissue which connects the pleura to the lung: in this way one or more bubbles of air are formed immediately under the pleura, and may be pushed along the surface of the lung by the finger,—by which cir- cumstance they may be distinguished from the vesicles that are formed in the true pulmonary emphysema, as the latter are prevented from being displaced in this way by their interlobular partitions. The formation of interlobular emphysema is explained by M. Laennec as necessarily depending on a rupture of some of the air-cells, and the con- sequent extravasation of the air contained in them into the cellular substance surrounding the lobules. It must, however, be admitted that, even in the most extensive cases of this disease, no such rup- ture has ever been detected, and that the rupture of several cells constantly takes place, and yet not a particle of air finds its way into the interlobular partitions; nay, that these partitions may them- selves be lacerated, and yet no interlobular em- physema be produced. Farther observations are required to elucidate this subject. This form of emphysema is as rare as the other is common. It is very seldom combined with the true pulmonary emphysema; and in the great majority of cases seems to result from some sudden and violent effort of the respiratory muscles, as in the forcing pains of child-birth, in raising heavy weights, in hooping-cough, &c. Notwithstanding the greater density of their lungs, children appear to be more liable to this disease than adults. (Laennec.) The only symptom from which the existence of this disease can be suspected, is the sudden supervention of dyspnoea after any violent effort of the lungs. Its stethoscopic signs are the dry crepitous rale with large bubbles, and the friction of ascent and descent already described. These sounds, it will be recollected, are likewise common to the vesicular form of emphysema when the pleura is projected by several air-cells thrown into one ; perhaps the only method of distinguishing between these cases is by the sudden supervention of the dyspnoea and of the stethoscopic signs in the interlobular form of the disease : fortunately, however, the diagnosis is not a matter of much practical importance, as in the slighter cases (in which alone any ambiguity can exist) the air ap- pears to be always absorbed, and the interlobular partitions gradually return to their natural stale. When the aerial infiltration extends to the exter- nal parts, the difficulty of diagnosis is at once removed, and the disease may be treated on the principles already stated in the preceding article on general emphysema. R Townsend. EMPYEMA. 'Eii-nvviia, formed of iv and iruoi. literally signifies an internal collection of pus, and in this general sense was employed by several ancient authors. By subseauent writers its signi' fication has been considerably restricted, and noso- logists now apply the term exclusively to thos-' 22 EMPYEMA collections of pus which are contained within the sac of the pleura. In practice, however, it is not always easy to determine, a priori, the precise nature of the fluid collected within the chest, as its physical characters are found to vary consider- ably, even in those cases that most closely resem- ble each other in their origin, progress, and symp- toms. In a case of empyema of two months' standing, occasioned by the bursting of a tubercu- lous abscess of the lung into the pleura, the effu- sion, as observed by the writer, presented all the characters of genuine pus ; while in another case, where the pleuritic effusion was produced by a similar cause, and assumed the same chronic form, the operation of paracentesis gave issue to a fluid as transparent and colourless as water. Other varieties, to be presently enumerated, have like- wise been observed in the appearance and compo- sition of these fluids ; and as there are no peculiar symptoms by which we can always discriminate their precise nature during the lifetime of the in- dividual, the term is now generally used without any reference to the puriform character of the effusion. When effusion into the thorax takes place in an individual of a dropsical diathesis, and seems to result from an obstruction to the circulation and the consequent transudation of the serous part of the blood, rather than from any irritation of the secreting surface, the disease is denominated hydrothorax. When the effusion is known to consist of blood, as in penetrating wounds of the chest, where the pulmonary or intercostal vessels have been injured, the term hemothorax is used to express it; and the name of pneumothorax is applied when the effusion is of a gaseous nature. With these exceptions, all cases of effusion into the pleura that are sufficient to compress the lung and impede the function of respiration, are com- prehended under the generic appellation of em- pyema. The pleura, like other serous membranes, con- stantly exhales a fluid in the form of vapour, by which its surface is lubricated and moistened. In the natural state, this perspiratory fluid always exists in the form of halitus or vapour; but in a morbid state, it is sometimes exhaled in much larger quantities, and instead of vapour assumes the fluid form. Its qualities are then also mate- rially altered, so that, instead of a slight moisture barely sufficient to facilitate the gliding motion of the opposing surfaces on each other, the serous sac is filled with certain morbid secretions, of which the following are the principal :— 1. Serum: its composition is sometimes the same as that of the blood, and sometimes differs from it in containing a greater or less proportion of albumen. 2. The same combined with a certain quantity of the colouring matter of the blood. 3. Pure blood. 4. Pus. 5. The spontaneously coagulable and organiza- hle matter of which false membranes are formed, and which, in their turn, are liable to undergo \arious morbid alterations : thus they may become inflamed and form new false membranes, or exhale blood, or secrete pus, melanosis, or tubercle; or lastly they may be transformed into fibrous, carti- laginous, or osseous tissue. (Andral, Anatomie Pathologique.) . These morbid productions, either singly or va- riously combined, form the principal, if not the only ingredients in all cases of pleuritic effusion. Our knowledge of the pathology of pleuritic diseases in general, and of empyema in particular, has been considerably advanced of late years by the labours of Laennec, Broussais, and Andral, whose works, (Traite d'Auscultation Mediate, Histoire des Phlegmasies Chroniques, Clinique Medicale,) contain the most complete history we possess of these diseases, and may indeed be said to form a new era in the pathology of this class of affections. The effusion of empyema, it is now generally admitted, is in all cases principally, if not entirely, formed by a morbid secretion from the pleura, and may in almost every instance be referred to in- flammation of that membrane, either in an acute or chronic, an evident or latent form ; and even in those cases where pus or other matter is intro- duced into the pleura from an extrinsic source, as from the rupture of a pulmonary or hepatic ab- scess, the collection of fluid which constitutes the empyema consequent thereon, does not consist so much of the matter of the abscess as of the morbid secretion from the pleura, which the irritation caused by the presence of that matter produces. The nature of the exudation in acute pleuritis and the successive stages of its organization and conversion into false membrane, are detailed in a separate article in this work. (See Pleuritis.) For our present purpose, it is only necessary to consider those morbid secretions of the pleura which evince no disposition to become organized or absorbed, but continue to accumulate in the shut sac of that membrane, where they act as a foreign body, and, by their pressure on the import ant organs contained within the parietes of the chest, present a constant obstacle to the due pei formance of their functions. In some cases the effusion consists of a cleai, transparent, or lemon-coloured serum ; sometimes the effused fluid, though it still retains its trans- parency, contains several flocculi of albumen, some suspended and others precipitated to the bottom. More frequently it is rendered quite turbid by the quantity of these minute flocculi that are partially dissolved and suspended in it, while the pleura, more especially the most dependent portion of it, is co- vered with an inorganic layer of a white or yel- lowish paste formed by these flocculi, which fall in the form of the sediment to the bottom of the fluid in which they were suspended. In other cases, and they are by far the most numerous, the effusion is still more turbid, and of a greyish brown or yellow colour—in short, it exhibits every intermediate variety of appearance until it pre. sents all the characters of genuine pus. These different varieties of effusion are some- times mixed up with the contents of abscesses formed in the neighbouring parts, as in the lungs or hver, and discharged into the pleura. In some cases the effusion is coloured by the admixture of a certain quantity of blood, and in some rare in- stances the effusion has been found to consist en- tirely of blood. This sanguinolent effusion some- times occurs at the very onset of the pleuritic at EMPY E U A. 23 tack, constituting the primitive hemorrhagic pleu- risy of M. Laennec, but is more frequently ob- served to occur at a more advanced stage of pleu- risy, particularly at the time when vessels begin to be formed in the false membranes, or when a fresh attack of inflammation supervenes in them. Much importance was attached by the old writers to the decomposition of these effusions and their tendency to putrescency ; but the best pathologists are now agreed that they never acquire an offen- sive odour, or exhibit any sign of decomposition unless when the parietes which enclose them be- come gangrenous, or when a communication has been established between the fluid and the exter- nal atmosphere. (Andral and Broussais, Op. cit.) The quantity of these effusions is sometimes so very great as to compress the lung into the small- est possible compass, and exhaust it of its air more effectually than could be done after death by means of an air-pump ; at the same time the pa- rietes of the chest which are in any degree sus- ceptible of motion are distended to the utmost; the ribs are elevated, and their lower margins everted, so as to increase their capacity as much as possible ; the intercostal spaces are protruded ; the diaphragm is forced down into the abdomen, and the abdominal viscera are consequently dis- placed, especially the liver, which, in cases of ex- tensive empyema of the right side, has been known to descend into the iliac fossa. (Stoll, Ratio Me- dendi.) The mediastinum, in like manner, yields to the distending force of the effused fluid, com- presses the opposite lung, and allows the heart to be thrust completely out of its natural situation. We shall presently see that this displacement of the heart is one of the most constant and least fallible symptoms of empyema. Without this great enlargement of the affected side, it would be physically impossible that one sac of the pleura could accommodate such an enormous quantity of fluid as has occasionally been found there. A patient of Dr. Croker, of Dublin, was lately operated on for empyema by Mr. Crampton, when the almost incredible quantity of fourteen imperial pints of pus was drawn off from the left pleura. In Dr. Archer's case of successful paracentesis of the thorax, recorded in the second volume of the Transactions of the Dublin Association, eleven pints of an inodorous fluid were drawn off, and in a few weeks after the patient was quite convales- cent. Many other instances might be quoted of effusions equally great, or even still more exten- sive. When the effusion is removed, it seldom hap- pens that the pleura is exposed to view, as its sur- face is almost invariably covered with a coating of adventitious matter, which gives the interior of the chest much more the appearance of the walls of a large abscess than of a cavity lined with se- rous membrane. When, as in cases of latent pleurisy, the pleura is covered with a layer of the inorganic sediment, which is deposited when the effusion is wholly puriform, the layer of matter may be scraped off with the handle of the scalpel, and then the membrane underneath presents an opaque blueish appearance, as if caused by the maceration to which it had been so long submit- ted. A few red dots or stri:e, as if laid on with a pencil, are generally dispersed over its surface; the membrane itself is seldom if ever really thickened, its apparent thickening being in al- most every instance caused by a coating of ad- ventitious membrane, which had been exuded during the earlier stages of inflammation. When the chronic pleurisy succeeds to an acute attack, this apparent thickening of the pleura is a very constant appearance : sometimes the adventitious membrane forms a delicate transparent pellicle, which appears perfectly incorporated with the subjacent membrane, but may, however, be dis- sected from it in one or more layers; sometimes the pleura is closely studded with minute trans- parent or opaque granulations of a flattened form, but most frequently the adventitious coating is of an opaque whitish colour, and varies in consist- ence from curd or soft cheese to fibro-cartilage, to which substances it often bears a very strong re- semblance ; and as it is generally composed of se- veral strata laid one over the other, it sometimes forms a dense solid layer many lines or even inches in thickness. When a coating of this de- scription is developed on the pulmonary pleura, it forms such an unyielding envelope round the lung in its compressed, contracted state, as must effect- ually prevent its expansion when the pressure of the fluid is removed ; and as the lung in this con- dition cannot dilate itself promptly enough to keep pace with the progress of absorption, when the disease terminates favourably, the parietes of the chest must necessarily fall in to occupy the space left by the removal of the fluid : in this way is produced the contraction of the chest which so constantly follows the removal of a chronic effu- sion from the pleura either by absorption or eva- cuation. The adventitious membranes which line the pleura are liable to a variety of morbid altera- tions ; they are evidently susceptible of inflam- mation, and likewise of ulceration ; for in many cases they have been observed eroded, as it were, with small circular pits, sometimes shallow and sometimes penetrating through the whole thick- ness of the false membrane : occasionally these penetrating pits communicate with each other by sinuses, or by a more extensive separation of the false membrane from the subjacent pleura, but at other times the ulceration penetrates through the pleura itself. When this happens on the costal pleura, it sometimes gives rise to the formation of external tumours, which either burst externally and discharge the matter of the empyema, or else form one or more sinuous passages by which the pus is infiltrated into the subcutaneous and inter- muscular cellular tissue ; but when it takes place in the pulmonary pleura, a communication is eventually formed with a bronchial tube, through which (according to the position of the body at the time) part of the fluid escapes, or air enters. Several cases illustrative of these morbid appear- ances are recorded in Dr. Duncan's interesting essay on empyema and pneumothorax, in the 28th volume of the Edinburgh Medical Journal. The pleura and its adventitious coating of false membranes is likewise subject to gangrene, and the detachment of the gangrenous eschars some- times serves, as in the case of simple erosion jusl noticed, to form an outlet by which the matter of the empyema is evacuated. 24 EMPYEMA. These false membranes are likewise liable to other morbid changes. Sometimes they are trans- formed into fibrous or cartilaginous tissue, and in some instances they have been found completely ossified ; they are also liable to the development of various morbid productions, particularly tuber- cle. The tubercles that are formed in false mem- branes are generally small and very numerous. We have, however, once or twice seen tubercles as large as filberts in the adventitious coating of the pleura; their development is usually a slow process, and generally occurs in cases of very chronic pleuritis; but sometimes they are gene- rated in great numbers with an extraordinary ra- pidity. M. Andral has seen the false membranes studded with tubercles in persons who died of acute pleuritis of only fifteen days' standing. (Clinique Medicate, vol. ii.) The morbid alterations which we have describ- ed may exist in both sacs of the pleura at the same time, constituting the double empyema of authors, or, as much more commonly happens, may occupy one side of the chest; or, lastly, may be limited to a part of one side. When the in- flammation is limited to a certain extent of the pleura, the effusion is generally circumscribed by adhesions which prevent its creeping into the ge- neral sac of the pleura; these circumscribed em- pyemas, as they are termed, may exist between the lower lobe of the lung and the diaphragm, or between two contiguous lobes, between the inner surface of the lung and the mediastinum, or be- tween any part of its outer surface and the costal pleura. Not unfrequently there exist between the pleura costalis and pulmonalis a number of dense firm adhesions, which, like so many shelves or partitions, intersect the effusion, and divide the sac of the pleura into a number of distinct com- partments. We examined the body of a patient who died of empyema in the Whitworth Hospital, in March 1830, in whom the effusion was divided r>y these partitions into three compartments, so perfectly distinct from each other, that had the operation of paracentesis been performed during life, that compartment only could have been eva- cuated into which the incision had been made ; so that in order to draw off the entire effusion, it would have been necessary to perform three seve- ral operations. The effect of the effusion in compressing the lung and diminishing its volume, has already been alluded to. When the effusion is very ex- tensive, the lung becomes flattened and complete- ly flaccid, and its surface corrugated like the shrivelled rind of a withered apple ; in this state the pulmonary tissue is soft, pliant and dense, like a piece of skin, without any crepitation, more pale than natural, and entirely without blood ; its blood-vessels are flattened and fiequently appear quite empty. (Laennec, Op. cit.) The lung thus circumstanced is incapabte of expanding for the admission of air so long as the fluid continues to press on its surface ; its alveolar texture, how- ever, continues very distinct; and, when its sur- face is not coated with an unyielding false mem- brane, it may be readily restored to its full dimen- sions by inflation. The usual position which the lung thus compressed occupies, is by the side of me spinal column, against which it sometimes lies so close as to have escaped the observatonof several distinguished anatomists who acc° Jmgfo described it as totally destroyed by »UPP»"^ Its position may, however, be materially altered by adhesions attaching it to different points of the thoracic parietes, and preventing its receding from them. We have known the lung retained in close contact with the whole anterior part of the chest, while the fluid was accumulated in the pos- terior part. Andral records a case of empyema, in which the upper and middle lobe of the right lung were retained in their natural position by adhesions, and formed a complete roof over the effusion, which filled the whole of the lower part of the chest. (Clinique Medicate, vol. ii.) Drs. Graves and Stokes relate two remarkable cases of empyema in the fifth volume of the Dublin Hos- pital Reports, in both of which the lungs were at- tached from their apex to their basis by a vertical adhesion of about two inches in breadth. Other observations might be adduced illustrative of the effects of adhesions in preventing the lungs reced- ing from the parietes of the thorax ; but for our present purpose it is sufficient to remark that, as there is no part of the pulmonary pleura which may not contract adhesions with the correspond- ing surface of the costal pleura, so there is no part of the chest with which the lung may not be retained in contact, even in cases of very copious effusion. The knowledge of this anatomical fact is, as we shall presently see, of considerable im- portance in some cases for determining the pre- sence of empyema, and likewise for selecting the site of the operation of paracentesis. The lung, when compressed in the manner we have described in the preceding paragraph, is sel- dom attacked with inflammation ; indeed its exsanguineous condition would seem to guarantee it sufficiently from attacks of that nature; but there is another morbid alteration which the lung under such circumstances frequently presents, namely, the development of tubercles. M. Brous- sais supposes that their formation is in most cases consequent to the effusion, and in a great degree, if not altogether, produced by the obstruction of the lympathic circulation in the part. (Op. cit. vol. i. p. 343.) A more general opinion however is, that tubercles are in this, as in other cases, the result of a general diathesis, and had probably existed in the lung before the effusion had taken place. M. Broussais's opinion, if correct, would furnish a strong argument in favour of operating at an early period of the effusion, in order to anti- cipate, if possible, the formation of the tubercles. Another morbid appearance which the lung occa- sionally presents is the formation of a gangrenous or phlegmonous abscess, by which, when the pleura is perforated, the effused fluid finds a passage into the bronchi, and is expectorated. Such are the principal morbid appearances that have been observed after death in cases of empy- ema: it now remains for us to investigate the causes of these anatomical lesions, and to consider the symptoms to which they give rise, and by which they may be distinguished during life. We shall thus be prepared to form a correct estimate of the progress and termination of this disease, and of the remedies best calculated to arrest its pro gress and remove its effects. EMPYEMA. 25 We have already seen that the matter of empye- ma is in most cases formed exclusively by a morbid secretion from the pleura, and that, even in those instances where pus or other matter is introduced into the pleura from the rupture of an adjacent abscess, the empyema which follows is principally formed by exhalation from the inflamed pleura. It may, therefore, be assumed that inflammation of the pleura is the proximate cause of empyema. As, however, the ordinary course of pleuritic in- flammation is not to terminate in empyema, but in the exudation of a compound fluid, the serous portion of which is subsequently absorbed, and the solid part organized and converted into false mem- brane, it becomes a question to determine what are the circumstances that cause the inflamed pleura to secrete the inorganic matter of empyema rather than the ordinary organizable product of pleurisy, or, in other words, what are the species of pleuritic inflammation which have the greatest tendency to terminate in empyema. These may be divided into four classes: 1. Acute pleuritis of intense violence. 2. Acute pleuritis degenerating into the chronic form. 3. Inflammation of the pleura of so low a type as not to present the ordinary symptoms of acute pleurisy. 4. Pleuritis caused by the introduction of foreign substances. 1. Acute pleuritis of intense violence.—It very rarely happens that inflammation of the pleura is so intensely violent as to induce gangrene. When it does occur, a copious effusion always follows. More frequently, when the pain and other inflam- matory symptoms present an unusual degree of violence, blood is effused from the inflamed sur- face ; generally speaking, the effusion of fluid is more abundant in the hemorrhagic than in the simple pleurisy, and the tendency to absorption is much less. (Laennec, Op. cit. Dr. Forbes's Trans- lation.) Lastly, when the pleuritis assumes this violent intractable character, a copious secretion of puriform matter may take place at an early stage of the disease. In a young woman who died in the Hardwicke Fever Hospital in the year 1826, after experiencing for twelve days before her death the symptoms of most violent inflammation of the pleura, we found, on dissection, nine pints of thick inodorous pus in the right pleural sac. M. Andral records another case in which a purulent effusion was formed with equal rapidity. Although the inflammatory symptoms were combated from the very outset of the disease by the most active treat- ment, on the fifth day the whole of the right side sounded dull on percussion, and respiration had ceased to be audible there; on the seventh, the side was evidently dilated ; and on the eleventh, when the disease terminated fatally, the right side was found, on dissection, so filled with pus that the lung was completely condensed and flattened against the spine. (Clinique Medicate, vol. ii. case 13.) Piso likewise relates several cases of acute pleuritis, in which the patients died on the fifteenth, and some even so early as the ninth day, with their sides full of pus. (De Affect, a Seros. Col- luv. ortis, sect. iii. cap. ix.) In those acute cases of empyema, the diagnosis is never difficult; the extreme violence of the symptoms, the acute pain Vol. II. — 4 . c of the side rendered almost insupportable by coughing, the excessive dyspnoea, general anxiety, and high fever, at once point out the highly in- flamed state of the pleura, and awaken our atten- tion to the possibility of its terminating by effusion: when under such circumstances the physical signs of effusion (to be presently described) rapidly supervene, the existence of empyema is placed beyond a doubt. This acute form of empyema is, however, much more rare than those chronic forms of the disease we are next to consider. 2. Acute Pleuritis degenerating into the chro- nic form.—In the greater number of pleurisies which terminate favourably, the process of the absorption and organization of the effusion is completed within a limited period, which, at an 'average calculation, may be estimated at three weeks or thereabout. (Broussais, Op. cit.) When- ever the symptoms of pleuritic inflammation out- last this period, or when, after a temporary abate- ment of the inflammatory symptoms, the patient is seized with rigors and irregular febrile parox- ysms similar to those of remittent fever, there is reason to fear that the disease is about to assume the chronic form, and empyema may be appre- hended. In many cases the passage of the disease from the acute into the chronic form may be traced to the circumstance of its having been neglected during its earlier stages, or not combated by sufficiently active treatment, or else to some indiscretion on the part of the patient during con- valescence, particularly in the article of diet; but we likewise meet occasionally with cases of acute pleurisy, which, however actively and judiciously treated, inevitably degenerate into the chronic form. M. Broussais, whose opportunities of ob- servation in this matter have been most extensive, states, as the result of his experience, that acute pleurisy passing into the chronic form is decidedly the most frequent cause of empyema. Whenever, therefore, the symptoms of pleuritic inflammation outlast their ordinary period, and are succeeded by those of effusion, we have the strongest evidence of the existence of empyema, inasmuch as the symptoms of empyema made their appearance under those circumstances which most frequently lead to such a termination. 3. Inflammation of the Pleura of so low a type as not to present the ordinary symptoms of Acute Pleurisy. — Several physicians of the last century, and particularly Stoll, had remarked that, in many cases of pleurisy, the stitch which com- monly attracts attention to the character of the disease, is altogether wanting, and that the insidi- ous mildness of the whole symptoms in the early stage is such as not even to excite any suspicion of a severe affection. This latent form of pleurisy' is essentially chronic in its progress. At no period of its course does it present the intense fever, severe pain, or energetic re-action, which charac terize an acute disease. It seldom occurs in per- sons of good constitution, but usually attacks those who have become cachectic from some cause or other, especially persons of a strumous habit (Laennec, op. cit. Dr. Forbes's translation.) Ttiere are, however, certain exciting causes, which are said to have a peculiar tendency to generate this latent form of pleurisy, amongst wmch may be enumerated contusions of the chest, wounds ot 26 EMPYEMA. the pleura, the cold stage of ague, and metastasis of rheumatism. These causes, says M- Broussais, (op. cit.) most commonly give rise to pleurisies that are latent in their origin and chronic in their progress. Effusion of puriform matter may like- wise take place into the pleura from other causes, and without beinjr preceded by the ordinary symptoms of pleuritic inflammation. A case of latent empyema, consequent on venous inflamma- tion, lately occurred in the Meath Hospital, under the care of Mr. Porter. The patient, a stout young man, in the course of a few days, after having been bled, was seized with symptoms of phlebitis, and diffuse inflammation of the cellular membrane extending along the arm to the axilla. The disease proved fatal, and on dissection, in addition to the morbid appearances of the diseased limb, the pleura of the same side was found to contain several quarts of pus. In this case, no symptom whatever was observed during life to excite any suspicion of the pleura being the seat of disease. We have also known the amputation for white swelling followed in two instances by copious depositions of pus in the pleura, and in neither case was there any symptom to indicate disease of that membrane. Several similar cases have appeared lately in the French journals of severe operations, especially those for the removal of suppurating parts, being followed by extensive depositions of pus in the interior, and on the sur- face of different organs.* In these and similar cases, it is probable that the depositions of pus are formed independently of any inflammatory process in the tissue where they are collected, or, to use the expression of M. Andral, " that the pus is first taken into the circulation, and subsequently separated from the circulating fluid, just as mer- cury, when injected into a vein, is found to deposit its globules in different parts of the body." (An- draPs Pathological Anatomy, vol. i. p. 503.) Whatever the cause of the latent character of the disease may be, experience has fully proved that in a considerable proportion of the deaths from empyema, no symptom of pleuritic disease has been observed until the effusion was fully formed ; for which reason the diagnosis of this form of empyema is often very obscure. 4. Pleuritis caused by the introduction of for- eign substances. — Foreign bodies may be intro- duced into the pleura either through the lung or through the parietes of the chest. Amongst the former may be enumerated the contents of tuber- culous, pneumonic, or gangrenous abscesses, or of pulmonary apoplexy bursting through the pleu- ra. Of these the rupture of a tuberculous abscess is beyond all comparison the most frequent in its occurrence. Within the last four years no fewer than eighteen cases of empyema, with pneumo- thorax from this source, have come under our own observation, fifteen of which were verified on dis- section, and we have heard of several other cases occurring in the hospitals of Dublin. The rup- ture of a pneumonic abscess was supposed, by the older anatomists, to be the most prolific source of empyema; but the researches of modern patholo- gists have ascertained that the formation of a * See Recherches sur certaines Alterations qui se de- veloppent a la suite dns blessmes ou des operations, par M. Mar°clial, in 4to. lt-sW. pneumonic abscess is in itself an exceedingly rare occurrence, and its bursting into the pleura an event still more rare. The rupture of a gangre- nous abscess, though of somewhat more frequent occurrence, must nevertheless be considered as an extremely rare cause of empyema. M. Laennec records a case of pleurisy and pneumothorax con- sequent to the discharge of a gangrenous abscess of the lungs, (Case 15, Op. cit.) ; and he alludes to another case in which a gangrenous eschar made its way into the pleura, determining a pleu- risy which lasted fifteen months. (Op. cit. 227.) Andral likewise relates a case of pleuritic effusion produced by the bursting of a gangrenous ab- scess. (Op. cit. vol. ii. p. 433.) More common- ly, however, the gangrenous affection proves fatal before sufficient time has been allowed for the formation of empyema. In all these cases, the rupture of the lung and its investing membrane not only pours into the pleural sac the contents of the abscess, but likewise allows the air to enter at each inspiration, (see Pneumothorax ;) and this elastic fluid, by compressing the lung at the same time that it irritates the pleura, produces an effusion which seldom terminates in adhesion, as the lung is, by the surrounding stratum of air, compressed against the spine, and thus prevented from coming in contact with the parietes of the chest. The bursting of pulmonary apoplexy into the pleura has, we believe, only been known to occur in four cases, and in each of these the acci- dent was instantaneously fatal. (See Pulmonary AropLExr.) Various substances may likewise find their way into the pleura through the parietes of the chest, and by their presence give rise to empyema. Ab- scesses of the liver have been known to burst through the diaphragm into the pleura. A case of the kind is recorded by Morgagni, (Epist. xxiv. No. 4.) and another example of this morbid lesion is detailed in the Journal de Medecine. (Tom. hi. p. 47.) These may, however, be regarded as very rare cases; for when an hepatic abscess takes this direction, the inflammation which precedes its progress generally produces an adhesion between the lung and diaphragm, which prevents the es- cape of the matter into the pleura, and directs it into the interior of the lung, from whence it may be expectorated through the bronchi: two speci- mens, exhibiting this course taken by abscesses of the liver, are preserved in the museum of the Whitworth Hospital. Abscesses formed in the walls of the chest may likewise burst into the pleura, though, like those of the liver, they more frequently open directly into the lung, or point externally, and suppurate on the surface. But in order to obviate the risk of their breaking inter- nally, the safest plan is to make an early opening and let out their contents. The importance of this practical rule is well illustrated in an inter- esting case related by Dr. Duncan, in the first volume of the Medico-Chirurgical Transactions of Edinburgh, in which the disease having com- menced by the formation of an abscess in the parietes of the chest, and no external opening hav.ng been made, the pus eroded the pleura cos- ahs, en ered the cavity, excited chronic pleuritis, and at last found an exit through the lungs by a bronchial tube, establishing a communication be- EMPYEMA. 27 tween the aerial passages and the external tumour. Other remarkable examples of the danger of al- lowing these abscesses to burst internally are re- corded by Sabatier, (Medecine Operatoire, torn. ii. p. 124,) and by De Haen, in his Ratio Medendi. Hemorrhage into the thorax from wounded ves- sels is not unfrequently followed by empyema, and extraneous substances introduced through penetrating wounds of the chest, such as spiculae of bone, bullets, pieces of wadding, clothes, &c, by their presence in the pleura give rise to inflam- mation, which sometimes terminates in empyema, but more frequently in the exudation of organiza- ble matter, which forms an investment round the foreign substance, and limits its effects to the spot where it is immediately situated.* Such are the principal lesions that usually pre- cede the formation of empyema. We would here observe that a knowledge of the antecedent disease and of the symptoms preceding the effusion is often as essential towards forming a correct dia- gnosis of empyema as a knowledge of those symp- toms which denote that the effusion has actually taken place, since the distinctive characters of the affection are often more strongly marked during its earlier stages than at its termination. Thus it frequently happens that a patient presents a train of symptoms which may be referred either to hepatization of the lung or effusion into the pleura; and so closely do the symptoms and physical signs of those affections resemble each other, that it is frequently impossible to distinguish between them so long as we confine our attention to the symp- toms actually present; but if, on referring to the preceding history of the case, we find that the present symptoms were preceded by those of acute pleurisy subsequently degenerating into the chro- nic form, the difficulty of diagnosis is at once removed : unfortunately, however, the symptoms which precede effusion are in some cases as obscure as those which attend its actual formation, and hence arises the principal difficulty in detect- ing the presence of empyema. Diagnosis. — The diagnosis of empyema has been most materially improved of late years. Laennec's happy application of the principles of mediate auscultation to the diagnosis of thoracic diseases has added a new and valuable set of phy- sical signs to the symptoms of this disease pre- viously known; and the researches of modern pathologists, by reducing those symptoms to their precise signification, and assigning to each its just value as a distinctive character, have rendered the diagnosis of empyema as remarkable for accuracy and precision as it formerly was for error and obscurity. Of the symptoms hitherto enumerated by noso- lOgists as characteristic of this disease, such as " fixed pain in the chest, breathing laborious, but easiest in the erect position, difficult decumbiture on the sound side, fluctuating enlargement of the side affected, and dry tickling cough," (Good's Study of Medicine, vol. ii. p. 264,) almost all are common to it with other affections, and even of these equivocal symptoms the greater number are frequently wanting. Under such circumstances it is scarcely to be wondered at if the disease was * See on this subject, Hennen's Military Surgery, and Baron Larrey's IWumoires. constantly mistaken, or its very existence over- looked, of which so many examples are recorded in medical literature, that the only difficulty lies in the selection. From a survey of the recorded cases of empye- ma, and from our own observation, it is evident that, as empyema may exist without its character- istic symptoms, so these symptoms may exist without empyema; of which fact, indeed, the annals of surgery furnish but too convincing proofs in the numerous cases where the operation for empyema has been performed, but where no empyema existed. A remarkable case of this kind is recorded by M. Baffbs, in his inaugural disser- tation, sur I'Empycme, printed in Paris in 1814. A patient in one of the principal hospitals of that city presented a combination of symptoms which was supposed to demonstrate so unequivocally the presence of empyema that the operation of para- centesis was performed, but to the surprise of the operator no fluid was found ; however, as the existence of empyema seemed indisputable, it was resolved in consultation to make an incision into the pleura of the opposite side; the second opera- tion was attended with no better success than the first—not a drop of fluid followed the incision into either pleura. Dionis relates a similar occurrence in the case of the Duke de Montemart, who was operated on for empyema, which he had not; and he mentions another case in which a similar mis- take cost the patient his life. (Diet, des Sciences Medicates, art. Empyeme.") Willis likewise notices the occurrence of such mistakes : « Novi enim (says he) in aliquibus thoracis paracentesin et frustra et non prorsus innoxie celebratam fuis- se." (Opera omnia; de Empyemate.) These examples may serve to show the uncer- tainty which formerly prevailed in the diagnosis of empyema, and the fatal results which too often followed these errors of diagnosis; it is needless to make any additional observations to point out the great practical importance of the improve- ments which have lately been made in this depart- ment of medical science, by which we are now enabled to detect the existence of this disease in every case where its diagnosis is a matter of prac- tical utility. The following symptoms and physical signs are those most characteristic of empyema, and when they are all combined, may be considered as quite pathognomonic: — Difficult respiration, increased by motion or exertion of any kind, and considera- bly aggravated by lying on the sound side; a sense of fulness and oppression in the chest, amounting in some cases to a sense of suffocation ; enlarge- ment of the diseased side; protrusion of the inter- costal spaces, with obscure sense of fluctuation and oedema of the integuments ; dulness of sound on percussion, and absence of the respiratory murmur in the diseased side, which remains per- fectly motionless ; puerile respiration in the oppo- site lung, accompanied with violent action of the respiratory muscles ; displacement of the heart; descent of the diaphragm and consequent protru- sion of the abdomen: to these characteristic marks may be added harassing short cough, small, rapid pulse, flushed cheeks, and other symptoms of hectic fever. From this combination of symptoms, especiallv 28 EMPYEMA. when they have been preceded by those of inflam- mation of the pleura, the existence of empyema may be certainly inferred. It is, however, to be remarked, that several of these symptoms vary con- siderably, according to the extent of the effusion, and even in those cases where the quantity of effusion is the same, according to the date of its formation. Thus, when the effusion is rapidly formed, the difficulty of breathing is extreme, the accompanying fever intensely violent, and the anxiety and dread of suffocation urgent and un- ceasing : but as the disease continues, these symp- toms often assume more of a chronic character; the dyspnoea gradually diminishes, and is perhaps only perceptible after exercise or taking food; the fever likewise disappears, or is only perceptible towards evening ; and the patient, encouraged by this abatement of the symptoms, complains only of weakness, and anticipates the speedy restoration of his health and strength. But if the physical signs of the disease be had recourse to, it will be found that this alleviation of symptoms is alto- gether illusory, and that the disease, instead of re- ceding, has been steadily advancing. As, then, the most characteristic symptoms of this disease are liable to considerable modification, and as several of them are occasionally wanting altogether, it may be worth while to examine each symptom separately, to consider how it is produced, what it signifies, and what is the precise relation it bears to the disease. We shall thus under- stand the just value of each, and see how far the existence of empyema is proved in the affirmative by its presence, or in the negative by its absence; for, as it is impossible to describe every variety of combination which the symptoms of empyema may present, the only alternative is to enable the physician, by acquainting him with the precise import of each symptom individually, to form his opinion of their signification collectively in what- ever form of combination they may present them- selves. I. Dyspncca.—The difficulty of breathing ex- perienced in this disease is generally proportionate to the degree of pressure which the lung sustains, or, in other words, to the quantity of the effusion. To this general rule there are, however, numerous exceptions; indeed there is scarcely an author who has treated of this disease that does not re- count instances of patients labouring under such extensive effusion as to compress the greater por- tion of one or even of both lungs, whose respira- tion was nevertheless not in the least affected. (See, for example, Frank, de Curand. Horn. Morb. t. viii. p. 232; Duncan, Edin. Journ. loc. cit.; Andral, Op. cit. p. 240.) We must, however, suppose that the aeration of the blood is as per- fectly accomplished in those cases as when both lungs are in the free exercise of their functions, for experience has shown that sooner or later these patients lose their flesh and strength, and their lives eventually fall a sacrifice to the disease. Experience has shown that the difficulty of breath- ing is extremely urgent when the empyema is formed rapidly, but that in more chronic cases the dyspnoea is generally proportionate to the violence of the fever, and the quantity of the effusion. Some individuals, however, have their breathing much more easily affected than others, and accordingly, under apparently similar circumstances, the dysp- noea continues extremely urgent in some from the commencement of the disease to its termination ; in others, the respiration is at first greatly affected, but the dyspnoea gradually diminishes, and recurs only at intervals when the circulation is excited ; whilst in a third set, the respiration continues ap- parently unimpeded from the beginning to the end of the disease. (Andral, Op. cit.) For these reasons, and as, moreover; the symptom of dysp- noea is common to almost every affection of the lungs, it can only be used in the diagnosis of empyema as corroborative of other less equivocal symptoms. 2. Decumbency.—The difficulty which patients affected with empyema experience from lying on the sound side has been noticed by all writers on the subject since the time of Hippocrates. The cause of this symptom, which by many is con- sidered as quite pathognomonic, has been differ- ently explained by authors. Le Dran ascribes the sense of suffocation, produced by turning on the side opposite to that in which the collection of pus is situated, to the mediastinum being on a sudden loaded with an unusual weight of fluid. (Observations on Surgery, p. iii., edit. 2.) M. Richerand, on the other hand, made several experiments, by producing artificial hydrothorax, to prove that fluid contained in one side of the chest, could not, by its gravitation, displace the mediastinum, or exert any pressure on the organs contained in the opposite side, and hence argued that the difficulty of lying on the sound side arises not from the pressure of the incumbent fluids, but from the obstruction to the dilatation of the sound side, produced by placing it under the weight of the body. In opposition, however, to this ingenious rea- soning, we have direct proof of the influence of the weight of the fluid; for we find that in cases of pneumothorax with empyema the patient can generally lie on the sound side so long as the effusion is principally gaseous; but as the propor- tion of ponderable fluid increases, decumbiture on the sound side becomes impossible. In like man- ner, in cases of empyema the dyspnoea is in gene- ral greatly aggravated by lying on the sound side; but when the fluid is evacuated, the patient is im- mediately enabled to turn on the sound side, al- though the necessity for its free dilatation conti- nues as great as before—the disease being still in a state of perfect inaction. In the case of pneu- mothorax with empyema, related in the fifth vo- lume of the Dublin Transactions, in which the operation of paracentesis was performed, the pa- tient was enabled to lie on the sound side the night after the fluid was drawn off, though it was ascertained by auscultation that the side was then filled with air, and the necessitv for the free dila- tation of the sound side consequently as great as before the operation. These observations render it probable that the difficulty of lying on the sound side arises from the load which is thereby thrown on the medias- tinum, as well as from the obstruction which the muscles of inspiration experience when the side which they have to dilate is placed under the weight of the body. To avoid this incoimnience patients labourmg under effusion into the rhest EMPYEMA. 29 generally lie on the diseased side, or else on the back, with a slight inclination of the body towards that side. This latter position is the more general of the two, and is so very characteristic as to lead in some cases to a suspicion of the disease even before any farther examination has been made. This position, however, is not so constantly observed but that we meet with frequent deviations from it. When the fever has completely subsided, and the thoracic viscera have become habituated to the pressure of the effusion, the patient can some- times lie indifferently on his back or on either side ; and there are even some cases on record where the patient lay constantly on the sound side. J. F. Isenflamm relates a remarkable case of this kind, in which a patient presenting all the usual symptoms of empyema, lay generally on the right side, which for this reason was supposed to be the seat of the disease. Accordingly the operation was performed, but no pus was found. The patient died, and on dissection it was discovered that the left side was the seat of the empyema. (Versuche einer praktischen Abhandlung neber die Knochen. Erlangen, 1782.) Morgagni relates a case of this kind on the authority of Valsalva, and M. Baffos (Op. cit.) records another instance. These, however, may be considered as exceptions to a general rule, and probably depend on some adhesions which confine the effusion, and prevent its gravitating to the most dependent part of the chest. When the empyema is double, the patient can seldom he in the horizontal position, but remains constantly seated with his body inclined forward. (Andral, Op. cit.) 3. Dilatation of the side.—When we strip a patient affected with empyema, and examine his chest, we generally perceive a marked difference in the size and shape of the two sides; that into which the effusion has taken place appears con- siderably larger; and this difference, which is most evident posteriorly, is rendered still more remarka- ble by the altered position of the ribs, which con- tinue fixed immovably in the position they naturally occupy during full inspiration, and contrast strongly with the increased motion of the ribs of the oppo- site side. The intercostal spaces are also remarka- bly wide, and in some cases, especially in thin persons, project beyond the level of the ribs: this latter sign is of considerable importance, as it serves to distinguish empyema from hepatization of the lung or enlargement of the liver. The increased size of the diseased side is in general very perceptible to the eye when it amounts to five or six lines: it seldom exceeds an inch and a half; but in Dr. Croker's case, already alluded to as having had seven imperial quarts of pus drawn off at one time, the difference amounted to three inches and a half. The most accurate way of ascertaining whether any and how much dilata- tion exists, is by measuring both sides with a tape carried from a central point in the sternum under the mamma to the spinous process of the corre- sponding vertebra. The xiphoid cartilage fre- quently deviates from the median line, and is there- fore an improper point to measure from: it may be also well to observe that the right side of the chest is generally some lines larger than the left, Drobably from the greater development of the pectoral muscles of that side. Another cause which might lead to erroneous conclusions from the measurement of the thorax is, that in those cases of empyema where absorption takes place to.a cer- tain extent, the parietes of the chest fall in as the effusion is removed: in this way the diseased side comes to measure less than the other ; and if the thorax were measured for the first time under those circumstances, the sound side would appear comparatively dilated, and might be mistaken for the seat of the disease. This error would, how- ever, be at once rectified on applying the stetho- scope. In deformed persons it is impossible to draw any inference from measurement of the thorax, and in fat persons, especially in females, the results are often very unsatisfactory. To sum up — dilatation of the diseased side may be con- sidered as one of the most valuable symptoms of empyema; but it is frequently wanting even in those cases where the effusion amounts to several pints; and as it may proceed from various other causes, such as pneumothorax, emphysema, and enlargement of the liver, so it cannot be relied on as a single symptom, though in combination with others it is a most valuable diagnostic mark of the disease. It should also be recollected that the diameter of the diseased side may be less than that of its fellow in consequence of the partial absorp- tion of the effusion; indeed this case is by no means uncommon. 4. CEdema of the side.—OZdema of the integu- ments of the diseased side, extending sometimes to the arm and side of the face, is an occasional but no means a constant symptom of empyema; it sometimes occurs at an early stage of pleurisy, accompanied with pain and tenderness in conse- quence of the inflammation extending to the superjacent parts, and in some instances does not make its appearance before the last stages of the disease. Purple ecchymosed spots have also been observed on the most dependent part of the thorax. They are said to occur chiefly when the effusion is composed of blood. 5. Fluctuation.—This can sometimes be felt, in very thin subjects, through the intercostal mus- cles. In a patient who was recently operated on in the Richmond Hospital in Dublin, it was very evident. It is one of the least fallible signs of empyema, but yet should not be trusted to exclu- sively, as abscesses occasionally form in the parietes of the chest, which yield a similar sensation to the finger. In November, 1830, a subject was placed on the table in the dead room of the W'hitworth Hospital, with considerable enlargement of the right side, and distinct fluctuation in the intercos- tal spaces. On removing the integuments, we discovered that both the enlargement and the fluc- tuation were caused by an enormous abscess of the liver, which had made its way through the diaphragm near its anterior attachment to the ribs, and had thence poured its contents into the cellu- lar tissue which invests the muscles on the side of the chest, and thus produced the sense of fluc- tuation so distinctly felt between the ribs. A case nearly similar is recorded by Morand, who per- formed the operation of paracentesis between the third and fourth false ribs, in a case which ho supposed to be empyema from the oedema of the integuments and deep-seated fluctuation; but \\c 30 EMPYEMA. found to his surprise that the chest was perfectly j sound, and that the pus which was situated in front of the pleura came from an abscess in the liver. (Richter, Chir. Bibl. t. iv. p. 146.) We have likewise heard of an encephaloid tumour, projecting between the ribs, having been mistaken for a case of empyema pointing externally, and opened accordingly. These examples are sufficient to show the im- portance of carefully examining every symptom of the disease, instead of trusting exclusively to any one sign, however unequivocal it may appear. Fluctuation is much more frequently perceptible through the intercostal spaces when the empyema is circumscribed, than when the fluid is effused into the general sac of the pleura ; in the former case it not unfrequently points externally, and by its rupture affords an exit to the encysted matter. When these fluctuating tumours communicate with the bronchi through the substance of the lungs, they usually acquire an emphysematous feel, as in the remarkable case related by Dr. Duncan, in which several tumours of this descrip- tion were formed over the surface of the diseased side. (Medico-Chirurgical Transactions of Edin- burgh, vol. i.) 6. Mgophony. — The peculiar modification of the voice, termed a?gophony, scarcely deserves to be enumerated among the signs of empyema, as it is only heard in those cases of effusion where the fluid interposed between the surface of the lung and the interior of the chest forms a thin layer of only a few lines in thickness. Whenever the effusion exceeds this quantity, the aegophony invariably ceases ; and hence it is seldom audible in empyema, where the effusion is generally very extensive, and accumulates in the most dependent part of the chest, instead of forming a thin layer over the surface of the lungs, as in cases of recent pleurisy. Whenever, therefore, sgophony con- tinues to be heard in cases of chronic effusion accompanied with cough, difficulty of breathing, and hectic fever, we may infer with tolerable cer- tainty that the empyema constitutes an inconsi- derable part of the disease, and that tubercles, or some other morbid structure, are formed within the chest. 7. Fluctuation on succussion.—The sound of fluid splashing within the chest, similar to that produced by agitating a cask partly filled with water, may sometimes be heard on applying the car to the chest while the body of the patient is gently shaken. This sound has generally been described as the most pathognomonic sign of em- pyema, but as it never occurs except when the pleura contains air as well as fluid, it should more properly be considered as a symptom of the em- pyema being complicated with pneumothorax, and consequently as affording a more unfavourable prognosis, especially where the pneumothorax proceeds, as it most commonly does, from the rupture of a tuberculous abscess in the lung. (See Pveimothorax.) 8. Dull sound on percussion. — When we em- ploy percussion over the chest of an individual labouring under empyema, the difference of sound elicited from the healthy and the diseased side is very striking, the former being clear and hollow, while the latter is as dull as if it were the thigh that had been struck. When the effusion is so extensive as to occupy the whole side of the chest, the sound is perfectly dull all over that side, unless in those parts where the lung is retained in contact with the chest by old adhesions. When the effusion only occupies the lower part oi the chest, the dulness of the sound is confined to that region ; and in cases of circumscribed empyema the dull sound corresponds exactly to the surface of the effusion, if the fluid be in contact with the costal pleura; but when it is confined between the lung and mediastinum or diaphragm, or be- tween two adjoining lobes of the lung, the sound on percussion is seldom appreciably altered, and hence the diagnosis of these affections is often extremely difficult. 9. Absence of the respiratory sound. — Over the same extent of surface, and for the same reason that the sound on percussion is rendered dull, the respiratory murmur is totally extinguish- ed. This absence of the natural sound is in general very apparent, and is among the most constant of all the physical signs of empyema. There are, however, some sources of fallacy in the evidence furnished by the state of the respiration in this disease, which it is important to be acquainted with. In some cases where the respiratory mur- mur is completely extinct, the air still continues to enter the bronchial tubes, though it cannot penetrate into the cells, and thus bronchial respi- ration may be heard over the situation which the condensed lung occupies ; and if the bronchial tubes be obstructed with mucus, the different varieties of mucous rattle may likewise be heard in the same situation. Another circumstance calculated to mislead is, that the puerile respira- tion of the sound side is sometimes transmitted along the parietes of the diseased side, and may thus lead the auscultator into the erroneous sup- position that respiration was going on in the dis- eased side : this error may in general be avoided by observing, that the intensity of the respiratory murmur gradually diminishes as the stethoscope is removed from the sound side ; and this criterion will be still farther confirmed by examining the ribs of the diseased side, which will be found in a state of inaction, if the respiratory murmur be really transmitted from the opposite side. Another source of error, still more calculated to convey a false impression of the true nature of the disease, arises from the lung being retained in contact with the parietes of the chest by old adhesions. In such cases the effusion cannot insinuate itself between the chest and the surface of the lung, so as to compress its substance or mask its sounds; and hence the respiration continues to be heard, more or less plainly, over an extent of surface corresponding to the internal adhesions; most commonly the lung is attached at its upper lobe, more rarely at its lower, and in some instances the attachment extends vertically from the apex to the basis. These extensive adhesions consti- tute one of the most perplexing obstacles to the detection of this disease. Whenever respiration is suspended in one lung, the other, if free from disease, invariably takes on a compensatory in- crease of action, and the respiration becomes EMPYEMA. 31 puerile : this phenomenon is therefore of consi- derable importance, as it announces the ineffi- ciency of the opposite lung. 10. Displacement of the heart.—The science of morbid anatomy furnishes numerous examples of the strongest membranes yielding to the appli- cation of constant and gradually increased pres- sure ; in empyema, and likewise in pneumotho- rax, the mediastinum yields to the distending force of the accumulated fluid, and allows the heart to De displaced by its pressure. When the left side is the seat of the effusion, the heart is thrust from its natural situation, either down into the epigas- trium, where it may be seen and felt pulsating, or over to the right of the sternum, where its pul- sation is sometimes so strong as to attract the at- tention of the patient. When the effusion is in the right side, the change in the heart's position is not in general so remarkable; but by careful examination with the stethoscope, it will generally be found to pulsate considerably to the left of its natural situation. In two cases, one of which we have already alluded to as having been lately ope- rated on for empyema, the apex of the heart was distinctly felt striking against the stethoscope be- tween the fourth and fifth ribs in the left axilla. As, then, displacement of the heart is constantly produced by effusion into either sac of the pleura, and seldom if ever arises from any other cause, it may be considered as the most constant and least equivocal of all the signs of effusion, and, when joined with other symptoms and physical signs of empyema, may he regarded as quite pa- thognomonic. 11. Depression of the diaphragm.—The dia- phragm in like manner yields to the pressure of the incumbent fluid, and descends into the abdo- men, thrusting the abdominal viscera before it. When the right side of the diaphragm is depress- ed, the liver is protruded beyond the margin of the ribs, and has even been felt so low as the iliac fossa, (Stoll, Ratio Medendi.) Such cases have repeatedly been mistaken for enlargement of the liver. Of this a remarkable instance has been recorded by Roux, in a memoir appended to the third volume of Desault's works, where, in a case pronounced by one of the most eminent medical men in Paris to be an incurable enlargement of the liver, the true nature of the disease was dis- covered by Bichat, who performed the operation of paracentesis thoracis, and thereby saved the patient's life. 12. Abdominal pressure.—Another test of the existence of pleuritic effusion imagined by Bichat, and described by Roux in the memoir just quoted, is the effect of pressure on that side of the abdo- men where the effusion is suspected to exist. According to those celebrated anatomists, pressure exerted on that side of the abdomen correspond- ing to the empyema, thrusts the diaphragm and the fluid which rests on it up into the thorax, and thus, by increasing the pressure of the effusion on the lung, produces an insupportable sense of suffocation. In those cases where we have em- ployed this test, the result was the very opposite of that above stated ; for while no uneasiness was produced by pressing up the diaphragm into that side where the effusion exiited, any attempt to stop the free motion of the diaphragm at the other side, where alone respiration was still carrried on, was most distressing to the patient. The same observation*has likewise been made by M. Cho- mel, (Dictionnaire de Medecine, Art. Pleurisie.\ 13. Cough and Expectoration. — The cough in empyema is generally short and single, and when there is no accompanying bronchitis, is often wanting altogether. If there be any expec- toration it is generally catarrhal, unless when a communication is established between the bronchi and the fluid effused in the pleura; in which case the quantity of matter expectorated is sometimes so great as to threaten suffocation. This, however, can only occur when a large communication is suddenly formed, and opens directly into one of the principal bronchi; but in those cases where the rupture is small and communicates only with the lesser bronchi, the evacuation of the fluid must go on slowly and by small quantities at a time. In such cases it is often difficult to deter- mine the source of the expectoration : some wri- ters describe it as possessing a peculiar fetor which is quite characteristic. Laennec compares the smell to that of gangrene. (Page 447.) Profes- sor Nespoli to the smell of assafoetida, " ma assai piu di questa penetrante e acido." (Discorso, &c. Firenze, 1825.) Some have compared this odour to garlic, some to that of phosphoretted hydrogen, and others to other ill smells. (Dr. Forbes's Note to Laennec, p. 447.) But as these, fetid smells have all been observed in the expectoration of gangrene, and even of simple bronchitis, too much importance should not be attached to this sign; more particularly as in many cases of fistulous communication between the pleura and bronchi no such fetor has been observed. When, however, this appearance of the expectoration is accompa- nied with a marked improvement of other symp- toms, and with a diminution in the diameter of the dilated side, we may conclude that a commu- nication with the bronchi has been formed ; and this diagnosis will be still farther confirmed if the signs of pneumothorax supervene in consequence of the atmospheric air entering through the com- munication. 14. Fever. — The febrile symptoms which accompany this disease vary considerably, accord- ing to the constitution of the individual and the progress of the effusion : ttius, while acute empye- ma is usually accompanied with rapid pulse, burn- ing heat of skin, and other symptoms of the highest degree of febrile excitement, the more chronic forms of the disease often present no other symptom of fever than a slight acceleration of the pulse towards evening, or after taking food ; and the patients sometimes even snjoy a state of perfect apyrexia. It has been remarked by Broussais, and the observation has been confirmed by Andral. *hat the hectic of empyema is never accompanied with profuse night-sweats, unless when tubercles are developed in the lungs or in the false membranes of the pleura. Another peculiarity in the hectic of empyema, according to Broussais, is, that the pulse generally returns to its natural frequency after rest, particularly after a night's rest; whereas, in the hectic of phthisis, the pulse seldom oj never comes down to its natural standard. The same author likewise states that in the hectic of 32 E M P Y E M A empyema there is scidom any flushing of the cheeks, unless when the difficulty of breathing is very great, in which case the face and lips present a bluish tint and congested appearance, arising no doubt from the deficient aeration of the blood; whereas in phthisis the circumscribed flushing of the cheeks contrasts strongly with the marked paleness of the rest of the countenance. When- ever, therefore, the hectic fever of empyema pre- sents the symptoms just described as appertaining to the hectic of phthisis, we may conclude that the effusion is probably complicated with tubercles in the lungs, or in the false membranes of the pleura. From these observations it appears, that although there is no one symptom or physical sign which, taken singly, can be considered as pathognomonic; yet, from the combination of these symptoms with the physical signs derived from auscultation and percussion, the presence of empyema may be inferred almost with certainty. It must, however, be admitted that we occasionally meet with cases in practice in which it is ex- tremely difficult to ascertain the existence of effu- sion. This difficulty, in some instances, depends on symptoms being present which appear incom- patible with the presence of effusion, and in others on the only symptoms present being com- mon to empyema with other affections, and con- sequently insufficient to decide the true nature of the disease. To the former class belong those cases of em- pyema in which the lung is extensively attached to the costal pleura, and those of circumscribed effusion situated in the interior or bottom of the chest; in both of which cases, contrary to what usually occurs in empyema, the respiration con- tinues audible, and the sound on percussion is little if at all affected. The diagnosis of these cases has already been the subject of considera- tion. The diseases which from the similarity of their general symptoms and stethoscopic phenomena are most liable to be confounded in practice with empyema, are tubercular consumption, hepatiza- tion of the lung, the development of morbid growths in the pleura, and, when the disease is at the right side, enlargement of the liver. We shall now offer a few remarks on the dis- tinctive characters of these different affections. 1. Tubercular Consumption. — The general symptoms of phthisis and empyema are sometimes so precisely similar as to have deceived even the most experienced practitioners. The stethoscopic phenomena of these diseases are, however, so very characteristic, that it is scarcely possible now to confound them. In the first stage of phthisis, when the tubercles are in their crude state, the respiratory murmur is seldom if ever so completely suppressed as in empyema. In the former disease the absence of respiration first commences, and is always most marked, in the upper lobe, and in the latter in the lower lobe. At a more advanced stage, when the tubercles' are softened, the charac- teristic signs of pectoriloquy, mucous rale, and guggling cough, at once point out the true nature <>{ the disease, and prevent the possibility of mistaking it for empyema. 2. Hepatization of the Lung.—Owing to the similarity of the stethoscopic phenomena which hepatization presents, it is much more likely to be confounded with empyema. The following signs will, however, seldom fail to enable the physician to distinguish these diseases. In hepatization the antecedent symptoms are those of the first stage of pneumonia, and the cough is usually attended with characteristic viscid sputa; the respiration is never totally suppressed, but its place is supplied by strong bronchial respiration and resonance of the voice; the side is never enlarged ; the inter- costal spaces are never protruded; and the heart is never displaced ; either of these symptoms occurring, will, therefore, at once decide in favour of empyema. To these distinctive characters we may add that chronic empyema is, comparatively speaking, a disease of common occurrence; whereas chronic hepatization is an affection so rare, that Laennec commences his chapter on the subject by questioning the reality of its existence. This opinion is confirmed by the experience of Andral, who states (Op. cit.) that of one hundred and twelve cases of pneumonia treated in La Charite only one exceeded thirty days, or could be regarded in the light of a chronic disease. Chomel and Louis likewise concur in describing chronic peripneumony as one of the rarest forms of pulmonary disease. 3. Tumours in the sac of the Pleura.—The same remark is likewise applicable to the develop ment of those tumours in the pleura which com press the lung and occupy its place. A remarka- ble case of this kind is related by Corvisart in the " Bulletins de la Faculte de Medecine." The patient's symptoms were such as to lead this accurate observer into the belief that the disease was empyema; but, on dissection, he was sur- prised to find instead of pus a solid substance answering to Laennec's description of enctpha- loide, occupying the entire of the left side, the lung having, as he describes it, totally disappeared. An analagous case is recorded by Boerhaave, as occurring in the person of the Marquis de St. Auban. (Zimmerman, Traite de 1'Experience.) M. Recamier found in the body of a patient whom he considered as affected with empyema, one side of the chest entirely filled with a mass of tuber- culous matter. A still more remarkable example of this disease is recorded by Laennec (Op. cit.), to whom it was communicated by M. Cazol. 4. Enlarged Liver.—The last disease which we shall enumerate as liable to be confounded with empyema is enlargement of the liver. This viscus is sometimes so much increased in size as to ascend into the thorax, and compress the lung into the upper and back part of the chest. In such cases the sound on percussion is as com- pletely dull, and the respiratory murmur as per- fectly extinct, as in empyema. Neither is the diag- nosis always facilitated by referring to the earlier symptoms of the disease, as empyema is often ushered in with the same dull pain in the hypo- chondnum that usually attends hepatic disease; and the projection of the liver beyond the margin of the ribs may proceed either from enlargement of that organ, or from its being thrust down by the pressure of the superincumbent fluid. Such are the principal points of similitude between these diseases, which have frequently imposed on EMPY the most experienced practitioners, but which it is of the greatest importance to distinguish, as is ex- emplified in the case already quoted from the me- moir published by Roux, where the life of the pa- tient supposed to be labouring under incurable disease of the liver was saved by the operation for empyema, which the accurate discernment of Bi- chat discovered to be the real disease. It is only necessary to allude here to the possibility of mis- taking these diseases one for the other, as it sel- dom happens that their diagnosis is not rendered sufficiently easy by the presence of some equivo- cal symptom, either of hepatic disease or of em- pyema. Prognosis of Empyema.—The prognosis in this disease is generally unfavourable, as by far the greater number of cases terminate fatally, what- ever treatment is adopted. But as empyema is ■ more properly the termination of a pre-existing disease than a primary or specific affection, it is impossible to form a correct prognosis of its proba- ble termination in any given case without taking into consideration the character of the pre-existing disease and the condition of the lung and pleura, as well as the amount of the effusion and the pos- sibility of its removal ; for on these circumstances the issue of the case principally depends. Thus, for example, white the empyema produced by the rupture of a tuberculous abscess in the lung has never, as we believe, been known to terminate otherwise than in death, the empyema which suc- ceeds to penetrating wounds of the chest has in a great number of cases terminated favourably. (See Baron Larrey's Memoire sur les effets de I'opera- tion de l'empyeme, Chirurgie Militaire.) In the former case the effusion is produced by, and com- plicated with an incurable affection of the lung, white in the latter it is unconnected with any or- ganic disease of the thoracic viscera. In acute empyema, when the effusion increases rapidly, and is accompanied with great difficulty of breathing and febrile excitement, the disease may prove fatal by suffocation during the acute stage, or, as more frequently happens, may de- generate into the chronic form. In chronic empyema, whether proceeding from acute or chronic pleurisy, the termination of the disease, when abandoned to the resources of na- ture, is almost invariably fatal; though, if we could place implicit confidence in the representa- tions of the older writers, it would appear by no means uncommon that it should terminate by ab- sorption, or even by critical evacuation. Billard states that a case of empyema, on which he was on the point of operating, terminated favourably by a critical sweat, produced and kept up by the internal use of the acetate of ammonia, which he therefore recommends as a most efficacious reme- dy in this disease. (Dictionnaire des Sciences Medicates, Art. Empyeme.) The effusion of em- pyema has also been stated to have passed off, by metastasis, from the intestinal canal, from the bladder, from the vagina; and is said in» one in- stance to have vanished on the eruption of a sca- bies. (Good's Study of Medicine, vol. 2.) Dr. Darwin relates the following extraordinary in- stance of recovery from this disease:—A servant man, after a violent peripneumony, was seized with symptoms of empyema, and it was determin- Vol. II—5 E M A . 33 ed after some time to perform the operation : this was explained to him, and the usual means were employed by his friends to encourage him, by advising him " not to be afraid," by which good advice he conceived so much fear that he ran away early next morning, and returned in about a week quite well. Without, however, incurring the imputation of scepticism, we may perhaps be permitted to doubt the accuracy of these observa- tions, and to question whether the disease thus marvellously cured had ever existed, especially as we have seen how very inadequate the means of ascertaining the existence of the disease were in those days. Of eighteen cases of chronic pleurisy record- ed by Broussais in his " Histoire des Phlegma- sies Chroniques," only one ultimately recovered. Laennec likewise states that the disease has sel- dom any natural tendency towards resolution, and this statement has been so fully confirmed by the experience of modern physicians, that doubts are now very generally entertained whether the fluid is ever removed by absorption in cases of genuine empyema; and, accordingly, it has been recom- mended on high authority, that the operation of paracentesis should be performed as soon as ever the presence of empyema can be ascertained with certainty, "In tali casu," says Willis, "phar- macia haud multum opus erit, sed tantum corpore preparato illico ad lateris apertionem procedatur. (De Empyemate, p. 97.) But although the instances of recovery from this disease by the absorption of the effusion are not sufficiently numerous to inspire us with much confidence in the efficacy of the remedies usually employed for that purpose, still there are a suffi- cient number of well-authenticated facts to prove the possibility of the disease terminating in this favourable manner, and, consequently, to establish the propriety of trying the effect of appropriate remedies before having recourse to the operation, unless in those cases where the effusion is so ex- tensive as to preclude all reasonable prospect of its absorption, or the symptoms of suffocation so urgent as to require the immediate evacuation of the fluid. Treatment.— In order to promote the resolu- tion of this disease, the first object of medical treatment should be to moderate any febrile excite- ment which may arise, as experience has fully proved that a state of perfect apyrexia is the most favourable condition for the absorption of the ef- fusion ; for this purpose it is seldom necessary to have recourse to general blood-letting, unless in cases of internal hemorrhage. Cupping over the part or leeches may occasionally be applied with advantage when an exacerbation of the pain and other symptoms indicates the supervention of a fresh attack of inflammation on the diseased sur- face ; but a rigid enforcement of the antiphlogis- tic regimen will be found the most effectual method of subduing the fever. " This point is of such paramount importance," says M. Broussais, " thai I regard it as the basis of the treatment in all those chronic affections of the chest which are sufficiently violent to excite fever; indeed, tho physician cannot be too strongly impressed with the idea that, so long as any fever continues, the more his patient eats the shorter time he Uvea 34 EMPYEMA. and that by lowering his diet he will take a more prompt and effectual method of removing the fe- brile paroxysms than by repeated bleedings, or by covering his chest with blisters." (Phlegmasies Chroniques, vol. i. p. 355.) These observations are particularly applicable to those paroxysms of fever which supervene during the course of chronic pleurisy : for so long as they continue, any at- tempt to repair the strength by the use of nutri- tious diet will only aggravate the fever and in- crease the consequent debility. When, however, the fever subsides, it is of the greatest importance to support the patient's strength by the use of light nutritious diet, and even by the administra- tion of tonics and stimuli when required, taking care, however, to avoid pushing the tonic treat- ment so far as to reproduce fever. At the same time, the absorption of the fluid may be promoted by increasing those natural discharges of which nature sometimes avails herself, as of so many emunctories, for the evacuation of internal suppu- rations, and by exciting artificial discharges from the surface by the use of counter-irritants and de- rivatives. Purgatives, according to Laennec, to be useful, ought to be pretty frequently repeated. They are particularly indicated subsequently to blood-let- ting, when the abundance of the effusion, or the rapidity of its formation, and the general symp- toms, give reason to presume that the pleurisy is hemorrhagic. On the same authority, diuretics are said to have no evident effect upon the absorption, unless they are given in larger doses than is customary. He was in the habit of carrying the acetate of potass to the extent of six drachms or even of two ounces in the day, and gave nitre in doses of from forty grains to three or four drachms if the patient bore it well. With this latter Laennec sometimes combined sal ammoniac, according to the method of Triller, and also gave with advan- tage the extract of squills, as recommended by Quarin, in a minimum dose of two grains every three hours. (Dr. Forbes's Translation of Laen- nec, p. 473.) Diaphoretics and expectorants have likewise been found serviceable in some instances, and may therefore deserve a trial, especially in those cases where the efforts of nature manifest any tendency to produce a critical evacuation by dia- phoresis or expectoration, in which case the pro- priety of promoting the discharge established by nature is manifestly indicated. So long as any fever is present, counter-irritants of any kind should be employed with the greatest caution; but when the febrile symptoms subside, a large blister may be applied with advantage over the affected side, and kept open for several days, provided it does not produce much constitu- tional irritation. If the effusion does not dimin- :sh under this treatment, it will be advisable to heal the blistered surface and try the effect of a different kind of counter-irritant; for this purpose setons or caustic issues may be used, but, in order to produce any decided effect, they should be kept discharging foi a considerable length of time. The use of the moxa is strongly recommended by Baron Larrey, who states that he has seen it act rnost beneficiallv as a revulsive in several cases of Observations sur les Effets de empyema. (Sec Moxa, in the Jourrial Complcmentaire, torn, v.) The actual cautery is another powerful revulsive, which was much employed by the older surgeons, who seem to have frequently had recourse to it with decided benefit as a means of establishing a counter-irritation and derivation from the diseased pleura. There is another mode in which the efforts of nature occasionally effect a cure in this disease, namely, by the formation of a fistulous passage through the lungs or through the walls of the chest, which serves as an outlet to evacuate the matter contained within the pleura. This spon- taneous evacuation of the matter of empyema occurs chiefly, if not exclusively, in those cases where the empyema is circumscribed, and the fluid is prevented from escaping laterally by adhe- sions. When no such adhesions exist, the fluid, having full liberty to accumulate within the chest, seldom points externally ; and, accordingly, it is extremely rare to find any appearance of erosion or ulceration in the costal or pulmonary pleura when the effusion occupies the general sac of the pleura, though such appearances are by no means uncommon when the effusion is circumscribed. Laennec states that the spontaneous evacuatioi of the matter of empyema is more frequently ef- fected by rupture into the bronchi than by ulce- ration through the walls of the chest; but in com- paring the records of those cases which have been published in this country as well as in France, it appears that their comparative frequency is pretty nearly equal. When the matter bursts into the bronchi, the communication is generally formed by the detach- ment of a gangrenous eschar, or by erosion and ulceration of the pleura and pulmonary substance. The passage thus formed is usually lined with an adventitious membrane, which prevents the matter from infiltrating the tissue of the lung, and con- ducts it directly into the bronchi, from whence it is subsequently removed by expectoration. Many instances of this mode of the escape of pus are on record. Dr. Forbes met with a case of this kind, and has had several undoubted instances re- lated to him by practitioners. (Op. cit.) Brous- sais gives two cases of gangrenous perforation of the pleura pulmonalis, and another in which the communication seems to have taken place from simple; ulceration. Le Dran met with four cases in which the disease terminated in this way. A case of rupture of a circumscribed empyema into the bronchi, followed by a copious expectoration of fetid matter, lately fell under the observation of the writer of this article. Laennec also has seen the effusion of chronic pleurisy burst into the bronchi, and Andral observed a similar occurrence in a case of acute empyema. Several other cases may likewise be found in the periodical literature of this country. When the empyema is about to make its way outwards through the parietes of the chest, the escape of the matter is usually preceded by the appearance of a soft, doughy, inelastic swelling of the integuments, which generally advances in the course of a few days, so as to form a distinct fluctuating tumour, and either breaks spontane- ously, or else requires an artificial opening to be EMPY made through the integuments, in' order to give issue to the matter contained underneath. This ulcerative process generally commences in the costal pleura or in the false membranes with which it is lined, and passes in succession through the superincumbent parts; sometimes, however, it commences by the formation of an abscess in the walls of the chest, which, bursting both externally and internally, forms a fistulous passage for the escape of the contained fluid. Instances of this termination of empyema are to be found in the writings of almost every author who has treated on this subject. Andral gives three cases in which the matter made its way through the inter- costal spaces, and a fourth in which it perforated the diaphragm. Several similar cases are recorded in lie Dran's observations, and in other works on surgery. The escape of the matter either through the bronchi or through the walls of the chest is gene- rally followed by immediate relief of all the most urgent symptoms, and in some cases the fistulous passage soon ceases to discharge, and cicatrizes; but in other instances the fistula remains open for several months, or even years, and continues to discharge a greater or less quantity of matter, until the suppurating surface gradually diminishes, and becomes at length obliterated by the cohesion of the walls of the abscess. Sometimes, however, the evacuation of the matter, so far from produc- ing any alleviation of the symptoms, seems only to aggravate the disease and accelerate its fatal termination. (See the seventeenth case in the se- cond volume of Andral's Clinique Medicate.) In some cases the formation of one outlet is fol- lowed by the formation of several others in suc- cession, as in a remarkable instance published by Dr. Duncan, in the 28th volume of the Edinburgh Medical Journal. A still more remarkable case of this kind is related by Dr. Betty, in the London Medical Repository for March, 1823. This successive formation of several outlets for the evacuation of the matter of empyema occurs chiefly in those cases where the matter is confined in distinct compartments, having no communica- tion one with the other, and, consequently, requir- ing each a separate outlet for the evacuation of its contents. A second orifice is also occasionally required when the outlet first formed is situated in the upper part of the chest; for in such cases that portion of the fluid which stands below the bed of the outlet has no means of escaping unless by the formation of another passage in a more dependent situation. Paracentesis.—When, however, as too often happens in this disease, there exists no reasonable prospect of the effusion being removed by absorp- tion, or evacuated by the efforts of nature, there yet remains the alternative of making an opening into the chest, and thus creating an artificial out- let for the discharge of the matter. This consti- tutes the operation of paracentesis thoracis, or, as it is sometimes called, the operation of empyema. This operation is at all times easy of execution, productive of little pain to the patient, generally followed by immediate relief, and has in nume- rous instances been crowned with complete suc- cess. Sprengel, in his erudite work on the his- tory of medicine, enumerates amongst the advo- EMA. 35 cates of this operation the names of almost all the most distinguished medical and surgical writers, from Hippocrates downwards, many of whom from their writings appear to have practised this operation with a degree of confidence and success unknown at the present day. The same work likewise contains brief notices of such a vast num- ber of cases in which the result was favourable, as are more than fully sufficient to establish the fre- quent success of this operation. If, however, we reflect that empyema is gener- ally the effect of a pre-existing disease of the lungs or pleura, and that the effect of the operation is merely to remove the effused fluid, while the dis- ease of the solids still remains behind, we must be prepared to expect that this operation should often fail of success. Another cause of the failure of this operation is the condensed condition of the lung, which, from long compression, has lost its expansibility and elasticity. In consequence of this it slowly regains its natural dimensions; and in some cases the un- folding of the lung is still further opposed by the formation of false membranes on its surface. The space thus left between the lung and the walls of the chest by the evacuation of the fluid is filled with atmospheric air, which rushes in through the wound, and excites a purulent discharge, so copious as to exhaust the patient's strength, while the inflammation it causes in the suppurating sur- face cannot produce the obliteration of the cavity, the parts being still too far apart to be aggluti- nated. It sometimes happens, also, that the operation is followed by the decomposition of the matter discharged from the wound, which assumes a dark ichorous appearance, and exhales an odour insupportably fetid. This alteration in the sensi- ble qualities of the secretion is generally attributed to the irritating effects of the atmosphere on the imperfectly organized membranes with which the pleura is lined. These considerations should certainly make us cautious in having recourse to the operation so long as there remained a reasonable prospect of the fluid being removed by other means, but should not deter us from the practice in those cases where other remedies had been tried and found ineffectual, or where the urgency of the symptoms precluded all reasonable prospect of relief from their use. In such cases the sooner the operation is had recourse to the better; for, as Willis tritely observes, " dummodo vires consta- bunt prsestat remedium anceps experiri quam nullum." (De Empyemate, p. 97.) Our greatest modern authority on the subject of pulmonary diseases, Laennec, was a great advocate for the performance of the operation. (See Translation, p. 191.) Notwithstanding these strong attestations in its favour, the operation has latterly fallen very much into disuse, as much, perhaps, from the uncer- tainty of the signs of empyema as from any expe- rience of its general inutility or danger. Now, however, that the diagnosis of this disease no longer presents the same difficulties as it did xor- merly, and that we are enabled to recognize at any early period of their progress, those casea which may be benefited by the operation, ant! 36 EMPYEMA. thereby have it in our power to operate early, and consequently with better chance of success, it is probable that the operation will be employed more frequently and more successfully than it has hitherto been.* Within the last year the opera- tion has been twice performed by the advice of Dr. Marsh, of Dublin, and in both instances the success of the operation has been complete. Dr. Crampton, and Mr. Crampton, the surgeon-general of Ireland, have also communicated to the writer the particulars of three cases from their practice, in which the operation was equally successful. The result of these cases is highly favourable to the more general adoption of the practice, and fully confirms the observation of a modern author, " that it is a measure which has frequently proved successful, and that too in a disease which is gen- * We learn that in London the operation has been repeatedly performed, more particularly under the direc- tion of Dr. Thomas Davies. Fur the following tabular view we are indebted to the kindness of that intelligent physician, by whose advice the operations were per- formed. Dr. Davies has requested us to state that five of the cases belonged to Dr. B. Babington, and one to Dr. Stroud; Dr. Davies was only called into consultation by these gentlemen. Nature of the case. Empyema Operator. Pneumotho- rax, with effusion .. !Mr. Stukely, late Apothecary to the Infirmary for Dis- eases of the lungs I Mr.Martin,Surgeon, | R.N............. Mr. Headington...... Mr. John Scott....... Mr. Herring, Apothe- cary to the Infir- mary for Diseases of the Lungs ..... Mr. Kiernan ......... Dr. B. Babington ..... Mr. Skey ...'.......... Total Empyema • ■ Mr. Headington ...... Mr. John Scott....... Mr. Kiernan......... Mr. Smith ........... Total pneumothorax .. Event of the cases. Hydrothorax . -. » » Total hydrothorax .. - 3 Grand total Number of cases .... 23 Notes by Dr. Davies. — 1. The result of the operation in the cases of empyema is very satisfactory ; eight of the patients out of ten having recovered. Of these, five were under six years of age, one was between eighteen and nineteen, and two were above twenty-five. 2. All the cases of pneumothorax were complicated with tubercular diseases of the lungs, a circumstance whiih, of itself, precluded a favourable result. All the patients were beyond twenty years of age. 3. All the cases of hydrothorax were the consequences of disease of the heart. Although none of the patients recovered, they were all relieved by the operation for a i:orsiderable time.—Editors. erally, if not always, beyond the influence of me- dicine, and too often beyond the power of nature to remove." (Forbes's Original Cases, &c, p. 258.) There are two cases in which this operation is particularly indicated :— 1. In acute empyema, when the breathing is extremely oppressed, and the effusion goes on rapidly increasing. In this form of the disease, however, it is always advisa- ble, if possible, to defer the operation until the inflammatory symptoms shall have subsided, as it will be of little advantage to evacuate the con- tents of the pleura so long as that membrane con- tinues in such a state of inflammation as to re- produce the effusion. When, however, the diffi- culty of breathing is so great as to render the immediate performance of the operation necessary in order to prevent the risk of suffocation, it is probable that this object may be sufficiently at- tained by making small punctures with a trochar from time to time, when the breathing becomes much oppressed, and drawing off only so much fluid as is necessary to diminish the pressure ex- ercised by the effusion on the opposite lung. By operating in this way the breathing will be imme- diately relieved, and the danger avoided of admit- ting the atmospheric air into contact with an already highly inflamed pleura. Perhaps, too, this partial abstraction of the effusion may at once aid the absorption and accelerate the conversion of the false membranes; such, at least, is the opinion of Laennec, (Op. cit.) When acute empyema succeeds to penetrating wounds of the chest, it is advisable not to operate before the orifices of the wounded vessels are so firmly closed as to prevent any danger of a recur- rence of hemorrhage; for this reason Baron Lar- rey recommends that the operation should not be performed in such cases before the seventh, or deferred after the eleventh, or, at the farthest, the fourteenth day. 2. The second case in which this operation is particularly indicated, is in those cases of chronic empyema where the ordinary means for promot- ing absorption have been tried and found ineffec- tual. In such cases it is impossible to lay down any general rule as to the precise period at which the operation should be performed, as that point must be determined by the state of the constitu- tion, the urgency of the symptoms, and the extent of the effusion, rather than by the date of its for- mation. So long as any reasonable prospect can be entertained of the disease being removed by the efforts of nature, or the influence of medicine, the effects of remedies should of course be tried, but at the same time it should be borne in mind that this disease is generally, if not always, be- yond the power of medicine to relieve, and that the persisting in the employment of remedies which experience has so often proved ineffectual, can only tend to diminish the ultimate chance of success by deferring the operation, as is too often done, until the effusion becomes so extensive, and the patient's strength and constitution so ex- hausted, as almost to preclude the possibility of recovery. It has been proved by experience that the ope- ration is frequently successful when the patient ia young and of good constitution, the effusion mod- EMPY erate in quantity, recently formed, and unaccom- panied with organic disease of the lungs. On the other hand, the prospect of success diminishes considerably when the effusion is very extensive, of long standing, and accompanied by symptoms of confirmed hectic. The copiousness of the effusion, however, though it generally diminishes the chances of re- covery, does not necessarily preclude the success of the operation. Baron Larrey operated success- fully in a case where the effusion amounted to fifteen pints; Dr. Hawthorne's patient lost twenty pints of pus during the first twenty-four hours; and in Dr. Archer's successful case, already quoted, eleven pints of fluid were drawn off at the first evacuation. The same remark is likewise appli- cable to the length of time during which the em- pyema has existed, and to the symptoms of hectic with which it is accompanied, as there are several cases on record where the operation was success- fully performed under those unfavourable circum- stances, (Dictionnaire des Sciences Medicates, art. Empyemc. In the numerous class of cases where empyema is complicated with pneumothorax from the rup- ture of a tuberculous abscess in the lung, the chance of any permanent advantage from the operation must necessarily be very small, in con- sequence of the incurable nature of the original disease : in such cases, indeed, little else can be hoped for from the removal of the effusion than a temporary alleviation of suffering, or the prolonga- tion of existence for a few weeks or months at the utmost; such, at least, is the conclusion that we have formed, after having witnessed the pro- gress and fatal termination of eighteen cases of this nature, in five of which the operation was performed with no better success than that just described. (See Pneumothorax.) Laennec, however, is of opinion that " we must not aban- don all hope of cure, even when there exists so serious a complication as this, provided there be no evidence of cavities in the opposite lung." (Op. cit.) The complication of pneumothorax does not seem to form so serious an objection to the opera- tion, when not coupled with the presence of tu- berculous abscesses in the lungs, as appears from its having been successfully performed in several cases where the sound of fluctuation, audible in the chest, sufficiently proved the coexistence of a gaseous and liquid effusion. Dr. Archer's remark- able case of this kind, published in the Transac- tions of the Association, has already been alluded to. A still more remarkable case of empyema with pneumothorax, terminating successfully by operation, is related by Dr. G. Hawthorne, in the Edinburgh Medical and Surgical Journal, No. 61. Neither does the existence of a fistulous pas- sage through the lungs necessarily preclude the success of the operation, as is evident from those cases where it was performed after the empyema had burst internally into the bronchi, and yet the communication thus formed through the lung did not appear in the least to impede the patient's lltimate recovery. Le Dran relates a case on which he operated for empyema where " the in- jection of a small quantity of mel rosarum and D EMA. 37 barley-water through the wound excited coughing, and part of it passed off by the mouth, mixed with pus ;" thus clearly proving the existence of a fistulous passage through the lung, notwithstand- ing which the patient recovered completely. Seve- ral similar cases are quoted in the Dictionnaire des Sciences Medicates, from the writings of MM. Jaymes, Robin, and Bacqua. In these cases, how- ever, the empyema must in all probability have been circumscribed, and the lung retained by ad- hesions in contact with the walls of the chest around the circumference of the wound; or else the injection, instead of entering the lung, would have fallen to the bottom of the pleura. It is unnecessary here to enter into any minute description of the mode of performing the opera- tion, as this is described in all treatises on the subject and in all systems of surgery; but the reader is more particularly referred to the works of Le Dran, Richter, Sharp, C. Bell, Larrey, and Boyer, [Ferguson, and Listen,] where he will find all the necessary information. [For the removal of the fluid, Drs. Prichard and Babington have recently recommended instru- ments, which are described under Ascites, (page 188,)—and should any doubt exist as to the pre- sence of fluid, a grooved or exploring needle, as advised by Dr. Thomas Davies, (Lectures on Dis- eases of the Lungs, <$fc, Lond. 1835,) may be passed into the chest, by which not only the pre- sence but the character of the effused fluid may be safely determined.] Authors make a distinction in the operation according as the matter points externally or not. The former they term the operation of necessity, from its site being necessarily fixed : and the lat- ter the operation of election, from the surgeon being at liberty to select at what part of the chest he makes his incision. In the empyema of necessity, as it is termed, when the matter points externally, the sooner an incision is made into the tumour the better, as there is no chance of the matter being removed by absorption, and the consequence of delaying the operation has too often been the formation of long sinuous passages through the parietes of the chest and abdomen, and caries of the ribs. In- deed this operation is much more generally suc- cessful than that performed at the place of election, which no doubt arises from the circumstance that those empyemas which point externally are almost invariably circumscribed, and confined to a small extent of the pleural sac. When no tumour appears, to fix the site of the operation, the place of election generally recom- mended by surgeons in this country is between the sixth and seventh true ribs, where the indigi- tations of the serratus major anticus muscle meet those of the obliquus externus. Laennec prefers the space between the fifth and sixth ribs. " Many reasons (he says) point out this spot as the best suited for the operation: for instance, we know that the upper lobe adheres to the ribs more fre- quently than any other part of the lungs, and that the lower lobe is frequently attached to the dia- phragm, while adhesions very seldom exist at the central part of the chest; and even should there chance to be any old adhesions in this point, they may be readily and certainly discovered by somo 38 EMPY remains of respiration over their site, and the place of the operation may then be varied accordingly : besides, we know that the thickest false mem- branes exist at the junction of the diaphragm with the walls of the chest, and that at the right side an enlarged liver frequently reaches as high as the sixth or even as the fifth rib;" in which case, when the operation is performed in the usual situation, the instrument, instead of entering the chest, would transfix the diaphragm and penetrate the abdomen; there are several cases on record of the operation having been frustrated by this accident. Laennec informs us that in a case of pleuro-pneumothorax, after making an incision through the integuments between the fifth and sixth ribs, he thrust the trochar, as he thought, into the thorax, and was much surprised to find that no fluid followed its introduction; but on dissection he discovered that the instrument had entered the cavity of the abdomen, after transfix- ing the diaphragm, which had been thrust up into the chest by an enlargement of the liver, and had contracted a firm adhesion to the seventh rib. (Op. cit.) A similar accident happened to La Motte, (Traite complet de Chirurgie, vol. ii. obs. 77, p. 292 ;) and Solingen saw the diaphragm wounded by the introduction of a canula after the operation, which was performed between the first and second of the false ribs. (Handgriffe der Wundarzney, Th. ii. Kap. i. p. 175.) The only object of operating so low down is to make the opening at the most dependent part of the chest for the more complete evacuation of the effusion ; but this object may be sufficiently attained by operating between the fifth and sixth ribs, which may in fact be made the most dependent point of the chest, by causing the patient to lie, as he gene- rally feels disposed to do, on the diseased side. The danger of wounding the intercostal artery may be avoided by making the incision close to the superior edge of the lower rib. [See on this subject Stokes on the Chest, Amer. edit. p. 483, Philad. 1844. Recently the writer directed the operation to be performed in a case of chronic pleurisy. The operator, in accordance with the recommendations of Dr. Ferguson, (A System of Practical Surgery, Amer. edit. p. 530, Philad. 1843,) selected the seventh rib, a little in front of the angle, for the place of puncture, but no fluid escaped. On repeating the operation immedi- ately above the fifth rib, half way between the spine and the sternum of the right side, he was completely successful.] When the incision is carried through the pa- rietes of the chest and the false membranes with which they may be coated, a rush of fluid is im- mediately expelled by the pressure of the parietes, and continues to flow in an uninterrupted stream until the surface of the fluid falls to the level of the wound, after which it issues in a series of in- terrupted jets corresponding to the motions of the diaphragm; for as this muscle descends in inspi- ration, the fluid which lies on its surface sinks along with it, and the atmospheric air rushes in to fill up the space created by its descent: again, as the diaphragm rises in expiration, the incum- bent fluid is elevated to the level of the orifice, and issues in a jet from the wound ; this alternate sucking in of air and expulsion of fluid continues EMA. until the quantity of matter is diminished so as no longer to rise to the level of the wound during expiration, after which each movement of the dia- phragm is followed by the alternate introduction and expulsion of air, so long as the wound is al- lowed to remain open. Many reasons, however, render it inexpedient to continue the operation to this period. The sudden removal of so large a quantity of fluid frequently produces such a sho;k to the nervous system as throws the patient into an alarming state of collapse; the withdrawing so great a degree of pressure from the heart and large blood-vessels and from the opposite lung must likewise derange materially the functions of these important organs, and consequently oppose the success of the operation ; and another inju- rious consequence of protracting the operation until all the fluid has been evacuated is, that the parietes of the chest are unable to accommodate themselves to the space which is thus left unoc- cupied, and which must consequently be filled with atmospheric air. For these reasons it is advisable to close the wound before the fluid begins to issue in an in- terrupted stream, and to repeat the evacuation at longer or shorter intervals, according to the extent of the effusion and the urgency of the symptoms. In general, the removal of twenty ounces of fluid at a time will be found sufficient to relieve the breathing, (as this effect is produced, at least in the first instance, by diminishing the pressure on the opposite lung, and not by restoring the func- tions of the organ at the diseased side,) and an interval of forty-eight hours may be allowed to elapse before the wound is again opened. When, however, the effusion is very extensive, and the breathing not sufficiently relieved by the removal of the quantity above specified, the fluid may be allowed to flow for some time longer, or the evacu- ation may be repeated at shorter intervals. When the principal part of the effusion has been remov- ed in this way, a large poultice may be applied over the wound, and the remainder of the fluid allowed to escape as fast as it is secreted. By this method of gradually removing the effu- sion, we diminish the shock to the nervous sys- tem, relieve the thoracic viscera gradually from the pressure of the accumulated fluid, and prevent the introduction of air into the thorax, until the parietes have had time to accommodate themselves to the diminished volume of their contents, and by their mutual approximation diminish, to the utmost, the space left by the evacuation of the effusion. The following measurements taken from a pa- tient of twelve years old, who lately underwent this operation, will serve to illustrate the diminu- tion which takes place in the capacity of the dis- eased side by the falling in of its osseous parietes: Circumference Circumference of the diseased of the sound side. side. Immediately before the operation 16^......"i Evening after the operation......16 3 u 6th day after the operation.......n ^........\i ™iday after the operation.......14 g........{4 8th day after the operation.......u %........\. 9th day after the operation ....... 13 9........\\ \ Thus, jn the space of nine days, the circumference of the diseased side diminished nearly three inches. 1 his contraction of the osseous parietee aided b, EMPYEMA—END EMIC DISEASES. 39 the ascent of the diaphragm, and the protrusion of the mediastinum from the increased dilatation of the opposite lung, reduced the cavity of the dis- eased side to so small a compass, especially in young subjects, whose ribs are susceptible of a much greater degree of motion than those whose cartilages are ossified, as to leave very little space unoccupied for the reception of air. This space is subsequently filled up as the lung gradually ex- pands and rises into contact with its parietes : this, however, is always a very slow process, as several weeks in general elapse before the slight- est trace of respiration can be perceived in the dis- eased side; as the lung continues to expand, the contraction of the side gradually diminishes, until at length the lung resumes its original dimensions and the contraction of the side disappears altoge- ther. In some cases, however, the dilatation of the lung is never complete, and the side remains permanently contracted in consequence. Lastly, there are some cases in which recovery takes place, although the lung never expands so as to fill the space left by the evacuation of the empye- ma. In these cases the wound made by the operation is converted into a permanent fistula, through which the atmospheric air is allowed to enter, and the matter secreted by the walls of the cavity to escape, without producing any very con- siderable inconvenience to the patient's health. Several cases of this termination of the operation are recorded by Plater and Schenkius, and by MM. Lefacheux and Audouard. (See Empyeme, in the Dictionnaire des Sciences Medicates.) But perhaps the most remarkable case of this kind on record is that recently published by Dr. Wendel- stadt of Hersfield, who underwent the operation of paracentesis for empyema in his own person, thirteen years ago, since which time the wound has remained open, and the fluid has been drawn off twice every day, sometimes so much as three or four ounces daily. Three years ago, be- ing anxious to ascertain the dimensions of the cavity which existed in the thorax, he found that it was capable of containing a quart of warm water. The diseased side is much contracted, and does not move at all in respiration, yet he can blow the flute, and walk faster than many persons who are in perfect health, and for several years he has resumed the active discharge of his professional duties. (Journal der Praktischen Heilkunde, Januar. 1831.) Various expedients have at different times been contrived for extracting the air out of the pleura, with the view of removing the pressure from the lungs' surface, and thereby facilitating their ex- pansion. A variety of syringes have been con- trived for this purpose, and recently M. Laennec has proposed to apply a piston-cupping-glass over the wound immediately after the discharge of the liquid, and to produce a vacuum in the chest more or less quickly, continuously and completely, ac- cording to the effects. If this suggestion were to be put in practice, care should be taken to avoid exhausting the air so far as to suck out a portion of the lung through the wound, as happened to the writer of this article, when trying the efficacy of the proposed plan on a dog. Another objec- tion to the success of this contrivance is the diffi- culty of preventing the air from again rushing in through the wound the moment that the exhaust- ing glass is removed. After all, it appears very doubtful whether the admission of air into the pleura is really as dan- gerous as is generally supposed, or whether the quantity of air which is contained within the chest affords any such serious obstacle to the ex- pansion of the lung, that its removal may not be safely entrusted to the power of the absorbents ; as the experiments of Nysten, and more recently those of Speiss, (De vulneribus pectoris penetran- tibus,) have fully proved that air introduced into the pleura is invariably removed by absorption in the course of a few days. In those cases where the introduction of air produces an unhealthy discharge from the wound, the practice of using injections may be had re- course to with advantage for the purpose of cor recting the morbid action of the suppurating sur face, and removing the putrescent qualities of the discharge. Willis relates a remarkable in- stance of the efficacy of injections in such cases The fluid drawn off at the time of the operatior was perfectly inodorous, and continued free from smell for the first three days; after which, when- ever the wound was opened, a smell, which he describes as " odor teterrimus, cloaca? cujusvis maxime putentis ftetorem superans,' infected the whole chamber; but by the repeated use of injec- tions, the horrible fetor of the discharge was en- tirely corrected, and the patient ultimately reco- vered. (De Empyemate, p. 98.) M. Freteau records another case in which, shortly after the operation, the discharge assumed a dark ichorous appearance, and exhaled a gangrenous smell; but by persisting in the use of injections for twenty days, the matter discharged from the wound as- sumed a healthy appearance, and lost its disagree- ble odour. Willis was in the habit of using a decoction of various aromatics and stimulating herbs for this purpose. MM. Freteau, Billery, and Audouard recommend the decoction of cin- chona as less irritating than that used by Willis, and equally efficacious. (Diet, des Sciences Med. art. Empyeme.) A weak solution of the chlo- rate [chloride] of lime will probably be found to act still more efficaciously as an antiseptic. [But it need scarcely be said, that all such applications must be used with the greatest caution, for fear that inflammatory action may be set up, which may not be easily subdued.] R. Townsend. ENDEMIC DISEASES.—Endemic is a word applied to those diseases which occur among the inhabitants of a particular place or country, in consequence of something local or peculiar in the air, or water, or soil, or in the food and habits of the people. Hippocrates has left a treatise, which, though containing some crude observations, is a model that has been too much neglected by me- dical writers. His book De Aeribus, aquis, locis, according to Halter, is composed in a style, and contains reasoning, worthy of its great author. If we except the Dissertation on Endemic Diseases. by Hoffmann, we have few works written express- ly on the subject. Yet it is one which we might suppose would have engaged the serious attention of physicians in all ages. DISEASES. 40 ENDEMIC The knowledge of those peculiarities in climate, soil, elevation, and site of dwelling, and especially in food, drink, and habits ; as well as of the moral and phvsical varieties which are found to coexist with certain forms of disease, in any part of the human family, is a branch of medical science that serins to include some of its essential principles. It is a field that well deserves to be further culti- vated ; and as we are now becoming better ac- quainted with different parts of the world by means of more accurate and intelligent observers, it is to be presumed that the data will soon be multiplied, from which, upon comparison of one country with another, many useful practical hints may be deduced, and the real causes of some hid- den things in this department of our science as- certained. Of late years, indeed, much to the credit of our professional brethren both in the east and west, many excellent monographs on the me- dical topography of different places have appeared. An interesting article, pointing out these and other works on the subject, is to be found in the sixteenth volume of the Edinb. Medical Journal, in the editor's learned review of the " Medical Topography of Upper Canada, by John Douglas." But it may be truly said of endemic diseases, ge- nerally, in the words of that able review, that " a complete work on the subject is one of the greatest desiderata in our professional literature." It is needless to expatiate on those things which are obvious to every enlightened observer. As in the body, different effects result from the dry and bracing wind of the mountain, compared with those from the moist and sluggish air of the val- ley ; so, as regards the mind, the observation of the poet is philosophically true,— "An iron race the mountain cliffs maintain, Foes to the gentler manners of the plain." Gray. "La terra molle e lieta e dilettosa Bimili a se gli abitator' produce." Tasso. But as the physical effects are liable to be varied by climate, elevation, temperature, winds, and the vicinity of wood and water, as well as by the quality of food and drink and the habits of life ; so the moral effects (if not indeed also the physi- cal) may be varied by the state of liberty or op- pression, of sloth or activity, of comfort or wretch- edness, of cleanliness or filth, of mental apathy or cultivation, in which our fellow-creatures in any part of the world may happen to be placed. From all these controlling circumstances need we wonder that diseases should assume such varied appearances ? or that many who are living toge- ther in the same community, and even born on the same soil, should escape some of the evils to which their less fortunate neighbours are liable ? If such escape, there is less cause to wonder that entire strangers should escape also. This in fact is often the case. And when the inhabitants of any particular country or place are especially liable to some form of endemic complaint, they are found to be for the most part exempt from other serious affections. It was a proposition of Dr. James Sims, a physician of acute observation, that if a patient on the verge of pulmonary consump- tion could be taken into a fenny country in the height of the season, so as to contract a severe i»£ue, ^ere would be little doubt of the phthisical I symptoms being at once arrested. The natives of a country often become inured by habit to circum- stances which very soon exert a dangerous influ- ence on strangers. The marsh miasmata of the tropics are more pernicious to strangers than to the natives. The cold winds of the northern climates most frequently affect the natives of Africa and the Indies with mortal pulmonary inflammations. It is demonstrated in countries which are inhabited by different races of men, as the negroes and Malays, the Americans and negroes, that the same circumstances do not pro- duce the same morbid effects on both classes. It has been frequently remarked that the water of the Seine produces a diarrhoea in every one except the Parisian accustomed to the use of it. The same treatment will not be required for the same diseases, or rather for diseases called by the same name, in different places and seasons, as in moun- tainous and in low situations, in summer and in winter, in hot and in cold climates, in affluent stations of society and in indigent. Baglivi says that at Rome ulcers of the legs are almost incura- ble, while wounds in the head heal without any trouble. Cleghorn tells us of an old proverb, that " Minorca is good for the head but bad for the shins." In France it is remarked that ulcers of the legs are more easily cured at Montpellier, and those of the head at Paris. (See Diet, des Sc. Med. art. Endemique.) Hippocrates and Celsus both remark that ob- stinate ulcers of the legs frequently exist in those who are affected with enlargement of the spleen. (Cleghorn, Op. cit. p. 71.) The cretin of the close gorges of the Vallais loses his stupidity in the dry and sharp air of the high neighbouring mountains, while the brisk mountaineer experi- ences less of hemorrhage and of acute disease in the heavy and cloudy air of the valleys. (Yirey.) It is an old observation that hemorrhages, acute diseases, and inflammatory affections, are more common in dry and elevated situations, especially if these are much exposed to the north wind. The contrary may be expected in opposite situa- tions, where the "plumbeus auster" tends its aid to weaken the body and depress the spirits. It would undoubtedly be a useful work to trace, on an enlarged scale, a connected outline of the endemic diseases in different countries, with their topography, and the food and habits of the people. But we must regret that the statements or observa- tions (within our reach) that relate to the sup- posed causes of such diseases, are many of them too loose and partial for scientific generalization. With such materials, all that can be proposed at present is a very general notice of some of the leading well-attested facts belonging to the most remarkable diseases that usually come under this denomination, and for obvious reasons every thing relating to their symptoms and cure must he com- mitted to other articles of this work. 1. Intermittent Fever.—No observation is more general than that ague is endemic among the inhabitants of places where marshes abound, and in seasons, as the spring and autumn, when the effluvia arising from them are more active, and the body perhaps more liable to be affected by their peculiar poison. There are few marshy countries, in temperate and tropical climates, in ENDEMIC DISEASES. ±1 which intermittent fever is not known. The con- nection, therefore, between them does not depend on a limited, but a comprehensive induction of facts; the truth is abundantly confirmed. Ague, indeed, sometimes appears where the influence of marsh effluvia cannot be traced ; and the term malaria has been brought into modern use to denote a morbific atmosphere, arising from the soil, capable of producing intermittent fever, in which marsh miasmata, properly so called, are supposed not to constitute an essential part. Many facts would seem to countenance this opin- ion, as well as that which assigns to malaria the production of continued fever under certain cir- cumstances. In the metropolis we have known persons attacked with ague, mostly however of an irregular type, by working in damp cellars. In temperate climates, under ordinary circumstances, the milder forms of the disease appear, and these in the spring, as the quotidian and tertian. The quartan, more obstinate and protracted, usually appears in autumn. In Sydenham's time, and even in that of Fothergill, the quotidian of spring became continued fever in summer; while the simple continued fever of summer often changed to a malignant type in autumn. These were sim- ple observations at a time when systematic ar- rangements had not put physicians in trammels. But now, lest we should be guilty of medical her- esy, we must not insinuate that ague can change into continued fever, and non-contagious fever into contagious typhus, either in an individual case or in the course of the year ! It has been commonly observed that the spleen suffers more in cases of protracted intermittents in temperate climates, and the liver in tropical. Nevertheless, Dr. Jackson tells us of enlarged spleen after such fevers in the West Indies : Cleg- horn noticed the same in Minorca ; and we have the testimony of W. Twining, that this organ is often found diseased from this cause, in Bengal and all the low districts of Hindostan, (Calcutta Medical Trans, vol. iii. p. 354.) When tropical heat is added to the influence of marsh effluvia, then we have the various shades of intermittent, remittent, and even continued fever, passing sometimes into each other by al- most imperceptible gradations, and complicated more or less with bilious symptoms. When in- temperate seasons, deficient or unwholesome food, and animal filth, are superadded to the causes above mentioned, and acting upon a condensed population, the highest grades of pestilential fever are often exhibited, as the plague of Egypt and the Levant, the pestilential fever of Spain, and the yellow fever of America and the West In- dies. When marshy land is brought to a very dry state in summer, after long-continued drought, ague is often but little known in the vicinity ; but the first heavy shower after the drought will some- times give rise to it. And on the contrary, in a wet season, white much water is lying upon the marshes, the disease is rare; but in proportion as they become dried to a certain point, the mias- mata are found to be active, according to the de- gree of heat, the season of the year, and the state of the population. A ce*tain quantity of mois- ture, therefore, seems to be necessary upon the Vol. II. — 6 i> * marsh, in order that the miasmata may be disen- gaged ; and of vapour in the atmosphere to con- vey them to a distance ; while a superabundance either prevents their evolution, or entirely absorbs them. Notwithstanding that the notion has been ridi- culed by a few, there can be little doubt that cur- rents of air will sometimes waft the effluvia to a great distance, so as to produce intermittent fever in places otherwise healthy ; and some facts would seem to show that hills of a certain elevation in the vicinity of marshy grounds have a sort of attraction for the miasmata, and are almost as unwholesome as the plains.* But it is upon a different principle that hilly grounds, in some cases, become more unhealthy than the plains. The British army in 1809 found that the hilly sides of the ravines in Portugal, after heat and rain, exposed the soldiers to a most destructive remittent, while the overflowed swamps below were more than usually free from disease : " and such," says Irvine, " is frequently the case on the lofty ridges of Sicily, when their fiumari, or water- courses, which are ordinarily dry, and used for roads in the summer months, are filled and inun- dated with sudden torrents of rain. For here the malaria changes its station, and quits the over- flowed low lands for the heights of the primitive hills. (Good's Study of Medicine, vol. ii. p. 166.) Plantations of trees have been known to inter- cept marsh miasmata, and thus to prevent their injurious effects upon the inhabitants at a short distance ; and for the same reason it is found that the site of a dwelling should not be too near such plantations. « It is wonderful," says Dr. Fergu- son, (loc. cit.) " to see how near to leeward of the most pestiferous marshes, in the territory of Gui- ana particularly, where these trees abound, the settlers will venture with impunity to place their habitations, provided they have this security; though every one is fully aware that it would be almost certain death for an European to sleep, or even to remain after night-fall, under the shade of the lofty trees that cover the marsh, at so short a distance." (Med. Chir. Rev., Dec. 1821.) There is something curious and not easily ex- plained in the circumscribed locality of intermit- tent fever in certain places. Perhaps, if the pre- valence of winds and the situation of such places as to exposure and wood and water, &c, were taken into account, the difficulty might be in part removed. A late writer on malaria states, that on the high Dover road, in Kent, not far from Ro- chester, some of the people living on one side of the road were attacked with ague, while on the other side all escaped. It is amply proved that marsh effluvia exert far more pernicious influence upon the body during * Medico-Chir. Review, vol. ii. p. 59], Dec. 1Q21 ; Dr. Ferguson on Marsh Poison. Dr. Robertson fully con- firms the observation of Dr. Ferguson, relative to the exposure of the inhabitants of high situ.itions in the vicinity of marshy grounds to the eliicts of t lie miuMiiata. (Med. Repos. vol. i. p. 3b7.) He knew people to be se- verely affected by this cause, who had not been for some time without the walls of the castle of Santa Barbara, at Alicante, 800 feet above the sea-shore ; while at the same time, persons living on a level with the sea, and exposed to ail the sources of marsh miasma, escaped every attack of fever. He considers that the high grounds present an impediment to the free dispersion of the exhalations through the atmosphere. 42 ENDEMIC DISEASES. the state of sleep, or even when it is exposed to them in the night air without sleep. It has also been observed, in illustration of the ague-giving qualities of the east-wind, that some time, even days or weeks, after an exposure to marsh mias- mata has taken place without producing any per- ceptible bad effect, the casual blowing of the east- wind has at once fixed an attack of ague. Sea- water flowing over marshy ground, cseferis pari- bus, seems to give rise to more pernicious effluvia than fresh water. The bogs or peat-mosses of Scotland and Ireland, on the other hand, do not appear to generate ague. Dr. [Sir James] Clark, in his late work " On the influence of Climate," states, that with regard to Rome, at the present time, " a certain period of residence in the malaria site is necessary, in gene- ral, to prepare the body for its attack; and that there is no reason for the fear commonly enter- tained of a sudden attack of malaria from simply passing quickly through a malaria district." " The German, French, and English artists were more frequently attacked with fever the second or third years of their residence at Rome than the first." But the situation of this city will not bear an ex- act comparison with that of a pure marshy district. Seamen, who after a long voyage venture to land on a marshy shore in the height of the sea- son, too often find that if they remain a single night on land they are attacked by the endemic fever almost immediately. Hence it has often hap- pened that vessels coming to a maritime city, on the eve of a pestilential visitation, although with clean bills of health, have been among the first to show s'gns of disease in some of the crew, and the fact has been eagerly laid hold of to counte- nance the suspicion that contagion from the vessel gave rise to the distemper; for it need not be told that mariners who have been long at sea are very susceptible of morbid impressions from a vitiated at- mosphere on first coming to land in a sickly season. As a common rule, regular sufficient diet af- fords some protection against the influence of ma- laria; and fatigue, low living, debauch, night- watching, and irregularity of every kind, favour its attack. In temperate climates, where these miasmata abound, the practice of over-excitement with stimuli will do less harm than in hot countries. 2. Broncliocele.—From the line in Juvenal, "Quis tumidum guttur miratur in Alpibus'?" it would seem that the swelled throat was so com- mon a complaint in the Alps in his time, as not to excite any wonder. It is still found in the "alleys of the Alps, and in some other mountain- ous countries, as the Pyrenees, the province of Bebar in India, in Derbyshire, &c. It has been observed also in some mountainous parts of Java and Sumatra; but it is rare in Scotland ; and Dr. Reeve states that it is very common in Norfolk. Mungo Park observed the bronchocele in differ- ent parts of Bambara, in Africa, along the course of the river Niger. Females are far more liable to it than mates. The opinion that snow-water is the cause of this complaint appears to be quite unfounded; nor can we ascribe it to the use of water impregnated with calcareous earth. Yet it is probable that air, water, and diet, each contribute something towards the cause. Sir S. Raffles tells us that there is a village near the foot of the Teng'gar mountains in Java, where every family is afflicted by this malady; while in another vil- lage, situated at a greater elevation, and through which the stream descends that serves for the use of both, there exists no such deformity. In the province of Behar in India, there is a district called Tirhoot, (Calcutta Transactions, 1S29, and Edinb. Med. and Surg. Journal, No. 106), in which bronchocele is common among the natives : " and a singular circumstance regarding it is, that on a small river of the district it is not uncommon to see a village on each bank, and quite contiguous, the one with scarcely an indivi- dual exempt from the complaint, white in the other the inhabitants are perfectly free from it." Dr. Johnson cogently remarks, (Med. Chir. Rev. vol. vi. p. 422,) " that we observe goitre more abundant in some than in other parts of Switzer- land, though the diet is the same. In the valley of the Rhone we see hardly any thing else than cretins and goitres; while in the valley of Cha- mouny, separated only by the Col de Balme, we see very few of either disease. We trace bron- chocele along the whole course of the Rhine, from Schafhausen to Cologne; it gradually decreases as we descend the Rhine; and among those who inhabit the banks and drink the waters of the up- per or turbid Rhone (in the Yallais) there are twenty goitres and cretins for one that can be seen on the banks of the lower or filtered Rhone." Taken in connexion with the Rhine, it forms (in his opinion) a strong ground of presumption in favour of the goitrifactive influence of alpine wa- ters. Dr. Johnson, however, does not ascribe all the effect to the waters; and he adds, that " Eng- lish children (who live as well as people in England) cannot be kept long at Geneva without having enlargements of the thyroid gland." He concludes, therefore, that the cause cannot be traced to sour bread, as Dr. Drug imagined, or to any particular article of diet, except water.* Notwithstanding the foregoing testimonies, the observation of Dr. Mason Good is very important, that at Matlock in Derbyshire he found "a large number of the poor affected with bronchocele, while the rich escaped ; and by far the greater part were exposed to all the ordinary evils of poverty. (See Study of Med. vol. v. p. 309.) Bronchocele has been observed to prevail most in situations where humidity is joined with ex- cessive heat; and it is found to increase in spring, and to diminish in autumn. Upon the whole, a more ample induction is required before the true causes of the complaint can be determined: the probability seems to be that these are not uniform, or, at least, that they are liable to be much varied; and that a peculiar combination of air, food, and water has much to do in causing the complaint * In the work of this able writer and philosophic ob- server, lately published, entitled, "Tour of Health, &x." he says "Dr. Bally, a native of a goitrous district in Switzerland, states the following very important fact. Bronchocele appears to me to be produced by certain waters which ..sue from the hollows of rocks, trickle ™* ,ffs; mountains, or spring from the bowels of the earth. I hat thls ,s the case Inm instance some famines in iny own country, Department du Leman.au IlRineau de Timet, the use of whose waters will ineiekl or ten days produce or augment goitrous swelling e//-water was in use, generally escaped. Three infants, from five to seven months' old, to whom their mothers had incautiously given the water of the well, had each a worm in one of their legs ; and a domestic negro boy, who in the year 1793 drank of the well-v/ater, had several Guinea-worms the same year, and only that year. In a third plantation similar facts were noticed; none of the whites on the estate had the disease except one, who inconsiderately or ignorantly drank of the well-water. Bruce and Mungo Park give a similar testimo- ny respecting the effects of particular wells in Africa ; and Dr. Chisholm concludes that " in all countries in which the dracunculus is endemic, the prevailing belief of the people is, that it pro- ceeds from drinking water which contains the ova i»r the embryo of the animal." It is a singular fact that the disease is observed 10 prevail at Bombay and along that part of the i,oast of India about the same time of the year when it prevails in the West Indies, viz., in the months of December, January, and February. It also appears in many other districts in the Car- natic and Madura, to within the distance of one »r two days' journey from the sea-coast. A learn- ed missionary, named Dubois, in a letter to Dr. Anderson, the physician general, states tnat tie has often seen villages in which more than half the inhabitants were affected by it at the same time. The inhabitants of a village who drink water from one well are attacked by the disease, while the inhabitants at the distance of only half a mile who drink water from another well are not affected by it. Besides, the inhabitants living on the shore of the Cavary and other rivers, who constantly drink their limpid waters, are never visited by it; while those who live at the distance of one mile on both sides, and are obliged to drink the saltish water of wells, are all, or the most part, yearly exposed to it. Dr. Smyttam (Calcutta Med. Trans, vol. i.) confirms the observation of Dr. Chisholm and others that « an argillaceous (and tuffy) soil, with a considerable impregnation of salt, or percolated by sea-water, is what the Guinea-worm affects." And another fact seems to be pretty well ascer- tained, both in the East and West Indies, that the worm not only insinuates itself into the body through the skin, but that its ova may be convey- ed into the system through the stomach, and de- posited in the cellular membrane under the skin, where it attains its growth, and at length pro- duces that local irritation which leads to its ex- pulsion. The fact that those who are affected with the dracunculus rarely suffer from any other disease at the same time, with a few other reasons which appear entitled to little weight, has ted some per- sons, and lately Dr. Milne of Bombay, (Edinb. Med. and Surg. Journal, No. 106,) to maintain the position that the substance which is observed in this disease «is not a worm, but a lymphatic vessel." We cannot take further notice of this opinion, nor is it necessary to advert to the cir- cumstances which led Sir James Macgrigor to conclude that the dracunculus was contagious, as the facts have been explained by Dr. Chisholm on a far more reasonable hypothesis. The Guinea-worm has been rarely seen in its native state out of the body. Nevertheless, the observations of Dr. Helenus Scott of Bombay, (See Medico-Chir. Review, vol. iv. 1823,) and recently those of Dr. Robert Grant, (Edinb. Med. and Surg. Journal, No. 106.) set the question of its independent existence at rest. 6. Nostalgia.*—The concourse of depressing symptoms which sometimes arise in persons who are absent from their native country, when they are seized with a longing desire of returning to their home and friends and the scenes of their youth, constitutes the disease called nostalgia. Some have considered it peculiar to the natives of Switzerland, because it was often observed in the Swiss soldiers when on foreign service. But, alas ! too many instances of this affection occur in the natives of other countries, and evince that it has its source in the very frame and constitu- tion of human nature in every part of the world. Though it might appear that the inhabitants of mountainous countries were more liable to nos- talgia than others, yet many instances have oc- curred in which a removal from the plain to the [* It is not easy to see how Dr. Hancock makes rhi. an endemic disease.] "'anes ring ENDEMIC DISEASES. 45 mountain has produced this melancholy. It would seem as if no country Were too wild and sav- age, if but the simplest means of supporting hu- man life were at hand, not to attach the natives to it. Our affections, like the tendrils of the vine, adhere to the objects that are first presented to them, whether animated or inanimate, with so firm an embrace that nothing but violence can break the connection. Every one accustomed to the variety and beau- ty of mountain scenery, and capable of feeling in- tensely the delights of rural manners, can conceive without difficulty the anguish and shock to the physical powers, which is often sustained by those who are thus ardently devoted to their friends and native country, when they have been rudely sepa- rated from them.* The Laplander feels the most enervating and listless despondency, when absent from his snowy mountains and frozen lakes. The North-American Indian sighs amidst the festivi- ties and comforts of polished life for the earthy couch in his native wilds, and the free range of his interminable forests. And the poor negro, even if cruel bondage were not his portion, might be expected to utter bitter complaints for the loss of family endearments and of the noontide repose in the sultry retreats of African luxuriance. Many of the ill-fated Africans, it is well known, perish from suicide and dirt-eating in those polluted and polluting islands, where we cannot say that "No fiends torment nor Christians thirst for gold." Even the hardy and almost unyielding nature of the British seaman, when he has just set foot on his native land after a long voyage, and been pressed against his will to leave once more the objects dearest to him in life, has often been sub- dued by this powerful influence so completely as to he quite disqualified for the duties to which he was called. Within the last forty years, perhaps no country in Europe has afforded so many in- stances of the overwhelming influence of the dis- ease in question as France, notwithstanding the natural buoyancy of spirit and thirst after military glory for which that nation is distinguished. There was scarcely an encampment during the war in which the skill of the medical attendants was not called forth, assiduously and painfully, to counteract the pernicious effects of nostalgia,— pernicious, and, indeed, often fatal in a high degree, when any other debilitating or depressing powers were applied at the same time, and acting together with this epidemic melancholy upon the young soldier. It was then observed that a slight wound, dysentery, fever, extra fatigue, or a disas- trous engagement, hurried multitudes into a state of mortal depression. (See Percy and Laurent, Diet, de Sc. Med. art. Nostalgic) 7. Tarantismus.—A disease was formerly supposed to be epidemic in Apulia, and only in that part of Naples, which was so called from the spider named aranea tarantula, whose bite was said to be the cause of it. The peculiarity of the disease mainly consisted in the uncontrollable pro- * The celebrated Swiss air called Rans des Vaches, imitating the full rebounding echo of the Alpine herd amongst the mountains, might well awaken mournful recollections in the bosom of the absent soldier, so as to require that" the plaving of it should be prohibited under a severe penalty pensity of the sufferer to dance in the most violent manner at the sound of certain music—some affected by one sort and some by another—till copious perspiration and excessive fatigue put an end to the disease, and thus destroyed the effects of the poison. This was the common opinion, and' men of science received it as agreeing with matter of fact. Tarantismus affords one of those humiliating lessons which may too frequently be drawn from medical records, on the difficulty of ascertaining facts, and the prevalence of unfound- ed opinions, even among distinguished physicians. Kircher, Sir Thomas Browne, Baglivi, Boyle, and Mead, have not hesitated to give credit and countenance to the statements relative to the wonderful effects both of the bite of the tarantula spider upon the body, and of the music as a re- medy. Yet it would appear that they were all misled by a popular error. The treatise on the tarantula of a physician so eminent as Baglivi, who was himself an Apulian, tended to confirm the delusion. On the contrary side of the question we have the strong testimony of Dr. Cornelio, a Neapoli- tan physician, so far back as 1672, of Dr. Serao, an Italian, and of Dr. Cirillo, professor of natural history in the university of Naples, so lately as 1770, besides that of many others since that time. (See Phil. Trans, for 1672 and 1770.) Cornelio says that " all those that think themselves bitten by tarantulas, except such as for evil ends feign themselves to be so, are mostly young wanton girls, who persuade themselves they have been stung by a' tarantula, according to vulgar preju- dice, in consequence of having fallen by some particular indisposition into this melancholy mad- ness." Dr. Serao has written an ingenious book, in which he has effectually exploded this opinion as a popular error. Dr. Cirillo asserts that, " hav- ing had an opportunity of examining the effects of this animal in the province of Taranto, where it is found in great abundance, he finds that the surprising cure of the bite of it by music has not the least truth in it. In Sicily, where the summer is still warmer than in any part of Naples, and in Tunis also, where this spider is found, the taran. tula is never dangerous, and music is never em- ployed for the cure of the pretended tarantism. (See Edinb. Med. and Phys. Diet. art. ArancaA Dr. Laurent, who lived in the kingdom of Na- ples for a long time as chief surgeon to the French army, says that the bite of the tarantula does really cause a slight inflammation, but that taran- tism, as described by authors, no longer exists. He has often seen, at Naples, ten or a dozen young girls running about the streets, each having a small tambour, and performing with a kind of violent effort, accompanied by the most wanton gestures, the dance thej call tarantella, a national dance from time immemorial known in that coun- try. Hence, Merat thinks it is probable that taran tismus, the disease, is nothing but tarantella, the dance, adorned with some fables. Nollet, an eminent physician, was satisfied, when in Italy, that the vulgar notion was unfounded; that. even in Apulia, sensible people gave no credit to it; and that it was only some of the very lowest class, who, pretending that they were bitten, ap peared to be cured by dancing and music in 46 ENDEMIC DISEASES-ENTERITIS. in every climate and in all situations in life, if man himself, or at least those who are in power would but apply the means—if luxury would make a small sacrifice of self-indulgence to the public good; and, lastly, on the physical blessings that would result from this wise paternal care, not only comforting and rejoicing the poor objects themselves, but enriching their benefactors, caus- ing the face of nature to smile around them, and giving them the never-failing reward of sound policy and of Christian benevolence. T. Hancock. order that they might gain a subsistence by this kind of imposture. We are assured that the opinion of all the physicians of the country is that the bite is harmless, if not aggravated by impro- per applications ; and that they consider the pre- tended tarantism arising from it as visionary. Baglivi himself admits that "that spider is only venomous in the dog-days, and in very hot situa- tions, for, at other times, and in the mountains, and in other countries, it is not so." This is a remarkable concession. The fact is, that the inhabitants of Apulia, breathing a hot and dry air, are liable to inflam- mations of the head and chest, and to spasmodic affections ; and sufficient grounds appear for con- sidering the aggregate of symptoms, called taran- tismus, as a nervous complaint, incident to a peo- ple naturally choleric, ardent, impatient, liable to insanity, fond of a dance of which violent gestures constitute a peculiarity, and easily affected by music. (Diet, des Sciences Med. art. Tarantisme.) Besides the diseases above noticed, some others are classed with endemics, as beriberi, attributed to the alternation of extreme heat in the day with cold and damp in the night; ophthalmia, in Egypt, to solar heat and an adust air imbued with impalpable sand ; elephantiasis, in the same coun- try, to corrupt water and the use of salt indigesti- ble food amongst the poor, added to the filth in houses and persons ; pellagra, in Milan, and a species of lepra, in Asturia, to bad food and sordid habits also; framboesia, or yaws, in Africa, and among the negroes in the West Indies; tetanus and trismus in tropical climates, east and west; the Barbadoes, or Cochin leg, &c, to causes not well ascertained. Respecting each of these some interesting facts might be stated ; but we have only room for a few general observations. In the first place, we may remark that abject poverty is the soil in which most endemic diseases spring up in every country. Upon the poor, ill- fed, harassed population, living in closeness and filth, these diseases commonly fall, while those who live well and are but little exposed to the in- jurious qualities of air, soil, and water, are in great measure exempt. Secondly, if we may form any just idea of the causes of physical evils in general, from a consideration of the means which have been found useful in preventing them, then it is clear that, although some complex appear- ances and seemingly contradictory facts enter into the catalogue of assigned causes of many endemic diseases, so far as they appear to depend on air, soil, food, and drink; yet, on the other hand, pro- per attention to these things is found, in almost every instance, to be effectual in suspending and finally removing the maladies in question. By draining marshes and cultivating lands, by pro- viding plain sufficient food and wholesome water, with airy dwellings for the poor, it cannot be doubted that a host of physical evils would be avoided. Thirdly, had we time to pursue this subject further, there is wide scope for reflection on the duties which devolve upon the rich in every country to relieve the necessary wants and sufferings of their poor neighbours ; on the provi- sion which is made in the nature of things, by a 3>y.intiful Creator, for the relief of human misery, ENTERALGIA. (See Colic) ENTERITIS. This term has been long used in medicine to express an inflammatory state of the intestines, but it is only within our own time that pathologists have attached any definite mean- ing to the expression. In the other books we read of gastritis, peritonitis, and enteritis, of which latter Cullen describes two species, the phlegmonous and erythematic; and it is remark- able that by a species of consent among medical men the term has been chiefly used to express the first of these species, or the acute inflammation of most if not all the coats of the intestine. But modern researches have greatly extended our views of enteritis, although the true pathology of the in- testine is not yet sufficiently recognised by most practitioners. Enteritis is now known as a disease perhaps the most protean of any of the affections of the body; occurring with every variety of intensity, from a slight and circumscribed vascularity to the most extensive disorganization ; simulating by its numerous sympathetic irritations many of the dis- eases of the nervous, respiratory, circulating and genito-urinary systems; accompanied by the most violent symptoms of irritation, or only pointed out by a profound adynamia; or, lastly, advancing with perfect latency to incurable disorganization. A formidable disease in its idiopathic form, its supervention in the course of other affections is a matter of daily occurrence, and in one particu- larly, (fever,) a common cause of its fatal termina- tion. We shall dwell on this part of the subject hereafter, and endeavour to show that the enteritis of typhous fever is more a consequence than a cause of the disease, but still not the less import- ant in its prognosis and treatment. Compared with other affections, both acute and chronic, the frequency of intestinal disease must strike every observer. Andral, who, from his vast experience, and the fact of his having no theory to defend, is the best authority on this subject, declares that in the great majority of acute diseases of other parts, a derangement either in the functions or structure of the intestinal canal will occur; and that in chronic diseases, whatever be their nature, it is extremely rare that the digestive tube escapes alteration. These complications of course fort* part of our subject, but here we shall merely remark that it is difficult to estimate the benefit which Broussais has conferred on medicine by calling the attention of pathologists to the fre- quency and importance of irritations of the diges- tive system; and if, in the ardour of discovery this great physician has in one instance passed ENTERITIS. 47 the bounds of strict induction, the error is more than atoned for by the extensive good of which he is the undisputed author. We shall here treat of the different inflamma- tory affections of the intestinal canal, from the pyloric end of the duodenum to the rectum, reserving the consideration of gastritis and perito- nitis for separate articles. We recognise inflammatory affections of the digestive tube by the alterations of function, the local phenomena and the sympathetic irritations which occur. The general symptoms may be enumerated as follows : indigestion, anorexia, vomiting, thirst, jaundice, tympanitis, constipa- tion, alteration of the fsecal discharges in quality or quantity; pain, tenderness on pressure, con- traction of the features, morbid state of the tongue, dryness of the skin, and conjunctiva; suppression of urine, sighing, stupor, delirium, headach, prostration, accelerated and thoracic respiration, fever. We shall find that the greatest variety in the combinations of thesje symptoms may occur, prin- cipally arising from the following circumstances : —the intensity and extent of the inflammation ;— the situation of the disease, both as to the differ- ent parts and tissues of the tube ;—the complica- tions with other diseases ;—the different degree of excitability of the nervous system in different individuals. Thus, when the inflammation is extensive and severe, occupying both the stomach and intestines, we may have the worst forms of bilious or gastric fevers ; when it occupies the duodenum, jaundice is a common symptom, and the disease may occur with or without fever: in the small intestine a slight inflammation is often nearly latent, or only pointed out by a little swell- ing or pain, while in the csecum or colon the dis- ease produces all the varieties of diarrhoea and dysentery. When the upper portion of the tube is engaged, constipation is a common symptom ; when the lower, the reverse takes place. If the mucous membrane alone is engaged, pain and costiveness are often absent; but when all the coats are in a state of acute irritation, we may find the most violent symptoms of peritonitis and ileus, with contractions, intus-susceptions, &c. The complication of the disease with other affec- tions also produces great varieties. Thus when it occurs in the advanced stages of phthisis, diarrhoea is often the only symptom ; or when complicated with erysipelas or pneumonia, its most prominent indication is an extraordinary prostration. The different degrees of excitability of the nervous system cause the greatest irregularity of symptoms: in the child, acute enteritis is commonly mistaken for inflammation of the brain ; in the adult a cir- cumscribed irritation will in one case be accom- panied by violent delirium, while in another, more severe, this symptom shall be completely absent. We have already spoken of the great frequency of abdominal irritations occurring alone, or in combination with other affections. This know- ledge is the discovery of our own time, and may be looked on as the greatest improvement in modern pathology. The humoral school could see in most digestive derangements nothing but the accumulation of sordes: and hence the emetic and purgative practice, in cases where a decided inflammation existed in some part of the tube. They never thought of treating inflammatory dis- eases of the abdomen as such, unless when they occurred in the highest degree of intensity, in- volving all the coats of the intestine ; and of the nature and symptoms of irritations affecting the mucous system they were almost wholly ignorant. The followers of Brown, on the other hand, saw in these affections only debility, because most of them are accompanied by prostration of strength, functional injury, a weak pulse, and in some cases by completely typhoid symptoms. Ignorant of the fundamental law of pathology, that local excitation or inflammation may coincide with a diminution of the general vital force, they prescribed stimu- lants, which only increased the debility by exas- perating its cause. The progress of medicine has shown, that to various modes and shades of irrita- tion of the gastro-intestinal surface, a great num- ber of affections, the nature of which was pre- viously obscure, are to be referred. We now know that many cases of what has been called idiopathic fever are of this nature, and that it is a common source of dyspepsia, hypochondriasis, jaundice, hepatic obstructions, and tympanitis; that diarrhoea and dysentery constantly arise from it; and that in very many cases ileus, constipa- tion, infantile remittent, tabes mesenterica, mela> na, and hemorrhage from the bowels, are results of this morbid state. To this cause also may be traced many of the irritations of other systems : it may produce hysteria, epilepsy, tetanus, mania, cough, and accelerated breathing, palpitation, sup- pression of urine, dropsy, rheumatism, and disease of the skin. We shall endeavour to study the history and symptoms of enteritis separately from those of gastritis, as far as this is possible; for in man} cases the coincidence of the two affections pre- vents this analysis. We shall examine first, the Acute akd Chiionic Enteritis of the l:i- faxt ; and, secondly, these affections in the adult. Enteritis may be an intra-uterine disease ; and it appears probable that many of those infants who continue in a state of debility and marasmus from birth, have really been born with this affection. In some infants who have died but a few days after birth, unequivocal marks of chronic inflam- mation of the intestine have been found; and in others who have lived but two days, the various appearances of more acute irritation have been observed. These facts render it probable that the delicacy of infants may often be owing to this cause, and should render practitioners much more cautious in the use of the tonic, stimulant, and purgative treatment. During the period of lactation, infants are ex- tremely subject to inflammation of the mucous membrane of the intestines—a circumstance at- tributable to the high degree of susceptibility which the tube is endowed with, and the great activity of the digestive function ; and in most countries also, the irregularities of diet, and the frequent use of stimulants and purgatives powerfully aid in producing this result. Enteritis may occur in the infant under two principal forms : in the first there is absence of fever, and frequently of the other sympathetic irritations, the symptoms being merely local: iv 43 ENTERITIS. the second we have the local symptoms, but with fever and signs of irritation in the nervous and respiratory systems. The first form is that to which the youngest infants are most subject, the second being more liable to occur as the child ad- vances in age. As in the adult, the symptoms vary with the portion of the tube affected, and in the youngest children they are most commonly those of gastritis and enteritis. Vomiting, diar- rhoea, tympanitic swellings and pain on pressure are the most common symptoms of this disease. The tongue is most generally dry, furred, and red at the tip, and the skin dry ; and when diarrhoea exists, an erythematous redness round the anus has been observed. Fever may or may not be present, and it often happens that the abdomen feels preternaturally hot. Towards the fatal ter- mination of the disease the skin becomes cold, wrinkled, rough, and of a dirty appearance; the emaciation, is extreme, and the muscles are soft and flabby. The character of the face is remark- able ; the hollow cheeks, corrugated forehead, and retracted mouth, giving to the child a melan- choly and singular expression of age and suf- fering. Dr. Abercrombie describes this disease in chil- dien of from six to eight months old, and states that in its early stages it is difficult to distinguish it from the ordinary bowel complaints of children at the period of dentition. He relies principally on the occurrence of fever, but we have seen that in the very young child this is insufficient, the symptoms being merely local. The following is his account of the symptoms:—"The infant is usually hot and restless in the early stages, with thirst; and the tongue is dry, or covered with a brownish crust; there is in general a good deal of screaming and fretfulness, disturbed sleep, fre- quently vomiting, and in many instances pressure on the abdomen appears to give uneasiness. The bowels are loose, but this is not in every case a prominent symptom, for even in the advanced stages the bowels may not be moved above three or four times in the twenty-four hours, white the disease is advancing rapidly to a fatal termination. In other cases, however, this symptom is more urgent, the evacuations being preceded by much restlessness and appearance of pain, and the mat- ters evacuated are sometimes discharged with a remarkable degree of force, so as to be propelled to a considerable distance. The evacuations vary considerably in appearance, and I have never been able to satisfy myself that any reliance is to be placed upon them in ascertaining the disease. They sometimes consist chiefly of a reddish- brown mucus, sometimes of a pale clay-coloured matter, and sometimes of a dark watery fluid; but in many cases they show little deviation from the healthy state, while in others their appearance is evidently disguised or modified by articles of nourishment, which pass through nearly un- changed. The disease often goes on for some time without exciting alarm or being distinguished from an ordinary diarrhoea, until attention is sud- denly directed to it by the occurrence of consti- tutional symptoms. These consist in some cases of a great degree of febrile oppression, with dry crusted tongue, thirst, and vomiting; in others, of a verv sudden and rapid exhaustion of the vital powers, which is unexpected, and not accounted for by the frequency of the evacuations; and sometimes the first appearance of unfavourable symptoms consists in the occurrence of coma, with a peculiar hollow languid look of the eye, and a pate waxen aspect of the whole body, while the pulse perhaps continues of tolerable strength. These symptoms may appear while the disease has been going on but for a short time, and while the evacuations have been by no means frequent; while the affection, in short, had not been distin- guished from the ordinary bowel complaints of infants." (On Diseases of the Stomach, &c.) Billard has observed out of eighty cases of in- flammation of the intestinal tube in infants at the breast, thirty of inflammation of the small intes- tine and colon; thirty-six of the disease in the small intestine alone; and fourteen cases of in- flammation of the colon. In twenty of the first set there was bilious diarrhoea, and in all swelling and tenderness of the belly: in twelve cases bilious vomiting took place, although there was no gastritis: in all, the erythematous redness around the anus occurred ; the tongue was in most cases red and dry, and the skin very hot and arid ; but the pulse was rarely excited to any fe- brile degree, and was frequently feeble. In the thirty-six cases where the small intestine was alone engaged, there were instances of vomiting in twenty ; and in fifteen of these latter the dis- ease was situated in the ileo-caecal region and valve. The belly was in all, at some period of the affection, tympanitic. In twenty-five there was purging of a yellowish matter, and of a sub- stance resembling meconium ; the tongue was al- most always red, the skin hot, but the pulse little excited. In these cases also the erythema around the anus was generally observed. The fourteen cases of inflammation of the colon were all ac- companied with diarrhoea, the tympanitis was much more slight, and in six of the cases only did vomiting take place. There was commonly great agitation, and a remarkable dryness of the skin, which was generally cold and livid. The pulse was scarcely excited. (Traite des Maladies des Enfans.) From these important observations it would appear that the tympanitis, vomiting, and diar- rhoea are the principal signs of the inflammation of the mucous membrane of the small intestine, while in the simple colitis it is most commonly indicated by a diarrhoea, attended with but little swelling of the belly. The absence of excitement of the pulse in these cases is a point of great practical importance, showing how guarded we should be in any case of intestinal disturbance during the period of lac- tation. This proposition then appears fully esta- blished, that in the infant at the breast fatal ente- ritis may occur without fever, and commonly with- out excitement of the pulse. We must never lose sight of this fundamental principle of diagnosis as applied in particular to sumTTi Chl drCn' that n° one Wtam is SaMv IZ^ tktdiSC™e With aM* certainty. A child may have vomiting alone or diarrhoea alone, or colicky pains without enter tS The occurrence of any one of these with fevel indeed a nearly unequivocal indication of infla^ ENTERITIS. 49 mation ; but, as we have seen, fever may be ab- sent, and then, as to diagnosis and practice, it is to the group of phenomena that our attention is to be directed. And it should further be borne in mind that although the symptoms of vomiting, diarrhoea, and pain, taken singly, sometimes can- not be connected with a state of inflammation, yet that in most cases they are really owing, if not to this condition, at least to an excited degree of action and irritability which demands the same principles of treatment. The sympathetic irritations which are most prominent in cases of the enteritis of children, are those of the respiratory and nervous systems. It is of the greatest importance that these should be well understood. It appears that although at first they are not necessarily accompanied by organic changes in the parts, yet that in most cases these will sooner or later occur, and an organ, at first only sympathetically irritated, become at last really inflamed. We may then have a true revulsion of disease, or, what is more common, a new visce- ral inflan* nation, in combination with the original disease. The child may then have bronchitis or pneumonia, or arachnitis, or encephalitis, together with the primary enteritis. We have often seen children who were sup- posed to be labouring under severe pneumonia, from the great acceleration of breathing and fever, yet on examination by percussion and the stetho- scope have found either that no disease existed in the chest, or that there was a slight bronchitis, not sufficient to account for the symptoms. In most of these cases the patients had been treated for pulmonary inflammation, and without success; and with scarcely an exception the symptoms have yielded to the application of leeches to the belly, the use of cold drinks, and the avoiding every thing calculated to irritate the gastro-intestinal surface. The symptoms of cerebral irritation are more common as a result of enteritis in the child than in the adult. We may observe all the ordinary signs of acute inflammation of the brain, such as pain, delirium, coma, &c, and yet on dissection, this organ be found without appreciable lesion, but the digestive tube highly inflamed ; and it is the opinion of some of the best pathologists, that in the infant the most common cause of hydrocepha- lus is a primary irritation of the digestive tube. On the other hand, we know that symptoms of abdominal disease will arise from an encephalitis; but of the two cases, the former appears to be the more frequent. There are three affections to which children are extremely liable, the essence of which appears to consist in an inflammatory state of the digestive tube; these are the weaning brash, the infantile remittent, and tabes mesenterica. It is now satis- factorily proved that a diseased state of the mu- cous membrane is the principal pathological phe- nomenon in these affections. The study of the symptoms, the history of the exciting causes, and the appearances on dissection, all go to establish this doctrine, which is not new, but by no means sufficiently recognised by medical men. The first of these is manifestly an acute enteritis, produced ny the change of food, and in which nature seeks to relieve the inflammation by a super-secretion; Vol. II. — 7 e and hence the danger of the too sudden suppres- sion of the evacuations, which lights up fever, and is commonly followed by cerebral symptoms. The phenomena of the second are all referable to a less violent irritation, but one which, if not relieved in time, will destroy life with the symptoms of tabes mesenterica, or if exasperated by improper treat- ment, may run the usual course of more violent inflammation. It may be objected to this view of the disease, that it is often relieved by the pur- gative plan ; but the reverse often occurs, and we constantly meet cases of tabes mesenterica, where the first symptoms were those of the infantile re- mittent, and in which this mode of treatment has altogether failed. This apparent paradox admits of explanation : where the first symptoms come on in children who have been over-fed, or have used highly indigestible articles of diet, the use of purgatives in the early stages may and does effect a cure by the evacuation of the noxious substances; but there is a period beyond which this treatment cannot be pushed with safety, and if the symptoms do not yield to the use of laxa- tives, different means must be adopted. These are means calculated to relieve inflammatory ac- tion in the mucous membrane, a state, the exist- ence of which is proved by the appearances on dissection, which include all the effects of inflam- mation on the digestive tube. The pathology of tabes mesenterica is not yet completely cleared up; but the following circum- stances are almost decisive in favour of the opinion that it arises in most cases from chronic enteritis. First. The mesenteric glands may become en- larged, inflamed, and suppurated in cases of acute and chronic enteritis both in the infant and the adult. Secondly. The great majority of cases of this affection have commenced with symptoms of enteritis. Thirdly. The dissections of most cases have shown an inflamed and ulcerated state of the mucous membrane. Fourthly. The treatment which is found most efficacious is that calculated to remove this condition of the intestine. It is true that a few cases are to be met with where the enlarged and tubercular state of the mesenteric glands cannot with certainty be traced to enteritis ; where in fact the mucous membrane does not present any trace of disease. These ap- pear to be examples of a general disposition to tubercular degeneration of the glandular system, and are exceedingly rare as compared with the others. The absence of vascularity in the mucous membrane may in some instances arise from revul- sion, such as would occur from a new and violent inflammation of some other organ; and we have seen cases where it would be attributed to mere anaemia, from the extreme emaciation of the pa- tient. This pathology of tabes mesenterica was first developed by Broussais, in his Examen des Doctrines Medicates, in the year 1816, where he declares that the tumefaction of the mesenteric glands arises from enteritis, in the same manner as bubo in the groin arises from chancre. In this disease the fever was attributed to the engorge- ment of the mesentery, when in fact both of these were secondary phenomena; the true cause was ■ not understood, and hence the uncertain and erro neous treatment of the affection. As we should expect, this result of enteritis is 50 ENTERITIS. much more common in subjects of the strumous constitution, or, in other words, in those where the lymphatic system is predominant. Hence the reason of its greater frequency in children, and, when occurring in the adult, in the scrofulous constitution. Two important facts are stated by the above author in reference to tabes mesenterica; one, that it has been observed to be more frequent during moist seasons; the other, that simple peritonitis will not produce the disease. [The inflammation of the lining membrane of the intestines of the infant, may vary in character, like that of other mucous membranes, and be ery- thematous, pseudo-membranous and ulcerated, or follicular. The inflammation of the patches of Peyer is often identical, except in intensity, with that of the typhoid affection. The appearance is the same; and, according to MM. Barthez & Rilliet, (Traite Clinique et Pratique des Mala- dies des Enfants, i. 482, Paris, 1843,) «if there be a difference between the two diseases, it must be sought for elsewhere than in the lesion of the patches (plaques.}" These gentlemen maintain, indeed, that there are many relations between ty- phoid fever and enteritis in the infant. The fol- lowing table is given by them to exhibit the man- ner in which the different intestinal lesions are combined; and to prove from the diversity of the combinations, that it is useless to endeavour to esta- blish the symptomatology of each anatomical form: Enteritis (erythematous, pseudo-membranous ulcera- ted or pustular,...................................45 Colitis, (of the same nature),.......................113 Follicular enteritis,................................ 90 Follicular colitis, ................................. 04 Softening of the small intestine, ................... 28 Softening of the large intestine, ................... 35 These lesions were associated in the same indi- vidual, so as to form the following combinations; 185 being the number of necroscopies: Enteritis alone,.................................... 2 Colitis alone, ...................................... 32 Entero-colitis alone................................ 11 Follicular enteritis alone, .......................... 12 Follicular colitis alone............................. 3 Follicular entero-colitis alone,...................... 10 Enteritis and follicular enteritis,................... 8 Colitis and follicular colitis,........................ 12 Enteritis and follicular entero-colitis............... 2 Colitis and follicular enteritis,...................... 17 Colitis and follicular entero-colitis,................. 11 Entero-colitis and follicular enteritis, .............. 7 Entero-colitis and follicular colitis, ................ 9 Entero-colitis and follicular entero-colitis,.......... 7 Softening of the great intestine,.................... 8 Softening of the small and great intestine, ......... 10 Enteritis and softening of the great intestine, ...... 1 Colitis and softening of the small intestine,......... 2 Colitis and softening of the gi eat intestine, ........ ] Enteritis, colitis and softening of the great intestine, 2 Softening of the sinall intestine and follicular enteritis, 1 Softening of the great intestine and follicular colitis, 1 Softening of the small intestine and follicular colitis, 1 Softening of the small intestine and follicular entero- colitis, .......................................... ] Softening of the great intestine and follicular enteritis, 3 Softening of the large intestine and follicular entero- colitis, ........................................... 1 Softening of the small and large intestine and follicu- lar enteritis, .................................... 2 Softening of the sma'i and large intestine and follicu- lar colitis,....................................... 2 ■Softening of the small and large intestine and follicu- lar entero-colitis,................................ 3 l.olitis, softening of the sinall intestine and follicular enteritis,............. .......................... 1 (. otitis, softening of the small intestine and follicular colitis, .......................................... 3 Colitis, softening of the small intestine and follicular entero-colitis, ................................. 3 Entero-colitis and s'ofteningof the great intestine, and follicular enteritis,............................. J Enterttis in the adult.—In describing this form of the disease we find the same difficulty in separating its symptoms from those of gastritis, on account of the frequent combination of the two affections. We still want a series of cases, observed with a view to this particular point, which, however, is not of very great practical importance; for the existence of inflammation being recognized in the digestive tube at any point of its extent, the general principles of treatment are essentially the same. We have already stated that the symptoms are found to vary with the portion of the tube affected; thus in the following affection the phenomena are often peculiar. Duodenitis.—This may be an acute or chro- nic disease, and rarely occurs without more or less of inflammation of the stomach. Hence the term gastro-duodenitis. It is now pretty generally admitted that irritations of the stomach and duo- denum have a powerful effect in inducing either functional or organic disease of the liver. Indeed, in the opinion of some pathologists, hepatic disease is almost always secondary to this state, a doctrine however which is too sweeping. But it appears certain, that in the notions hitherto received of affections of the liver, the influence of gastro-duo- denitis in their production has been greatly over- looked : thus, when jaundice supervenes in the course of a gastro-enteritis, we may diagnosticate inflammation of the duodenum in most cases, and we shall find that to this lesion are to be attributed a great number of examples of icterus. This duodenitis is quite sufficient to produce the jaun- dice, independent of any mechanical obstruction to the flow of the bile, or the occurrence of an acute inflammation of the liver; and the yellowness appears to arise either from the direct transmission of inflammation along the ducts, or, according to Ribes, by the branches of the porta, or what is more probable, from the sympathetic irritation of the liver, an irritation which will produce a com- plete jaundice, without arising to the degree of actual inflammation of the organ. This is the doctrine of Broussais; but the fact that many cases of the most acute hepatitis will occur with- out jaundice, renders it probable that we must seek some other cause than the mere degree of irritation, to explain the phenomenon. In the third volume of the Dublin Hospital Reports, Dr. Marsh details several cases of this form of jaundice, and insists on the importance of the state of the intestinal mucous membrane. In his cases, the usual cause of the affection was the drinking of cold fluids when the body was much heated, or the sudden and repeated exposure of the surface to cold after a similar state,—causes, among the most powerful in inducing gastrointes- tinal inflammation. He there instances, also, the patients were generally ailing for some days before the jaundice occurred, and the symptoms were those of a disordered state of the mucous mem- brane. The first case detailed presented the dis- ease completely predominant in the digestive tube. This state was pointed out by the symptoms, which were a deeply florid tongue, unquenchable thirst, epigastric tenderness, anorexia, or at other ENTERITIS. 51 times a canine appetite, great prostration, rapid emaciation, and dysentery. We have seen jaun- dice apparently connected with an acute inflam- mation of the gastro-duodenal surface, under two circumstances. An individual is seized, after an excess at table, or other exciting causes, with symptoms of fever with decided indications of an irritated state of the stomach. There is prostra- tion, thirst, general pain, vomiting, anorexia, foul- ness of tongue, diarrhoea, or constipation. The epigastrium is generally tender, somewhat full, and a dull pain is often felt in this situation. These symptoms may continue for a time, vary- ing from a few hours to several days, when the patient becomes deeply jaundiced. At this time the heat of skin may subside, but the prostration generally continues much longer. By judicious treatment this case generally does well, but if not relieved the affection may be fatal; and in the great majority of cases, death takes place more by an extension of disease through the intestinal tract, or by sympathetic irritation of the brain, than by the production of an acute hepatitis. This appears to be one of the most frequent forms of jaundice; and the symptoms, as to intensity, may vary from a very slight .to a severe dis- ease, accompanied with remarkable indications of irritation of the nervous system. Coma is a frequent and most unfavourable symptom; and we have observed delirium and tetanic shocks to occur. The second case in which we have seen jaun- dice connected with an inflamed state of the gas- trointestinal mucous membrane, was observed in a good many instances during the last epidemic of fever in Dublin. In the Meath Hospital, Dr. Graves and the writer of this article treated many of these cases, which, from the dreadful severity of their symptoms, and their almost complete analogy with the yellow fever, excited the greatest interest. Of this fatal form of disease, the fol- lowing description is abridged from the report of the Meath Hospital, printed for the use of the stu- dents of that institution. " In all the cases, symptoms of gastric fever, of greater or less intensity, preceded the yellowness for a few days, and without an exception, the su- pervention of the jaundice was ushered in by a great exacerbation of the symptoms of gastroin- testinal inflammation. The patient, often without any premonitory indications of the approaching danger, became seized either with spasms of the abdomen, called by the nurses " twisting of the guts" a tame which agreed singularly with the morbid lppearances found after death, or with merely hardness and extreme tenderness of the epigat-.iium and hypochondria. This hardness, accomp inied with a knotted feel of the abdominal muscles-., was speedily followed by universal jaun- dice, ge.ieral uneasiness, anxious expression of countenance, a hurried pulse, cold extremities, and death, commonly within twenty-four hours from the appearance of the jaundice. About one- half of the persons so affected raved and betrayed great restlessness, while the remainder seemed in perfect possession of their intellectual faculties to the last, but at the same time appeared in a most nervous, irritable, and desponding state of mind. They could not rest for a moment tranquil, but tossed their arms about and looked at their attend- ants with an expression of suffering and despair. Most of them vomited, and in two cases a matter resembling coffee-grounds was discharged from the stomach and bowels. The tongue was parch- ed, and in some instances covered with a black coating; and in one patient, the attempt to swal- low produced general spasms. In all, the most exquisite tenderness of the epigastrium existed; and in several the tip of the nose became purple, giving to the countenance a truly frightful appear- ance, particularly when it spread from the nose to the upper portions of the cheeks. This change was preceded by pallor and coldness of the part; this was succeeded by a leaden hue, and in twelve or twenty-four hours the purple hue was complete. The toes were in some cases similarly affected; and where the patients recovered, a partial destruc- tion of parts resulted from the disease. On dis- section the appearances in all the cases were re- markably similar. The mucous membrane of the stomach and duodenum was found in an intense state of inflammation, which also extended more or less into the small intestines, where numerous recent intus-susceptions were constantly found. The spleen in almost every case was greatly en- larged and softened, but in none did we find evi- dences of inflammation of the liver, or obstruc- tion of the gall-ducts. Slight yellowish effusion below the arachnoid was found in several cases; and in one there was a remarkable dryness of the arachnoid. Such were the appearances in about fifteen cases of this disease. There were some cases in which general convulsions were reported to have occurred, but we could not corroborate this by personal observations. In every case a general hardness and knotted feel of the abdomi- nal muscles, with extraordinary tenderness of the epigastrium and hypochondria, were observed. This was often so extreme as to make us suspect the existence of peritoneal inflammation; yet on dissection no instance of this lesion occurred. The bad symptoms generally came on without any indication of the approaching danger; the intestinal spasms being speedily followed by gene- ral jaundice of various degrees of intensity; and in the fatal cases death took place in a space of time varying from six to twenty-four hours. In every instance the patients suffered from extreme thirst, and there was nausea, and frequently vom- iting, and in one case the genuine black vomit occurred for some hours before death." With respect to the cause of the jaundi<(b in these cases, we are more disposed to connect it with the severe gastro-intestinal inflammation than with any other lesion. Perhaps the violent spas- modic action, by constricting the orifices of the ducts, might have had some effect; but the fact that many of the patients had bilious stools, and our commonly finding bile in the intestines, is against this supposition. That it did not depend on hepatitis is certain, as in no case did we find marks of inflammation in the liver. That the liver in such cases is more or less irritated is pro- bable from the sympathy which it possesses with the gastro-intestinal mucous membrane, but in both cases this irritation is secondary, and seldom amounts to actual inflammation. In one case hepatitis was observed, but the patient was n« 62 ENTERITIS. under our care; and symptoms of suppuration of the liver, with discharge of the matter through the lungs, occurred in one of our convalescent patients. In this case perfect recovery followed. In no instance did any of the attendants of the hospital contract this form of fever; from which circumstance we conclude that the change of cha- racter did not increase the contagious nature of the disease. In this country, where it is so usual to attribute many complaints to affections of the liver, it is of great importance that the connection which com- monly exists in the relation of cause and effect, between irritations of the upper part of the diges- tive tube, and derangements of the hepatic func- tion, should be carefully studied. It is true that gastro-duodenitis may exist without jaundice, or that hepatic inflammation may arise independent of disease in the mucous membrane; but it is equally true that the symptoms of gastro-duodeni- tis, both acute and chronic, are those commonly received as indicative of hepatic disease ; and that this last affection may commence by inflammation in the digestive tube. These principles must be borne in mind ; and in the treatment of such affections, if any doubt exists as to the diagnosis, it is better to give the patient the advantage of that doubt; to treat the patient for gastro-duo- denitis before we have recourse to the hazardous modes supposed to be useful in hepatic disease. It constantly happens that cases of chronic gastro- duodenitis are treated as disease of the liver. This, if proper practice was pursued, would not lead to any serious injury, as the* principles of treatment in both affections should be essentially the same ; but where purgatives and mercurials are blindly lavished, without regard to the state of parts or the constitution of the individual, the distinction becomes of no slight importance to the safety of the patient and the character of medicine. Inflammation of the Jejunum and Ileum. —It is difficult to lay down the symptoms of this affection, from its frequent combination with disease in the stomach and colon; but where the disease is predominant in this part of the tube, the symptoms are generally the following : thirst, often without any vomiting, tympanitis, tender- ness on pressure, pain, when present, not severe. In fact, if we abstract the symptoms of irritation at the upper and lower portion of the tube, such as vomiting and diarrhoea, we may have the remaining signs of intestinal inflammation arising from this cause. It would, however, be wrong to conclude that vomiting and diarrhoea always point out an extension of disease to the stomach and colon ; the contrary is the fact; but as a general rule the existence of these symptoms should lead us to suspect that the disease is not confined to the small intestines alone. When the disease is severe, we commonly ob- serve stupor, a red tongue, great thirst, tenderness on pressure, tympanitis, which is often excessive and occurring at an early period of the case, ten- derness on pressure principally observable in the hypogastric and iliac regions. Diarrhoea may be present or absent, but the latter is, we believe, the most frequent case. The pulse is generally small »nd frequent, and the features are contracted. In case of inflammation of the ileum in its lower third, which lately came under our notice, the abdominal symptoms were great tympanitis, pain on pressure, and thirst, without vomiting. In the commencement of the case there was some diar- rhoea, but this soon subsided, and was succeeded by constipation. On dissection, the stomach and colon were found perfectly free from vascularity; but the lower portion of the ileum presented a vast number of extensive ulcerations. In this case, the absence of vomiting and of diarrhoea in the more advanced periods is extremely interest- ing, as connected with the healthy state of the stomach and colon. We have more than once observed, in examining the bodies of phthisical pa- tients who never had diarrhoea, that the ulcerations and other marks of inflammation were confined to the ileum alone. In the present state of our knowledge it appears, that in cases of inflamma- tion of the ileum, the absence of vomiting and diarrhoea seems to imply a healthy state of the stomach and colon ; but on the other hand, these symptoms may occur independently of disease in these portions of the tube. The symptoms arising from sympathetic irrita- tion vary with the idiosyncrasy of the patient and the intensity of the disease. There may be a vio- lent continued fever, a remittent or hectic fever, or a completely apyrexial state. We have known one case where the most prominent symptom was so violent an excitement of the heart as to lead to the belief that pericarditis and hypertrophy of the organ existed. In the Meath Hospital we have often observed increased pulsation of the abdomi- nal aorta in these cases, a symptom which has not been sufficiently attended to. Here the exci- ted state of the vessel seems analogous to that of the radial artery in cases of whitlow, and may be perceived even where the belly is not collapsed. Under proper treatment this subsides, with the other signs of abdominal irritation. In the inflammation of the small intestines in the adult, cerebral excitement is generally not so prominent a symptom as in that of the child, nor is it so often followed by structural disease of the brain. It is sometimes very difficult to say whether symptoms of irritation of the brain, under these circumstances, are really indicative of actual inflammation of that organ. Andral relates a case where the patient, aged 35, was attacked with pain of the head, followed by great loquacity and exaltation of ideas, and other symptoms of cere- bral excitement. The tongue was natural, and the abdomen soft and not painful. He had soon after furious delirium, and indications of strong determination to the head. Copious general bleed- ing, and the application of leeches to the neck, produced no alleviation ; and the patient expired suddenly in the midst of a general spasm. The only local symptom of an affection of the bowels during the disease was a slight diarrhoea. On dissection the brain and its membranes were found perfectly healthy ; but the lower third of the ileum was in a state of acute inflammation. Other instances of anomalous symptoms might be quoted. In many cases the disease is termed simple continued fever, and extensive destruction may be going on without the occurrence of any decided local symptoms. The affection, however, should be suspected, if in addition to the general ENTEE symptoms there is much thirst, tympanitis in the early stages, and irregularity of the bowels, which are sometimes constipated, or the contrary ; the state of the evacuations does not afford much in- formation, as fatal cases have occurred where they continued perfectly natural. It is in these cases that the excess of the system of purgative treat- ment is so liable to do injury. We believe that many patients are thus lost; ulcerative perforation being induced, or the disease aggravated and ex- tended to the colon. We have also constantly seen the exhibition of turpentine, with the inten- tion of relieving the tympanitis, produce the very worst consequences. As a general rule, this sub- stance should never be exhibited in the early stage of a febrile affection where tympanitis exists. This is the disease described by Petit, under the name of the entero-mesenteric fever, of which the following accurate description should be borne constantly in mind. " There is at first a feeling of debility and general illness, with anorexia and irregular attacks of fever, but more often diarrhoea. The countenance is expressive of prostration and dejection; the eye dull, and the skin pale and livid, particularly about the lips and the als nasi; decubitus on the back; disinclination to motion ; skin dry and harsh; torpor, and a certain degree of prostration of the intellectual faculties. The fever is obscure in the course of the day, but gradually comes on in paroxysms, without rigors or much heat, but with injection of the eye and slight delirium; there is great thirst, the teeth are dry, and the tongue is covered with a greyish paste : the stools are bilious or serous, variable in their frequency or abundance, but not sufficient to account for the prostration of the patient; belly soft and not swollen; little or no pain, but on pressure pain is felt generally on the right side, between the umbilicus and crest of the ileum : there is retraction of the lips and ate nasi. The symptoms gradually increasing, we observe the cheeks to become livid, the eyes are sunk and in- jected, and somnolence and delirium become con- stant, although the answers of the patient, though painful, are correct. Petechia, subsultus tendi- num, and continued fever, with nocturnal exacer- bations, supervene; the pulse is frequent and easily compressed; the teeth are covered with sordes, and the tongue with a brownish or black crust; the belly becomes more painful, the pain being sometimes still confined to its original situa- tion, and without tympanitis, at other times more extended and with meteorism. The alvine evacu- ations become serous, fetid, and frequent, and the urine is scanty. Excoriations of the nates com- mence, and where the patient has been blistered there is a tendency to gangrene." On dissection, the digestive tube is generally found healthy until we arrive at the middle of the ileum, which presents all that class of appearances constituting the exanthcme interne of the French pathologists, the dothinenteritis of Bretonneau. This disease appears to be a common cause of what is termed an imperfect convalescence in fever. A patient, after suffering from fever for some time, becomes so much improved, that a speedy convalescence is hoped for ; but in a few days it is found that strength is not returning, the pulse continues quick, and the appetite, though E* UTIS. 53 sometimes restored, is more often deficient and capricious. A degree of stupor comes on, and there is an occasional flush on the cheek. Under these circumstances there is often reason to sus- pect this disease of the ileum, which may go on insidiously to a fatal termination, or suddenly de- stroy life by ulcerative perforation. Dr. Cheyne describes these cases in his Report of the Hard- wicke Fever Hospital for 1817, from which we extract the following important remarks:— " In these cases the distress of the patient often bore no proportion to the danger he was in; the former was very little, while the latter was ex- treme. The disease would proceed without vio- lent symptoms; nay, a patient would seem to be recovering, although without any critical dis- charge: he would call for full or middle diet, and for days take his food regularly. The only cir- cumstance in his situation which demanded atten- tion was that he regained neither strength nor flesh; he expressed no desire to leave his bed. Then his pulse again became quick and his tongue dry, and he would complain of dull pain and uneasiness in his belly, attended with sore- ness on pressure, and a degree of fulness in the upper part of the abdomen. Then came on a loose state of the bowels and great weakness : probably at the next visit the patient was lying on his back, with a pale sunk countenance and a very quick feeble pulse; his mind without energy. Then the stools (mucous") passed from him in bed, and the urine also; perhaps a hiccup came on ; next his breathing became frequent, in which case death was at no great distance. Attempts to check the diarrhoea by astringents and opiates, or to rouse the patient by cordials, were alike una- vailing ; such remedies only seemed to accelerate death." Dr. Cheyne states that in all these cases the mucous membrane and glands of the intestine were found in a state indicating decided inflam- mation during life. See also Andral, Clinique Medicate. The history and symptoms of inflammation of the large intestine, colitis, are described in the article Dysentery, to which we refer, [A few remarks may be made, however, upon Inflammation of the Coecum, to which great attention has been paid by pathologists, of late years more especially. To this the names Typhlitis and Typldo-enteritis- have been given. This inflammatory condition has already received some notice under Constipation, (p. 484.) Simple acute inflammation of the lining mem- brane of the caecum may be an accompaniment of colitis or dysentery; but it may occur independently of these. The most marked symptoms are, violent pain in the right iliac fossa, increased on pressure, by which it is rendered lancinating. The pain is constant, and often proceeds in the direction of the ascending colon. The evacuations are copious and frequent, sometimes from ten to twenty in the day, and are mucous or bloody, or both; and, along with these symptoms, there is generally gastric disturbance and fever, the pulse being accelerated and hard, the skin hot and dry, and the urine high-coloured, as in ordinary cases of severe internal inflammation. Inflammation may likewise attack the peritoneal 54 ENTERITIS. coat solely, or along with all the coats of the intestine, and these are the cases to which atten- tion has been mainly directed of late years. They are attended with more or less tumefaction in the iliac region, and are owing to some mechanical impediment in the caecum, constituting Typhlitis stercoralis. Where the disease affects the perito- neal coat, it is marked by the ordinary signs of peritonitis, or rather of inflammation of the perito- neal coat, of which constipation is one. The inflammation may extend to the cellular tissue surrounding the caecum—Perityphlitis—and is indicated by an inflammatory pain in the iliac region with distinct hardness, constipation and numbness 6f the thigh — owing to the tumour pressing upon the nerves as they pass down to the right lower extremity—and occasionally retraction of the testicle. This form of the disease may terminate by resolution, or in any of the results of cellular inflammation. Pus may form and be discharged into the caecum, or into the cavity of the abdomen -, or perforation may take place through the intestine and the parietes of the abdo- men ; and where the disease terminates fatally, a large cavity is generally observed in the vicinity of the caecum, separated from the cavity of the abdomen by the peritoneum. In a case, which fell under the writer's care, the pus was discharged into the urinary organs, and the female recovered. Idiopathic inflammation of the caecum from ordinary causes, as from exposure to vicissitudes of weather, is certainly rare. Yet the author has observed three or four cases in which no other cause could be assigned than such as might have induced inflammation in any other part of the digestive tube or of any internal organ. The symptoms, that indicate typhlitis induced by mechanical causes, are—very decided evidences of local inflammation coming on without any very obvious cause, when the patient is in health; and the comparatively slight implication of the general system, as shown by the greater or less freedom from fever. The pain commences in the very seat of the ctecum ; gradually augments for from twelve to twenty-four hours, and is constant. Careful examination now shows fulness and ten- sion of this part of the abdomen, with tenderness on pressure, and dulness on percussion ; the bow- els are constipated, and the functions of the sto- mach disturbed. The general system now sym- pathizes, and the ordinary symptoms of internal inflammation declare themselves. Any motion of the body induces pain, so that the patient lies on his back, inclining towards the right side, with the thigh bent on the abdomento to relax the abdominal parietes. The symptoms go on in this manner for some days, the affection gradually extending, more or less, over the abdomen, which now becomes full and tense. The pain over the caecum is lancinating, and the slightest touch with the finger, or the slightest covering, excites excru- ciating torture. Still, the danger does not seem so imminent as in acute enteritis, although in the sequel it may prove equally fatal. It is obvious, that a favourable termination of a case of this kind cannot be expected until the mechanical impediment yields; but if this be removed, all the symptoms soon vanish. This, however can rarely be accomplished in less than a week. About this period, it may happen that, if the bowels have not responded to the means employed, the patient's strength declines and he dies ; and it has been conceived by one writer,— Dr. Burne, — that if much blood has been ab- stracted, he may sink rather from exhaustion than from the effect of the inflammation: this, however, is scarcely probable; but if life be prolonged, there may he discovered, about the tenth day, a circumscribed emphysematous tumour in the right ilio-inguinal region, or posteriorily in the corre- sponding ilio-lumbar region, which is a fsecal abscess making its way to the surface. If in the former case, the peritoneum must be perforated after adhesions have been formed around the part to be perforated; if in the latter, the abscess tends upwards and backwards towards the least resisting part of the lumbar parietes, which is at the outer edge of the quadratus lumborum muscle. In this way, the abscess may be discharged, and recovery take place, or the patient may die worn out by irritation. Perforative abscess of the caecum must be esteemed a serious malady. Of seventy-three cases, death occurred in twenty; and in eleven others, the symptoms were so severe as to threaten life. Stercoraceous abscesses appear to be the most fatal, the ratio being five in seven, according to M. Grisolle. Inflammation of the Appendix Verrnl" formis Cseci. — The appendix vermiformis, the use of which is so obscure, and its presence even by no means indispensable, communicating, as it does, with the caecum by means of an open ex- tremity, may have substances impacted in it, which give rise to inflammation and perforative ulceration, attended with fatal consequences; for although adhesion may take place between it and the peritoneum lining the parietes of the abdomen, the more common result is for the abscess to break into the cavity of the peritoneum, and to induce fatal peritonitis. The symptoms which indicate this affection are by no means diagnostic. Generally, there is a deep-seated pain in the caecal region, with more or less fever, vomiting and obstinate constipation. The pain is aggravated by pressure ; and careful examination exhibits tumefaction, which may be unhesitatingly referred to the cajcum or to its appendix; at other times, the inflammation spreads over the whole of the peritoneum, so that the diagnosis, when the physician is first called, may be—peritonitis, general or partial. The position of the appendix is not always the same; a fact which must be borne in mind. Generally it is curled up beneath the cjecum, con- cealed by it, and on the outer side of the psoas mag- nus muscle, and, according to its position, different parts in its vicinity may be prominently impli- C£Lt6Ua It has been already remarked, that the affection may be induced by small substances becoming impacted in the appendix. In one instance, it was an intestinal concretion; in another, a pin, ncrusted with a calculous deposit, in another, a che ry-stone; in another, a grape-stone, and, in another, a tooth, which had been swallowed Ihe appendix has been found perforated-a portion having sloughed away-with evidences of E N T E E a high degree of mischief, the result of inflamma- tion ; as effusion of coagulable lymph, suppura- tion, or gangrene, in the neighbouring parts. Inflammation of the Colon. — This, like inflammation of the rest of the intestinal canal, may affect either the peritoneal or the mucous coat. When seated in the latter, we have the phenomena of dysentery, (q. v.) When the peritoneal coat is inflamed, there may be constipation, and the usual signs of exo- enteritis, except, that the mischief is referred to some part of the colon,—the ascending, transverse or descending portion, and that the affection of the general system is much less than when the same pathological condition is seated in the small intes- tine. The nearer, too, the inflammation is to the rectum, the less acute and violent is the disease. When in the transverse colon, it is often ex- tremely obscure. Commonly, there is considera- ble pain upon pressure, with more or less disten- sion of the colon, meteorism, constipation, vomit- ing, great restlessness, along with the signs of internal inflammation. When colitis passes into the chronic state, we may have all the results of chronic inflammation of the peritoneal surface of the small intestines,— adhesion of the colon to other viscera, thickening of the parietes of the intestines, with diminution of the caliber,—at times, to such a degree as to occasion obstruction, and death, &c. &c. Many morbid conditions, that are referred to the stomach or liver, have their seat in the colon. Owing, too, to the attachments of the colon, and its immediate proximity to several important organs, its unequal distension and frequent changes of position, various sympathetic affections are induced, the nature of which is often mis- understood.] The foregoing view of the symptoms of inflam- mation of the mucous membrane of the intestine will suffice to give a general idea of the disease, of which, however, there are many other modifi- cations. To enter more fully into these would occupy too much space, and hence we shall pass at once to the consideration of the pathological anatomy of the digestive tube. Now, in order properly to estimate the morbid, it is necessary, in the first instance, to take a view of the healthy condition of this organ. It is now demonstrated that a great variety of shades of colour may exist in the mucous mem- brane, independently of any diseased action what- soever. The situation of the part, the age of the patient, the process of digestion, and the length of time after death, will all modify the colour of this tissue. Its natural colour, however, may be stated to be greyish-white in the duodenum and jejunum; the greyish tint diminishes to the end of the ileum, and in the large intestine the colour is white. This may serve for a general descrip- tion. When we examine the intestinal mucous membrane of the foetus, we find it of a rosy colour, which diminishes after birth ; in youth, the white colour becomes gradually less vivid; and as the individual advances in age, the greyish tint be- comes manifest. The mucous membrane, however, is seldom met with so slightly coloured, and when we speak of the value of redness as a sign of disease, we ilTIS. 55 shall examine the various sources of this change of colour. In the state of health the gastro-intestinal mu- cous membrane varies in its thickness, according to the part of the tube examined. Billard has described it as most thick in the duodenum, and the thickness as diminishing in the following order of parts: the stomach, rectum, jejunum, ileum, and colon, where it is thinnest: it is obvious, however, that unless the increase or diminution of thickness be considerable, its value in a patho- logical view cannot be great; and, independent of intestinal disease, it may present appreciable differences. Thus, in cases of great emaciation, the atrophy of the membrane is often extreme, while in examples of mechanical congestion its thickness is frequently much increased. Louis has attempted to determine the exact depth of the mucous membrane by measurement; but this is a mode not applicable to general use. As to its consistence, this is stated to be in the direct ratio of the thickness; hence, if in those situations where the membrane has naturally the greatest thickness, we find its consistence only equal to the thinner portions, it is plain that from some cause this has been diminished. It is difficult to meet with cases on which to try the accuracy of this assertion. We have been led to doubt il more than once, but the impediments to the in- vestigation are very considerable; the greatest experience is required to enable us to decide on the healthy consistence of the part; and we seldom meet with the tube free from some active or passive congestion : add to this, that many other circum- stances cause variations in the cohesion of the membrane, such as the presence of liquids in the tube, putrefaction, atmospheric heat, and a fluid state of the blood. The mucous follicles have lately attracted the particular attention of patholo- gists ; and to their inflammation several remarka- ble disorganizations may be referred. Thus, in very many cases of intestinal ulceration, the de- structive process seems to be primarily seated in these glands. Bretormeau has indeed described a peculiar disease, called by him dothin-enteritis, consisting in an inflammation of these glands alone; but it is still to be shown whether this disease in reality differs from other examples of intestinal inflammation. In these countries the writings of Drs. Hewett, Bright, and Abercrombie have contributed to draw the attention of physi- cians to these glands. We find these bodies, in the state of health, most developed in the duodenum and stomach, and in some cases also the glands of Peyer are observed distinctly in the small intestine. This is more remarkable in children, but still their en- largement alone in the adult must not be consi- dered as an unequivocal indication of former or actual disease. Lastly, we have the sub-mucous and sub-seious cellular membranes, and the two orders of muscu- lar fibres, in which tissues disease may produce a great increase or diminution of volume. The muscular fibres are compared by Andral to the muscles of white-blooded animals, and are found strongest at the pyloric portion of the stomach and in the rectum. This tunic of course appears thicker where the intestine is contracted, and 56 ENTERITIS. like the heart, may become atrophied in cases of general emaciation. We often, indeed, meet wit.i cases where the demonstration of these fibres is a matter of great difficulty. The natural condition of the intestine is a col- lapsed but pervious state. Dr. Abercrombie, in his theory of ileus, holds that the cord-like con- traction is the normal condition of the part; but in this opinion he is completely singular : con- traction of a muscle implies the communication of a stimulus, and cannot be considered as its natural state. But the consideration of these tissues alone will throw little light on the physiology or patho- logy of the intestinal canal, if we do not take into account that its surface presents a prodigious vasculo-nervous expansion, where, in a manner analogous to the retina in the eye, or the portio mollis in the internal ear, the (sentient) extremities of the organic nerves, and to a certain degree of those of the life of relation, are extended. It is, to use the words of Broussais, an internal sense, and thus can be understood its numerous sympa- thies in health and disease. There is no organ in the body where the deter- mination of the value of morbid appearances is so difficult, and hence it is necessary to investigate a great number of circumstances before we can say whether the mucous membrane has or has not been in a state of disease. In general these diffi- culties are not sufficiently estimated ; and it is to be regretted that one class of pathologists are too hasty in ascribing every change from the physiolo- gical condition to a process of irritation ; in these eountries, indeed, vascularity alone is too often taken for an unequivocal indication of the previous existence of inflammation, a circumstance which invalidates many of our accounts of morbid changes in the digestive system. We shall see that vascu- larity alone, in all its forms, does not prove the previous existence of inflammation ; and that, fur- ther, the converse of the proposition will sometimes be found to be true. It may be laid down as a general principle, that no morbid appearance what- soever, taken singly, is a certain proof of the oc- currence of inflammation. Even ulceration, per- haps the most certain of all, may occur under circumstances in which it is difficult, if not im- possible, to trace it to an inflammatory origin. The following are the results of inflammation on the intestine:—1. Increased vascularity, or hyperemia. 2. Increase or decrease of develop- ment. 3. Induration, or softening. 4. Ulcera- tion * Obange of secretion in quality or quan- tity. 6. Alterations of sensibility. Vascula-ity.—The great principle to be recog- nised in determining the value of this condition, as a proof of inflammation, is, that there is no- thing in its intrinsic characters sufficient to point out the nature of its origin. Many authors have described certain kinds of injection indicative of active or passive congestion; but the researches of Andral have shown that the distinctions relied on are by no means certain, and this also is the result of our experience. By a careful examina- tion, however, of the concomitant circumstances, we shall, in most cases, be enabled to decide the question. Capillary iniection, putting aside some if its rarer sources, may generally be stated to arise from one of the following causes :—1. ac- tive irritation; 2. congestion from abstraction of the venous circulation ; 3. congestion from posi- tion. We may compare, by opposite characters, the inflammatory and non-inflammatory redness. Non-inflammatory redness. Inflammatory redness. 1. Occurring indifferent- ly in the depending or non-depending portion of the tube. 2. General injection rare. 3. Without venous struction. ob Most distinct in the depending position. 2. General injection com- mon. 3. Commonly arising from obstructions in the porta, heart, or lungs. 4. Generally occupying a large portion of the intestine. 5. Without much soft- ening. 6. Without these altera- tions. 4. Sometimes slight and local. 5. With softening of the submucous cellular membrane. 6. With alterations the quality or quanti- ty of mucus. By means of this table, which, with some alter- ations, is taken from the work of Billard, we may in most cases determine the nature of vascularity occurring in the intestinal mucous membrane. The presence or absence of ulcerations, of fun- goid elevations, of lymph, the state of the submu- cous follicles, the occurrence of thickening, and, lastly, the history of the case, will aid further in deciding the question. It has been remarked that the active and passive congestion differ in the cir- cumstances of their formation; in the latter the injection proceeds from the large vessels, which are first distended to the capillaries, while in the former the reverse takes place. This may be a test in the earlier stages of the process. From the consideration of the different causes of redness in this tissue, it would appear that be- fore we conclude that vascularity in any case is an unequivocal sign of inflammation, we must in the first instance inquire whether it is not the re- sult of the process of digestion; secondly, whe- ther it may not be owing to a fluid state of the blood, as observed by Morgagni; thirdly, whether it arises from putrefaction, exposure to air, or the depending position; fourthly, whether it is the result of the congestion which occurs immediately before death in tissues abounding in vessels; fifthly, whether it is caused by obstructions in the aorta, heart, lungs, cava, or vena porta. Other causes of redness, independent of inflammation, are noticed, but they are not of great importance, except in the case of a patient dying in the cold stage of intermittent, where the viscera are found loaded with blood. These considerations show the difficulties that exist in the decision of this question, and should make us doubt the reports of inflammatory appearances in the digestive tube, unless made by the most experienced patho- logist. The shades of colour which are produced by a process of irritation are very numerous, but may be reduced to modifications of red, brown slate- ENTERITIS 5? coloured, and black; of these, the first is most commonly, though by no means universally, the product of an acute inflammation, while the three last are nearly exclusively the result of a chronic process, in which the colouring matter of the blood, variously altered, becomes incorporated with the tissue of the mucous membrane. Of the red colour, Billard enumerates six varieties, viz., the ramiform and capillary injection, the punctuated and striated redness, that occurring in patches, and, lastly, the diffuse. Bearing in mind that all these may be the result of other causes besides irritation, and that we must look to the ;oncomitant circumstances to decide upon their nature, we must admit, with the author just men- tioned, that the first of these, consisting of a very slight injection, must be the result of a feeble irri- tation, one to which the flux is by no means con- siderable. In the second species the injection is finer and closer, and points out a much higher degree of irritation. This is often seen in the neighbourhood of ulcerations. The punctuated redness is less common in the-intestines than in the stomach ; its appearance may be compared to that produced by finely sprinkling a surface with red paint, and it does not point out an intense de- gree of irritation. As to the striated redness, we have most usually found it in cases of chronic enteritis, where, for a considerable length of the tube, the prominent edges of the valvulae conni- ventes were of a deep red colour, giving to the intestine the appearance of circular stripes. It sometimes coincides with a puriform secretion and an indurated state of the submucous cellular tis- sue. The last two species are the most import- ant ; here the vascularity is intense ; so much so as to obliterate the traces of the capillary vessels, and give to the membrane a continuous blood-red colour. They may both be the product of an acute or chronic inflammation, but generally arise from the first cause. The diffuse redness is sometimes found of great extent, and points out a most se- vere disease. We have often seen the mucous membrane, in such cases, exactly similar to the conjunctiva of the eye-lids in the worst forms of purulent ophthalmia. This appearance was found in most of that singular set of cases, greatly re- sembling the yellow fever of warm climates, which were observed at the Meath Hospital dur- ing the late epidemic of fever. It is the result of the highest degree of idiopathic inflamma- tion ; it is no longer an injection, but an active ecchymosis. The brownish, slate-coloured, and black appear- ances of the mucous membrane are generally re- lerred to a very chronic irritation. The last, in- deed, is most commonly seen in cases of diarrhoea of long standing, and occurs with other indica- tions of a profound morbid action. It is, however, seen in some cases of a high degree of acuity, as in instances of corrosive poisoning, and in the yel- low fever and dysentery of tropical climates. This is important, as connected with the opinion of Broussais, where, in speaking of the black colour of mucous membranes, he holds that in most of these cases an acute had preceded the chronic state. An important question here arises—do these ippearances of inflammation always furnish an Vol. II—8 accurate measure of its intensity. We have seen that there are circumstances foreign to irritation that may increase this vascularity, such as posi- tion, mechanical impediments to the venous cir- culation, &c. Hence, in certain cases, the appear- ance of inflammation may point out a greater de- gree of disease than had really existed. But does the reverse ever occur ? Can inflammatory in- jection exist, and yet wholly or altogether disap- pear after death 1 Bichat and Broussais are both in favour of this opinion, and hold that although no redness may be found in the part after death, yet, notwithstanding, it may have been inflamed and vascular during life. This is a doctrine of importance from the dangerous use which may be made of it in pathology. It is true that after death the traces of erysipe- las will greatly, if not altogether, disappear in some cases, and the same has been observed with re- spect to the redness of a sore throat. Bichat ex- plains this by stating that the injection of the ca- pillaries ceases as soon as the irritation which caused it becomes extinct with the life of the pa- tient, and lays great stress on this point in its ap- plication to morbid anatomy. But cadaveric pal- lor of parts previously inflamed, though occurring in some cases, is far from being a general pheno- menon, and where the inflammation has been in- tense, as in severe cases of erysipelas or angina, the redness will remain long after death. Besides, it is scarcely logical to draw conclusions as to the viscera, from what occurs on the surface. We know that in most cases of death the blood ap- pears to forsake the exterior, to accumulate in the interior of the body, and that this process goes on for some time previous to the extinction of life. If this post-mortem emptying of the capillaries went on in the mucous membranes as we see it in the skin, redness of these tissues should be as rare as that of the skin ; but the contrary is the fact. We may admit the possibility of this subsidence of the appearances of inflammation of the mucous membrane in very slight cases; but looking at the phenomena of death in general, we must hold it more probable that these appearances will be aug- mented rather than diminished on the cessation of life. But there is one cause for the want of redness even where a high degree of irritation has existed in parts, namely, the supervention of inflamma- tion in other viscera, which, from its excess, causes an actual revulsion. Thus, when a bronchitis subsides on the supervention of a fatal diarrhoea, we may find the bronchial membrane free from vascularity, or vice versa. The cause is alluded to by Billard. In the severe gastro-catarrhal fever, we constantly observe alternations of seve- rity in the abdominal and thoracic symptoms, and more than once we have seen cases in the early stages of which the symptoms of enteritis were severe, but subsiding when the thoracic irritation became intense, and have found thi intestinal membrane pale, although ulcerations and other disorganizations were present. With respect to the relative frequency of inflam matory redness in different parts of the digestive tube, it is agreed that the stomach and lower pari of the ileum are most commonly engaged, and il is remarkable that the two affections often coin 58 ENTERITIS. cide. This has led to the term gastro-enteritis ,- a term, however, which cannot be adopted, as the coincidence is by no means universal, and as by a too great generalization, it leads to an erroneous view of the disease. The order of frequency, as given by Andral, in the remaining portion of the intestine, is as follows :—the cscum, colon, rec- tum, duodenum, superior portion of the ileum, and, lastly, the jejunum. Increase of development, or hypertrophy of the coats of the intestine, is generally the result of a process of chronic irritation ; the thickening of the mucous membrane which occurs in acute affections being more apparent than real, and owing to vascular turgescence merely, white that in the chronic cases is a true hypertrophy, the re- sult of an increase of nutrition. The parts which, in acute diseases, are most usually increased in bulk, are the mucous membrane, and the glands of Peyer and Brunner, while all the constituents of the tube may become hypertrophied in the chronic enteritis. The thickness of the sub-mu- cous cellular tissue is rarely altered in acute, but commonly in chronic cases. When the mucous membrane is hypertrophied, we find the change to be circumscribed, or the contrary, and seldom observe the tissue equally thickened. In the large intestine we have com- monly found the mucous membrane elevated into numerous nodules, of about the size of a pea, be- tween which ulcerations, or a lesser degree of hypertrophy, existed. Numerous varieties of these elevations are described by authors. In cases of this hypertrophy the consistence is gene- rally increased, and the colour dark : and it rarely happens that the change is confined to the mu- cous membrane alone ; it occurs much more fre- quently in the large than the small intestines. But of the forms of hypertrophy of the intesti- nal tunics, that of the sub-mucous cellular tissue is the most important. In this state we find it a dense white layer, sometimes more than two or three lines in thickness, presenting a distinct fibrous structure, and giving to the whole tube a remarkable feeling of thickness and rigidity. The induration is often so great as to cause a grating- sound when the intestine is divided by the scis- sors. The principal seat of this alteration is the sub-mucous, but we have often seen it to engage also the sub-serous cellular membrane. It is in the large intestine that the change is most usually observed, where, after chronic dysenteries, it is found in conjunction with other disorganizations. In the small intestines, however, it may be met with, generally partial, and in the vicinity of old ulcerations ; but in a few cases of severe chronic enteritis we have found hypertrophy of the whole cellular membrane from the pylorus to the anus. These were cases where severe symptoms had continued for months, the patients presenting that 6'mgular tenacity of life observable in greatly ema- ciated subjects. To this change is to be referred most of the cases of organic stricture of the intestine : indeed, when examined anatomically, we can see in this disorganization nothing but a partial hypertrophy of this tissue, generally traceable to a process of inflammation in the mucous membrane. We say generally- traceable, for although in the present state of the science we must attribute most of these cases to this cause, yet in some it may arise from a morbid process, not originating in or ex- tending to this tissue. These, however, may be looked on as exceptions to a general rule, and, at far as we have seen, seem connected with a dispo- sition to cancerous degeneration of the cellular membrane, both in the solid and hollow tube. This alteration, as a result of chronic enteritis, may be met with in all ages, from the infant to the octogenarian. It is, however, stated to be most common between the ages of thirty-five and sixty-five, and that between puberty and the first of these periods it rarely occurs. We have already alluded to the atrophy of the intestinal tube, a change which may be confined to the mucous membrane alone, or engage all the coats of the intestine. How far atrophy can be referred to a process of inflammation does not yet appear to be determined, as there is a difficulty in the circum- stances of the general nutrition being impaired in these cases. We have seen ulcerations coinciding with an atrophy of the intestine, but in all these cases great emaciation had existed some time pre- vious to death. This atrophy appears always to coincide with a softened state of the mucous mem- brane. Change of consistence is always admitted as one of the consequences of inflammation, and, with a few exceptions, the rule, that a chronic irritation tends to harden, while an acute tends to soften parts, is generally found to be true. In the gastro-intestinal mucous membrane the latter part of this proposition is, in our experience, always true; but we cannot make this statement with respect to the first part, the fact being that an indurated or softened state may result from a chronic enteritis, though the first effect is the most usual. We have found the indurated state of the mucous membrane under the two following cir- cumstances : first, in cases of chronic dysentery, where the mucous membrane of the colon was hypertrophied and ulcerated ; between the ulcera- tions the consistence of the membrane was greatly increased : secondly, we have seen, in cases of scirrhous degeneration of the subjacent cellular tissue, the mucous membrane of the small intes- tine singularly changed ; it resisted traction re- markably, had lost the velvety feel, and gave to the touch precisely the sensation that is presented by the vagina in cases of advanced cancer of the uterus. The parts most indurated appeared to be the projecting edges of the valvulae conniventes, and the whole of the membrane was studded with extremely minute and hard granulations. We now come to the consideration of the inflammatory ulcerations of the intestine. When we compare the bronchial and intestinal mucous membranes in their pathological states, we must be struck with the difference in the frequency of ulcerations in these tissues. In the first, they are of rare occurrence, in the latter extremely com- mon ; in the first we constantly see an acute or chronic inflammation without a trace of ulcera- tion, in the latter this effect constantly results from both these forms of disease. This difference may be explained by considering the great pre- dominance of the mucous crypts in the gastro-in- testinal system, as compared with the respiratory. ENTER In fact, for the healthy performance of the respira- tory function, a very small quantity of mucous secretion is required, but the reverse is the case as to the function of digestion. We must also take into account the greater exposure of the di- gestive canal to chemical and mechanical stimula- tion. The circumscribed ulcerations of the intestine may be divided into two classes, those affecting the mucous membrane alone, and those engaging both this tissue and the mucous glands. The first of these species is the rarest; the second is ex- tremely frequent, and is called the follicular ulcer- ation. As the minute description of these ulcerations is not of much practical importance, we shall not enter into the subject here, and shall merely refer to the late works on pathological anatomy, and to the article Fever, for complete information. Suffice it to say, that they are extremely frequent, and that their varieties, with respect to number, appearance, and accompanying disorganizations, are infinite. The cases in which they are most frequently met with are the following :—typhous fever, with predominance of gastric symptoms ; dysentery ; long-continued diarrhoea ; stricture of the intestine; infantile remittent; tabes mesente- rica ; tuberculous phthisis, and in cases of hyper- catharsis, from an over-dose of purgative medicine. In the great majority of cases these ulcerations do not perforate all the coats of the intestine, but in a few this does occur, and the result is most commonly an effusion of the contents of the in- testine into the peritoneal cavity, and consequent rapid peritonitis. Two important facts seem as- certained with respect to these perforating ulcers, first, that they are almost always the result of disease in the mucous follicles, and, secondly, that they are more liable to occur from acute and circumscribed than from chronic and extensive disease. We may explain this by considering, that in the chronic ulcerations the cellular mem- brane at the base of the ulcer is generally more or less indurated and hypertrophied, which gives it an increased power of resistance to the ulcerative process, and also that from the general emacia- tion which commonly occurs in such cases, the tube is in a state of anaemia, where, of course, in- flammatory action will occur with a lesser degree of activity. The extent of the disease, by dimin- ishing its intensity in any particular point, may also contribute to this result. The situation of the perforating ulcer is remark- ably similar in most of these cases. In the ten examples recorded by Louis it occurred somewhere in the last twelve inches of the ileum, and out of the same number observed by us in the Meath Hospital, but one instance occurred where it was in a different situation, namely, the csscum. This ulcer was also remarkable in not presenting the follicular character. We may remark, that these observations as to the situation of the perforating ulcer apply principally to the acute cases. Effusion of the contents of the intestine is not a necessary result of this lesion, as the serous co- vering of the adjacent fold of intestine may form adhesions round the edges of the ulcer, and thus constitute its base, or a direct communication may 1ITIS. 59 be formed between two portions of the tube pre- viously in contact. In both these cases the oc- currence of general peritonitis is not a necessary consequence. (See the article Peritonitis.) Treatment. — We shall first examine the treatment of the disease as it occurs in the infant and child. In most instances of this affection we may admit of two stages, indicating a different treatment; the first, where the antiphlogistic me- thod is to be our chief resource; the second, where revulsives and the cautious use of the tonic plan are indicated. In this affection it is not often necessary to have recourse to the lancet, although such a case may arise, as where the symptoms are violent, the fever high, and the constitution healthy and ro- bust : here venesection cautiously performed will generally be followed by the best results, and be the best preparative for other measures. In these countries a prejudice against bleeding in the child sometimes exists, but we believe that it is un- founded. More than once have we seen the symptoms continuing with violence, and even re- sisting the employment of leeches, until blood was taken from the arm; then the remedies which had before failed acted well, and recovery was pro- gressive and ultimately complete. When we cannot succeed in opening a vein in the young infant, the mode from which most advantage is derived, is the application of a leech or two to the back of the hand or foot, and afterwards plung- ing the part into warm water; in this way we can obtain a considerable quantity of blood, and the hemorrhage is easily controlled by a bandage. If the bowels should not be open, it is advisable to procure a moderate evacuation of the tube, but no violent or irritating purgftive is on any account to be given, and we should trust chiefly to the mildest laxatives and to injections, which are al- most always productive of the best effects. It sometimes happens, after the above means have been employed, that the disease appears either to be subdued or greatly lessened in its intensity; the tongue cleans and the fever is much diminished ; but in more violent cases this alteration is scarcely perceptible, and then no time is to be lost in ap- plying leeches to the belly. This may be done at all ages, and is without exception our most pow- erful remedy in most cases. The number must be proportioned to the violence of the disease and habit of the patient. We have seen three or four leeches applied to the abdomen of an infant of twelve months old with the best effects ; but, as a general rule, a leech for every six months of the child's age up to that of four years would not be excessive. These may be re-applied according to circumstances, for it often happens that symptoms, scarcely if at all affected by the first application, will subside on the second. The prejudice against the use of leeches in the diseases of children is fast wearing away; in fact, the only objection of weight is the difficulty of arresting the hemor- rhage. For this purpose the simplest and most efficacious mode is the application of the solid nitrate of silver to the leech-bite. A stick of caustic should be cut down to an extremely fine point, and being pressed to the bottom of the wound, (which should be previously dried by a 60 ENTERITIS. little lint,) and given a turn or two, is then to be withdrawn : this seldom fails to stop the bleeding at once. The internal remedies from which we have s-en most advantage are the combination of a mild mercurial with Dover's powder, and, in the next place, gummy solutions. The hydrargyrum cum creta, with Dover's powder, may be given in repeated doses, proportioned to the age of the pa- tient. An over-degree of narcotism is, of course, to be avoided; but it frequently happens that, after a decided opiate effect has been produced, the symptoms of intestinal irritation greatly sub- side. It is a remedy that requires caution in its exhibition, but one of great utility. It sometimes constipates, and when this occurs it may be omitted, and a small quantity of castor oil or manna may be given, assisted by an emollient injection ; and when these have performed their office, the remedy can again be resumed. In some cases it may be desirable to produce a decided mercurial action. To excite this in the child is a matter of great difficulty, and our own experience leads us greatly to prefer the external application of mercurial ointment to the adminis- tration of much calomel. We have known a mer- curial plaster, or dressing a blistered surface with the ointment, answer remarkably well. But in every case we should endeavour to remove the disease without the exhibition of a great deal of mercury, as its effects in children of an unhealthy habit are often most formidable. Blisters have been used in this disease with various results, and if they are not employed until the advanced stages of the affection, and are em- ployed only as secondary to general or local bleed- ing, they will often be useful. In young children they should never be left on for more than two or three hours, and in older patients they should be removed as soon as uneasy sensations are per- ceived from them. It is always advisable to insert a piece of silver-paper between the blister and skin. As a general rule, it may be stated that blisters should not be used when the skin is very hot, the fever high, and the patient in a state that would admit of general or local bleeding. Perhaps they may be more safe in those cases where the mucous inflammation has arisen from the suppres- sion of a cutaneous irritation. There is a difference of opinion about the utility of the warm-bath. We have found it chiefly useful in the advanced stages, and where there is much diarrhoea; but it appears to us that the practice of diligently fomenting the belly is as serviceable, and one which may be used in all stages. The little patient must be kept on an extremely strict regimen, and every thing that could possibly disagree must be avoided. A strict regimen is peculiarly necessary in the enteritis of children, as the slightest irregularity in this respect may pro- duce a fatal relapse. Cold water may be freely ■illowed and may be slightly acidulated, according to the feelings of the patient; in addition to which we have always been in the habit of administering in some quantity a solution of gum arabic, and have seen, in cases where the disease predomi- nated in the lower portion of the tube, the most decided benefit from it. But after the first week of the disease it becomes necessary to attend to the support of the patient. Many children are lost bj the practitioner neglecting this point. Small quan- tities of the farinaceous foods, milk and water, and very weak chicken-broth may be used, and their quantity regulated by the effect on the symptoms. These should be given at stated intervals of time, say every third hour ; and it may even be neces- sary in the advanced stages to administer a little wine, particularly when the skin is cool, the coun- tenance sunk, the mouth covered witr sordes, and the stools involuntary. Should this excite a too strong re-action, it can be omitted, and again re- sorted to if necessary. Great attention must be paid throughout to prevent excoriation of the back, and to preserve the warmth of the extremities, and the apartment should be kept at a regulated tem- perature. This, among its other advantages, will tend to prevent the liability to bronchitis, which disease sometimes carries off the patient after the subsidence of the enteritis. Enteritis in children is commonly mistaken for worms, and thus improperly treated. Drastic purgatives are lavished; the increase of symptoms and the marasmus are attributed to the persistence of the worms ; until at length typhoid symptoms appear, or the child falls into the state of tabes mesenterica. These cases are always of the worst description from obvious reasons. It would appear that when the disease arises from the use of indi- gestible food, or from constipation, purgatives cautiously exhibited at the outset are useful; but if after the unloading of the bowels the symptoms continue, it is a sign that something more than mere irritation from the presence of noxious sub- stances exists, and that we must treat the disease as one of enteritis. These remarks apply equally to the enteritis of the child and adult. The indis- criminate system of purging in all cases is the opprobrium of British medicine; for it is a fact that, since the writings of Hamilton and Aber- nethy, too many practitioners have had, in the treatment of digestive derangements of most kinds, but two objects in view, the one, of giving doses of purgative medicine, the other, the quantity and quality of the fascal discharges ; while the gastro- intestinal surface, that prodigious vasculo-nervous expansion, has been wholly unheeded and for- gotten. Cerebral symptoms often supervene in the course of this affection, and it is sometimes difficult to say whether they proceed from actual disease of the brain, or merely indicate a sympathetic excite- ment not amounting to positive inflammation. But we know that sympathetic irritation cannot long exist in so delicate an organ as the brain without producing disease, and further, that we cannot tell when this change takes place. Hence the safe mode of proceeding is always to treat the cerebral symptoms as if they really proceeded from encephalitis. In such a case it is generally unne- cessary to use the same degree of vigour in treat ment as if the disease was idiopathic inflamma- tion. When the disease occurs in the adult, the chief remedy will be found to consist in the detraction of blood generally and locally, but particularly the latter, unless in cases where the symptoms run high and threaten peritoneal inflammation. Here the lancet is never to be neglected, and ENTERITIS. 61 its use must be repeated frequently if the vio- lence of the disease is not subdued. Dr. Aber- crombie recommends the practice of following up Ihe first bleeding by smaller detractions of blood, so as to keep up a decided impression on the sys- tem. It seems, however, that in most cases we may look on general more as a preparative for local bleeding, which, when properly performed, is a means of extraordinary value. Facts, how- ever, oblige us to admit the efficacy of general bleeding alone in reducing inflammations of the mucous membrane. (See Cheyne's Report on Dysentery.) When the disease exists in the small intestine, we have always found most ad- vantage from local bleeding. It may be performed at various stages of the disease, even when there is great adynamia, and will seldom disappoint the practitioner. Leeches should be applied abun- dantly round the navel or to the ileo-cascal region, and the hip-bath used when they fall off. If the symptoms do not yield at once to this treatment, the leeching is to be boldly repeated, and a large poultice applied over the belly. The bowels are to be gently opened by the mildest laxatives, and emollient injections should be frequently given. The most distressing symptoms in this disease are the vomiting, thirst, tympanitis, and diarrhoea. It is often very difficult to allay the first of these. We have found nothing so efficacious as the ap- plication of a dozen leeches to the epigastrium, and the liberal use of iced water, or even plain ice, which may be given nearly ad libitum. It is a most grateful and important remedy, and one from which we have never seen any unpleasant results. In the more advanced stages of the dis- ease we have constantly applied leeches to the epigastrium, though in a smaller number, and have seen that assemblage of phenomena which constitute the typhoid state speedily disappear after their use. In addition to this, we have in the hospital often applied a small blister over the region of the stomach, and afterwards sprinkled the surface with a little acetate of morphia, a practice which, in some cases, succeeded remark- ably. Effervescing draughts, with the carbonate of soda or ammonia, may be exhibited, but not in too great quantity, as violent diarrhoea and exas- peration of all the symptoms may be the result of this excess. Lastly, opiates, and, in some very advanced and low cases, stimulants may be used with advantage. The thirst may be moderated by the use of cold acidulated drinks, such as lemonade, the cream of tartar solution, and tama- rind-tea; but let it never be forgotten that the means best calculated to remove these symptoms are those calculated to reduce the inflammatory action. The tympanitis, when it arises, is a symptom commonly maltreated from ignorance of its pathology. Occurring in the early stages of the disease, it is generally in proportion to the in- tensity of the inflammation. It is a distressing symptom, and hence practitioners are over-anxious for its removal, and are tempted to exhibit turpen- tine. From witnessing a great number of cases where this practice has been pursued, we feel certain that the exhibition of turpentine or analo- gous remedies for the removal of tympanitis in the early stage is a practice pregnant with danger. ft often, indeed, renders the belly flat; but this apparent advantage is commonly followed by an increase of the other symptoms ; and the tympa- nitis is sure to return. If the symptom be not severe, its presence should not make us modify our treatment; if it is excessive, it becomes a sign for increased activity in means calculated to reduce the inflammation without endangering the safety of the patient. In addition to this, stimu- lating injections, where there is not tenesmus, may be used, and enemata of cold water in all cases. In the stages of the disease, however, where depletion can no longer be practised, the use of turpentine is sometimes successful, a cir- cumstance reconcileable with our knowledge of the effects of stimuli in the advanced periods of mucous inflammation. Nearly the same remarks apply to the diarrhoea. The exhibition of astringents in the early stages is generally followed by the worst effects, a cir- cumstance favouring the doctrine that the secre- tion is the relief of the inflammation ; but when the powers of life are low, and the disease not acute, we must moderate it. This is best done by the warm bath, a flannel roller, the occasional ap- plication of a blister to the belly, anodyne injec- tions, and the use of small doses of Dover's pow- ders, with or without rhubarb. Where the diar- rhoea was severe and the patient much depressed, we have often used large doses of opium with the best effect. The remarks as to revulsion, regimen, &c. which we made in treating of the enteritis of children, apply equally in this form of the dis- ease. [The treatment adapted for inflammation of the caecum is that of local inflammation in gene- ral. General blood-letting may be required, but it cannot be nscessary to repeat it often. The great indication is, to temper the inflammation as far as possible, and especially to remove the cause, where the disease is owing to hardened excrement, or to any undigested matter,—as stones of fruit, char- coal, magnesia, &c, which are sometimes known to lodge in the caecum. Simple typhlitis of the mucous membrane re- quires the same treatment as colitis; and peri- typhlitis the same management as any case of partial inflammation of the cellular or serous mem- branes. In cases of inflammation of the caecum from mechanical causes — typhlitis stercoralis—after general blood-letting has been practised, leeches may be repeatedly applied ; the practitioner bear- ing in mind, however, that if he be unable to pre- vent the supervention of suppuration, he may do mischief by reducing the powers too much. After the leeches have dropped off, a large warm poul- tice may be applied, or if this cannot be borne, a hot and dry fomentation of chamomile flowers in a flannel bag. The most important fomentation is warm water sent copiously into the colon, which may be thrown in by means of one of Dr. O'Beirne's rectal tubes. In this manner, the im- pediment may be removed. If repeated glysters be unable to accomplish this, cathartics—as oleum ricini, or infusion of senna with salts — may be administered, in addition, by the mouth. It can rarely be necessary to have recourse to more powerful remedies than these, repeated every 62 ENTERITIS —EPHE LIS two hours until an evacuation takes place, and aided by the enemata recommended above, or with the addition of castor oil. The hot bath has been proposed, but it possesses no advantage over hot fomentations, whilst the motion, to which the pa- tient's body is necessarily subjected, renders it ob- jectionable. In the course of a few days, the bowels may begin to be evacuated, and lumps of undigested matter — the cause of the whole mis- chief—may be perceptible in the discharges. If signs of suppuration occur, poultices may be applied ; and if there be reason to believe that the parietes of the abscess adhere to the walls of the abdomen, which may be determined by trying whether the latter glide over the tumour, the sooner the abscess is opened the better. Com- monly, the tumour gives an emphysematous feel, and if a free incision be made into it, a fetid gas with an offensive fluid will be discharged.— This emphysematous condition must be distin- guished from the sound rendered on percussion, when the pus has formed on the posterior surface of the caecum, and pushed the intestine before it. In such case, the intestine may be wounded, as has happened, we are told by Grisolle, in one case. After the abscess has been opened, the dis- charge of its contents must be favoured by placing the patient on his right side, and the system be supported by wine-whey; arrow-root, or sago and wine; beef tea, and the preparations of bark. Opi- ates will likewise be required to produce sleep. Where the perforation takes place into the ca- vity of the peritoneum, the case must be managed as directed under the head of Perforation of the Intestines. Little, however, can be done except to administer full doses of opiates. Lastly,—where the abscess is so deeply seated, that an opening into it cannot be made with safe- ty, it has been proposed to endeavour to promote the absorption of the pus by means of repeated blisters, or by moxa applied over the abscess. The treatment of inflammation of the appen- dix vermiformis cscci is the same as in perforative inflammation of the caecum. As in all cases of inflammation likely to terminate in extensive sup- puration, in which the recuperative powers have to be greatly exerted, care must be taken not to reduce too much by general blood-letting, too often, or too largely practised in the early stages. Every practitioner is aware of the difficulty of arresting the suppurative process; and, conse- quently, if the inflammation be not got under by antiphlogistics in the first few days of the disease, the farther use of depletives should be had re- course to, under a wise caution ; for it is proper to remark, that the disease occurs at times very insidiously. The treatment of sero-colitis is the same as re- commended in acute and chronic inflammation of the peritoneal coat of the small intestines, and in inflammation of the caecum.] W. Stokes. [Robley Dunglison.] [ENTERORRHCEA. (See Diarrfkea.)] EPHELIS (from hi and ijXjoj, sol,) a genus of diseases of the skin, of the order maculse, (see the article Macule,) characterized by discolora- tions, varying from dark brown to greyish-yellow, and presenting a great diversity of form, from small distinct points, sometimes scattered, some- times grouped, to large confluent or continuous patches. Syn. Maculae fuscae (Plenck) ; Ephehdes (Ali- bert). We use the term ephelis in the extensive sense which has been given to it by Gorrceus —" non quod a sole tantum vitia ilia in cute contrahuntur, sed quod a reliquis inducta causis, similem aspe- ritatem et colorem habeant;" (Defin. Med. ad voc. ?i/u;Xii/,) although we do not altogether agree with Bateman, (Synopsis, p. 442,) that this acceptation of the term is sanctioned by the authority of Hip- pocrates, (Praedict. lib. 2. xxxi. 9; de alimento, iv. 11; de sterilibus,vi. 8; de morb. mulier. lib. 2, Ixvii. 6, lxviii. 1,) for he appears to have distin- guished between lenticula (ipaicbs) and ephelis, both included in this definition. Celsus went far- ther ; he not only distinguished between lenticula and ephelis, but also between lenticula and the tpa>cLa of the Greeks. (De MedicinS, lib. vi. cap. 5.) These distinctions were lost sight of, and the term ephelis was made more comprehensive by Oriba- sius, (De loc. affect, cur. lib. iv. cap. 52 ; Synops. viii. 33,) ^Etius, (Tetr. ii. serm. iv. cap. 11,) and Actuarius. (Meth. Med. iv. cap. 13.) Senner- tus (De cutis vitiis, lib. v. pars 3,) revived the an- cient distinctions, in which course he was followed, more or less, by Sauvages, Lorry, and Plenck; but whilst the first of these raised distinctions on one hand, he removed them on the other, and thus included under ephelis morbid appearances which have no relation to it. This last is also the error of Alibert, who, in his order of Ephelides, includes scorbutic blotches. These affections of the skin seldom demand or deserve, on their own account, the attention of the practical physician ; but as signs of internal disor- ders they sometimes afford very valuable diagnos- tic evidence, as much as erysipelas, urticaria, pru- rigo, and many other eruptions. And we perfectly agree with Alibert, that they afford matter of in- teresting research to the physiologist, showing how the integuments may become discoloured, and re- vealing in some manner, by external appearance, the alterations to which the human body is sub- ject. Besides, it is shown in the study of the natural sciences that the most trifling facts may be useful, because, being connected by an almost imperceptible chain with phenomena much more important, they sometimes indicate, sometimes ex- plain them. The process of the formation of the ephelis is unknown. It is not the result of any particular alteration of the epidermis, but some modification of the pigmentum of the skin which science is not yet able to explain. It would seem sometimes to be a consequence of an inflammatory action; it is frequently accompanied with signs of a determi- nation of blood to the skin, but neither of them is constantly observed. It is very variable in its progress and duration, sometimes developing itself fully and extensively in the course of a night. sometimes very slowly; sometimes it is perma- nent, continuing indelible for several years, and sometimes it disappears after a single bath or lotion. Not having found any previous arrangement of this genus which satisfactorily comprehends all EPHELIS. G3 its varieties, we propose considering it under two species, viz. 1. Ephelis lentigo; 2. Ephelis diffusa. 1. Ephelis lentigo. Syn. (paxi; (Hipp, et Grxc.) ; Lenticula vel lentigo (Latin); Ephelis lentigo (Sauvages and Alibert); Lentigo (Lorry, Plenck); Lentigo ephelis (Frank); Sommers- prossen et Sonnensprossen, Sommerflecken (Teu- 'onici). Freckles. An eruption of small minute spots of a fawn, yellow or brown colour, sometimes disseminated, sometimes in clusters, unaccompanied with any pain or itching. This eruption presents itself under two circum- stances ; it is either hereditary, a natural deformity of the skin, or is purely accidental, the result of exposure to the sun's rays. This affords the di- vision of the species into two varieties: a. Ephelis lentigo materna. b. Ephelis lentigo aestiva. a. Ephelis lentigo materna. Taohes de rous- seur (Gallice). The well-known lenticular erup- tion, forming, as it were, part of the natural com- plexion of yellowish or reddish-haired persons, who are, besides, distinguished by the strong odour exhaled by the secretions of their skin. (Alibert, PI. xxvi.) It is more rarely, but sometimes, ob- served in persons of a fair and delicate skin with dark hair and eyes. The colour and shade of the eruption bear always a near relation to the colour and shade of the hair, being sometimes as dark as coffee or chocolate, and sometimes of a light yel- low. The eruption is not confined to the parts of the body exposed to the light and air, but some- times occupies the whole surface; neither does it disappear in winter. It is to this variety that the French term, " taches de rousseur," strictly applies. They who would attempt to cure this deformity would deserve a severer rebuke than that of Cel- sus — Pene ineptise sunt, curare varos, et lenti- culas, et ephelidas. But the importance attached by the fair sex to this discoloration has not left the matter unattempted — eripi tamen fseminis cura cultus sui non potest. It would be idle to repeat the various means which have been used for this purpose. They who are curious in such matters may consult iEtius, lib. 1. serm. 4. cap. ii.; lib. 4. cap. xiii.; Haly Abbas, lib. 9 ; Avi- cenna, Fen. 7. tr. 2 ; or the monograph of Bender on Cosmetics. (Phil. Ludov. Bender de Cosmet. Argent. 1764.) b. Ephelis lentigo aestiva.—Syn. Ephelis: ma- culae solares (Plenck) ; Ephelis a sole (Sauvages); Nigredo a sole (Sennert); lentigo aestiva (Jos. Frank) ; Le Mle (Gallicee). Sun-burn. To this variety exclusively belongs that very common lenticular eruption, chiefly observed in young females of a delicate complexion, superven- ing with the summer and disappearing with the winter, and confined to those parts of the body exposed to the sun and air. This eruption is purely a local affection; the radiation of the sun upon the exposed surface of the skin, more particularly observed in youth, being the only cause of this eruption; hence those occupied in the labours of the field, moun- taineers, those accustomed to expose themselves bareheaded, or persons pent up and etiolated in cities, when they visit the country are particularly subject to it. This cause may operate quickly or slowly, and the colour of the freckle always bears some relation to the complexion and colour of the hair. When this eruption does not cease with the removal of its cause, or with seclusion, or the use of veils or shadowing hats, its disappearance may be accelerated by the use of certain local applica tions ; and, indeed, even under the influence of its cause, it may be much moderated by them. Every country supplies some of these nostrums, chiefly domestic, the results of vulgar experience. They are most of them more or less stimulating, but some of them soothing and demulcent. The best practice is for the bland and emollient appli- cation to precede that of the stimulating. The former consists of such things as vapour (that of milk was an especial favourite) ; emulsion of the seeds of cucumbers or melons, or pomatum pre- pared from those seeds; decoction of the flour of lupines, of tares ; the boiled pulp of the roots of narcissus; paste of bitter almonds, and such like. The latter consisted of poultices made of the seeds of cauliflower, or of the flour of tares or lupines macerated in vinegar, or the bulbs of the narcis- sus boiled in vinegar, to which was added some of the roots of the wild cucumber, bryony, and the leaf-stalks of the fig-tree; the juice of the house-leek, the leaves of the cherry-tree, the leaves of ivy, the ashes of sepia, the bulb of the Illyrian iris, and the bulbs of the lily, mixed with nitre and honey. Ox-gall has been always celebrated. The favourite remedy in the harem of Turkey is said to be a pomatum prepared from balsam of Mecca, the seeds of the garden cucumber and cerussa : in the north of Europe, Goulard's lotion, the juice of sorrel, lac sulphuris macerated in the juice of currants, solution of sulphates of zinc or copper, lemon-juice, oxycrate with camphorated mixtures, rubbing the part with a slice of lemon or of a sour apple. But all these various means may be more 'conveniently represented by any weak alkaline solution, (R- Liquor, potassae, gi. Aq. rosar. ^ii. fiat lotio.) or a diluted spirit or acid lotion. The following were favourite formulae much vaunted : R 01. amygdal. amar. gi. Tartar, per deliquium, ^ ss. 01. rhod. gtt. ii. M. R Sapon. venet. ^ii. solve in succ. limonis, §i. adde ol. amygdal. amar. Tartar, per deliquium, aa. §ss. 01. rhodan. gtt. vi. M. fiat poma- tum part, illin. 2. Ephelis diffusa, an eruption of distinct or confluent large, irregular, round patches, of a tawny, yellow, or brown colour. This form of ephelis may be symptomatic as well as idiopathic. a. Ephelis diffusa symptomatica.—Syn. Ma- culae hepaticae (Sennert, lib. 3, pars iii. sect, i, cap. viii.) ; Hepatizon ( Var. Auct.) ; vitiligo he- patica (Sauvages); kelis fulvescens (Swediaur) ; Ephelis (Plenck) ; Chloasma (P. and J. Frank) ; Ephelis hepatica (Alibert); chaleur du foye, taches hepatiques (Gallice'); Leberflecke (Teu- tonice). This eruption, which is generally preceded by 64 EPHELIS —EPIDEMICS. a slight itching, is of the colour of saffron or rhu- barb, sometimes pale like the withered leaf; it is most commonly situated on the neck, sometimes surrounding it like a cravat; on the abdomen, especially on the region of the liver, over the kid- neys, or on the groins ; sometimes on the fore- head. The patches are at first distinct and dis- tant, but extending gradually they run into each other, or they form groups more or less numerous. (Plate lxix. Bateman's Delineations; Plate xxvn. Alibert.) They are sometimes slightly elevated, and terminated by a desquamation of fine thin yellow scales assuming somewhat of the nature of pityriasis, the pityriasis versicolor of Willan, the chloasma pseudo-porrigo of Frank ; and sometimes they are complicated and coinci- dent with the wheals of urticaria. The itching is sometimes much greater than that of pityriasis ; it is much influenced by the weather, and increas- ed by being heated by exercise. Alibert has ob- served that the patches of ephelis are not trans- pirable, but very dry, whilst the surrounding skin is soft and moist. This variety of ephelis is sometimes permanent and sometimes transient. In the first state it is met with chiefly in men of close sedentary habits, presenting large blotches upon the ab'domen, some- times entirely encompassing it as a belt, or large patches over the shoulder. Some of these spots it is not difficult to disperse, but some remain in- delible. In the second state they are more fre- quently observed in women in the form of isolat- ed circular patches, appearing and disappearing very rapidly, sometimes in the course of half a day ; they are chiefly seated on the back part of the neck, on the throat, breast, and hypochondria. In some women they return at every menstrual period; in others they coexist with suppression of the catamenia, the chloasma amenorrhoeum of Frank; they afford sometimes a sign of concep- tion, (Hippoc. de morbis mulier. Sennert. Pract. lib. 5, parts iii. s. 1, c. 2,) appearing as superficial spots as broad as the hand, of a pale yellow or dark tawny colour, without roughness or inequal- ity, most frequently on the forehead, breasts, and abdomen, occasionally disappearing at the end of the first month, but frequently continuing during the whole period of gestation, and not always dis- appearing on parturition—the ephelis gravidarum of Plenck and Sauvages, the chloasma gravida- rum of Frank. It is remarked that those who are most indisposed by pregnancy are most liable to this eruption. In men they are observed some- times precursive of a hemorrhoidal flux. In wo- men, the itching attendant upon them is always increased on the approach of the menstrual period. Sauvages says he has not unfrequently observed the eruption of ephelis to be periodical after ter- tian and quartan agues, and sometimes an attend- ant of nostalgia. Besides the state of body just mentioned as predisposing to this variety of ephelis, it is fre- quently accompanied by a serious disorder of the function of the liver, but most constantly con- nected with chronic irritation of the stomach and intestines. In such cases it is sometimes suddenly excited by any trifling vexation, chagrin, or con- trariety, or by protracted application or study. The treatment of this eruption consists in the appropriate cure of the primary disorder ot which it may be a symptom: when connected with the natural functions of the body, it can only be remedied by promoting their more easy perform- ance; when symptomatic of uterine disorder, it demands the treatment of amenorrhoea or dysme- norrhoea, when of chylopoietic disorder, its cure falls under dyspepsia. In general, mild cooling cathartics, light diet, sulphurous preparations, par- ticularly the sulphurous mineral waters, as those of Harrowgate, Cauterets, &c, and, if necessary, a mild alterative of some mercurial and antimonial preparation, constitute the internal remedies. The best external preparations are sulphurous baths, particularly of the natural warm mineral waters, the warm sea-bath, or locally a lotion of sulphuret of potass. R Potass sulphuret. gi. Aquae lib. ii. fiat lotio. Camphorated vinegar is also a good local applica- tion. When the spots are indolent, friction, and, if not extensive, a sinapism applied for a short time, or a poultice of soft soap, have been known to succeed. b. Ephelis diffusa idiopathica. We only notice this variety that we may not omit two forms of ephelis enumerated by other writers. 1. Ephelis ignealis (Sauvages) ; ephelis spuria (P. Frank) ■, lentigo ab igne (J. Frank) ; inches de brulure (Gallice). The mottled spots pro- duced by artificial light and heat, observed on the legs and arms of those who bask over the fire, oi on the tegs and thighs of women who during winter make use of the chauffepie. 2. Nigredo a sole (Sennert); fuscedo cutis (Plenck) ; ephelis umbrosa (J. Frank); die braune haut (Teutonice). The dark, swarthy, brown colour of the skin acquired by Europeans who inhabit tropical climates, or by those exposed to salt water and hard weather. T. J. Todd. EPIDEMICS. Epidemic diseases (v6aoi imo- iiiioi, from M, among, and tripos, people,) are those which attack a number of persons, in any city, district, or country, about the same time or season. They are generally uncertain in their recurrence. When they produce great mortality they are called pestilential. Epidemic diseases are chiefly of the acute or febrile class, some of which are apt to prevail in spring, some in summer, and some in autumn; some in one country, and some in another. Endemic diseases are found to prevail more or less at all times, in districts where the local causes act, and among people exposed to their operation: but the production of epidemics, inasmuch as they depend on circumstances of a wider range, which are in their nature variable, (such as the vicissi- tudes of heat and cold, the prevalence of particu- lar winds, the varieties of season and weather, as to drought and moisture, the deficiency or deterio- rated quality of different articles of common food, and other things, is liable to great uncer- tainty in almost every part of the world. As epidemic diseases are above defined they do not exclude some that are contagious ' Dis- tinctions have been attempted to be established, it EPIDEMICS. 65 would appear unwisely, between epidemic and contagious diseases. An attentive and unbiassed observation of facts removes these unphilosophical distinctions. Many epidemic diseases appear, under certain circumstances, to be communicable by contagion; and some diseases, avowedly con- tagious, prevail epidemically. Facts, in all ages, would seem to show that most epidemic diseases have a tendency to spread by intercourse with those exposed to the same causes of disease, and thus predisposed to it. This tendency has been made too much of by systematic writers, in some cases; and in other cases, too little. No epidemic disease either attacks simultaneously, or rages with indiscriminate violence, among all classes, in any community; and no contagious disease attacks every one who is fully exposed to its influence. Epidemic diseases, whether contagious or not, have their assigned laws. Even when highly pestilential and destructive, they observe stated seasons, and periods of rise, increase, and decline. When their attack is most sudden and general, they pass over a large proportion of the community. In the former case the disease loses its malignity ; in the latter, some constitutions are proof against the common destroyer, without any apparent immediate intervention of art. It is a rare thing that any one form of epidemic disease rages alone, that is, without being preceded or followed by another. Different forms of epi- demic diseases usually succeed each other in a series, either in the same year or in different years : and this is called an epidemic constitution. Sydenham was, of all English physicians, the chief observer of these phenomena, and was pre- eminently entitled to the appellation of the English Hippocrates : he was of too honest a nature to let preconceived opinions and mere arbitrary names of diseases prejudice his correct observation of their changes from one season to another. Viewed practically, epidemic diseases require minute and cautious observation on the part of the physician ; for diseases of the same name, as Sydenham remarked, often require different treat- ment at the beginning of the epidemic and at the decline ; as they require different treatment in dif- ferent countries, and frequently in the same, under different epidemic constitutions. The diseases of an epidemic constitution will sometimes show an unusual tendency to one part of the system, and sometimes to another; as they will affect a parti- cular type. This tendency is either to the skin, or the head, or the chest, or the stomach and bowels, and often continues for many months, or even years, in the reigning diseases. It was re- marked that at the time the sweating sickness raged in England, other diseases assumed the sweating tendency. It is much to be lamented that many things stand in the way of accurate knowledge on this subject. It is comprehensive, and surrounded with difficulties, in proportion to the extent and variety of the observations which are requisite for forming scientific conclusions. If medical ob- servers had been contented to look with simplicity into the series of events belonging to epiacrniL diseases, like Hippocrates and Sydenham, we should not have been so much in the dark at the present day. Facts apparently contradictory, at Vol. II — 9 t * least as to the proper name and the contagious quality of certain epidemic diseases, such as the Levant plague, the Asiatic cholera, and the yellow fever, have been brought forward by men justly eminent in their profession, but wedded to parti- cular opinions. Hence has arisen the extreme difficulty of knowing the truth. Physicians, on the very site of pestilence, have sometimes, like children at play, taken opposite sides, and main- tained their ground with unseemly pertinacity ; so that we may look in vain to either party for unprejudiced observations. The records of all modern visitations of pestilential epidemics pre- sent us with opinions and statements as much at variance as light and darkness; and hence we must conclude either that one set of observers are right and the other wrong, or both partially in- formed but blinded by prejudice, so that they can- not see any truth in their antagonists' assertions; consequently, that many things which they report as facts are only partial observations, or vague rumours, or hastily formed conjectures, or uncon- nected and adventitious appearances. Truth is sacred, and error cannot be propagated without some injury. How incumbent, then, is the duty of medical observers to inquire impartially and to report with fidelity! He that presents us with a physical observation clouded by his prejudices, on a subject so deeply important to the health and welfare of his fellow-creatures, is but a degree less culpable than the man who gives a false colouring to some moral or religious truth, which involves the dearest interests of humanity. If this view be correct, where shall we look for the facts—strictly such—which may assist our reasonings on this weighty subject ? It is not, clearly, to recorded observations of infection and of non-infection, adduced by contagionists and their opponents, that we must refer for those un- exceptionable data on which some safe practical conclusions may be built. We may perhaps ad- mit something from each, but must reasonably doubt their wholesale inferences. The subject would be involved in a cloud of darkness which no diligent and honest inquiry could penetrate, if there were not other things be- sides facts of infection and non-infection — in short, other facts connected with the origin, spread, and decline of pestilential epidemics, (for to these we shall chiefly confine our attention in the pre- sent article)—which, though too much overlooked, throw a good deal of light upon the whole ques- tion, and not only point to something quite inde- pendent of their contagious and non-contagious nature, but help us to determine how much im- portance we should attach to these circumstances in the general estimate. It is fortunate for our science that there is such a class of facts, and that the lover of truth has not to range in a wilderness of uncertainty. It is also a source of gratification that many of these facts are admitted by both parties, or at least, with few exceptions, aie not denied by either. Now, tne tacts of a comprehensive nature above tiiuded to, wnicn belong to pestilential epidemics, may be classed under the following heads; on each of which it is proposed to make a few gene- ral observations, with a view ">f drawing «nai« conclusions from the whole. 66 EPIDEMICS. I. The natural signs, which arc either the an- tecedent indications or the concomitants of a pes- tilential epidemic, such as intemperate seasons and unusual weather, deficient or unwholesome food, mortality among any species of the lower animals, uncommon abundance of some of the insect and reptile tribes, departure of birds, &c. 2. The singular changes which have been ob- served to occur in the common or reigning dis- eases of the place, before, during, and after an epidemic pestilence. 3. The changes in the symptoms, or type and character of the epidemic pestilence itself, and the circumstances attending its migrations from one place to another. 4. The facts relating to the connection of epi- demic pestilence with offensive cities, marshy grounds, and low filthy situations, bad food, and a condensed, filthy, and ill-fed population, in all countries ; and, on the other hand, the exemption of those places where due attention has been given to cleanliness, wholesome and sufficient food, and a rational system of health police. 5. The facts given in evidence from quarantine establishments and lazarettos. Before we proceed further, it is proper to ex- plain what is meant by an epidemic pestilence : the term is used generically to include several species. It denotes a destructive or fatal disease, which ap- pears at uncertain periods or intervals, but at sea- sons of the year peculiar to different epidemics and to different countries, in large assemblages of human beings, already predisposed to receive it: it attacks its victims in succession with various degrees of violence, leaving however many un- touched, during the course of a few weeks or months, in a particular place or city, and then de- clines by degrees, as it began, but with diminished force, either moving onwards to other places which it invades in the same manner, or entirely disap- pearing for the time. The plague of Egypt and the Levant, the bilious fever of Spain, and the yellow fever of America, the cholera of India, and the low malignant fever of our own country, are different forms of pesti- lence, observed sometimes to prevail epidemically in their respective countries ; for different coun- tries seem to have their particular forms of epi- demic ppstilence to which they are more liable than to others, and which, in common experience at least, do not invade each country indiscrimi- nately. When individual cases of any of these forms of disease occur at unusual seasons, or at times when there is no tendency in the disease to spread; in other words, when there appears to be no predisposition in the population of any city or town to receive it, the disease is said to be spora- dic or local : such cases may appear at any time in the country which gives birth to the disease. If such sporadic or local cases should by any ;hance appear in other countries, by whatever means occasioned or introduced, a multitude of facts seem to demonstrate that there is no danger of their spreading, at least to any alarming extent. 1. It is stated, by Dr. Mead in his learned Trea- tise on the Plague, (Chap, i.) that a "corrupted state of air attends all plagues." Dr. Mead was an enlightened physician, and though his work p'as written professedly to establish the contagious nature of the disease, yet his researches nto oc histories of the various visitations of pestilence in different countries compelled him to admit that «:. corrupted state of air is, without doubt necessary to give the contagious atoms their full force. Dr. Russell, who practised at Aleppo during the plague of 1760-1-2, admits in its fullest extent the dogma of Mead, but expresses the fact in other terms, more philosophically perhaps; and denominates that state of air which is alone favourable to the propagation of disease, a pestilential constitution of the air ,■ without which, he states, « it is incon- testable that the plague will not become epide- mical." It must not be forgotten that Dr. Russell was a warm advocate for the foreign origin of pes- tilential contagion; and that he maintained no combination of indigenous circumstances could give rise to the plague in Syria. Sydenham, also, who witnessed the rise of the plague in London in 1665, found it necessary to take a "pestilential constitution of the air" for granted. (Chap. ii. sect, ii.) Here, then, is an ultimate fact, so far as the testimony of such eminent physicians can establish it — a principle on which to found an argument as clearly laid down as any other in natural history. We might not be disposed to contend either for the propriety of the terms used by Mead, or for the absolute correctness of those employed by Sydenham and Russell; but for a state of air, present or just past, and perhaps also of the body, indispensable to the epidemic rage of pestilential fever. It is a fact too well known to be questioned, that plagues and pestilential fevers, whether the bilious yellow fever or malignant typhus, have of- ten been preceded and accompanied by irregular and intemperate seasons ; in other words, by great extremes in the weather. If we examine the his- tories of the plagues of London in 1625 and 1665, of the Netherlands in 1635-6, of Aleppo in 1740 and 1761, of Marseilles in 1720, and of Malta in 1813; if we turn our eyes to the modern visita- tions of pestilence in Spain and the United States, and the East Indies; or if we look back to the de- scriptions of the plagues of Athens and Rome, as recorded by Thucydides and Livy, without laying any stress on the poetic colouring of Homer, Lu- cretius, and Ovid, we find that some remarkable intemperature of the weather and seasons has been the antecedent, and, generally, a warm southerly constitution of the air a concomitant of these events. This intemperature, whether marked by excessive cold followed by excessive heat, or ex- cessive rains followed by excessive drought, and vice versa, has so often concurred with fatal epi- demical distempers to form one series of events, that we have the pestilential constitution or Karda- ramg \otpu>Sr]g of the observing ancients, especially the Greek physicians, as clearly laid down as any aphorism in our science, and prognostics of pesti- lence framed accordingly. A volume might easily be filled with facts illustrative of this position- but we must premise one general remark, that, straitened as we are, by the nature of the work, within narrow limits, yet in so comprehensive an argument some genera] results must necessarily be assumed; pledging ourselves at the same tim« for the trnfh of the principle, whilst we are omiv ting the details on which it is founded. EPIDEMICS. 67 [About the time cholera first made its appear- ance in England, in 1832, Dr. Prout noticed a positive increase in the weight of the air, similar to what might be produced by the diffusion of a heavy gaseous principle through the lower regions of the atmosphere. See art. Cholera, Epidemic, p. 421.] There can be little difficulty in tracing a con- nection between intemperature of the seasons and famine or unwholesome food; and the relation of the latter to the production of epidemic pestilence is more clearly manifest when we consider that its violence almost invariably falls upon the poor. It is a remark of Dr. Mead, deduced from his pre- vious enquiries, and confirmed by every pestilen- tial epidemic subsequent to his time, " that it has never been known when the plague did not first begin among the poor." This observation is strengthened by the histories of the yellow fever in America and in the south of Spain, of the cho- lera in the east, and of our own epidemic fever, particularly in Ireland. The poor are the chief victims, because they are principally subjected to the exciting causes. (Heberden, On the Increase and Decrease of Disease, &c.) Mortality among some tribes of the lower ani- mals not unfrequently follows intemperature of the seasons. Sometimes this mortality is noticed among dogs, cats, horses, and mules ; and some- times among sheep and cattle used as the food of man. In the pestilence that raged at New Or- leans in 1819, we are told that the cattle died :— " horses, oxen, and cows with rotten tongues; sheep and hogs with their hoofs dropping off, and calves with rotten ears." Dr. Hodges bears a very striking testimony to this fact in his Loimologia, or Account of the Plague of London in 1665 :— " Many knowing persons," he observes, " ascribed the pestilence to the quantity of bad meat from the preceding sickness among the cattle, which was sold so cheap to the poor that they fed upon it even to gluttony." «It is incredible to think how it raged among them—to such a degree that it was called the poors plague." The question does not seem to have been en- tertained, whether the same physical causes which acted upon the cattle might not have acted also on that part of the human species which was most exposed to elemental vicissitudes. Salvaresa supposes the epidemic fever of 1764, at Cadiz, was occasioned by the old and corrupted corn. " Amongst the poor," he says, " the disor- der was most violent. In this year the animals were first affected; and the mortality was princi- pally observed among birds that fed on grain, as pigeons, poultry, &c." (Dr. Maclean.) In the fever of Cadiz of the year 1800, Sir James Fellowes asserts that " the air, from its stagnant state, became so viliated, that its noxious qualities affected even animals; canary-birds died with blood issuing from their bills; and in all the neighbouring towns which were afterwards infect- ed, no sparrow ever appeared."' (Dr. Good, vol. ii. p. 74.) Dr. Mead states that " it has been observed in times of the plague that the country has been for- saken by the birds." This curious fact does not belong only to the form of pestilential fever called plague: it is one of the many phenomena which are scarcely reconcileable w.th the notion that gives to the causes of pestilence so confined a range as the intercourse with an infected individual or the exposure to fomites. Livy tells us that in the pestilence at Rome, A. U. C. 571, " not a vul- ture was to be seen for two years:" and Thuey- dides relates that in the plague of Athens " the birds that usually preyed on human flesh entirely disappeared." Diemerbroeck, the learned and can- did author of the work on the plague of Nimeguen in 1636, records that it often happened when canary-birds died without any obvious cause in any house, the plague showed itself not long after in some of the family." He also states that birds were much more scarce than at other times: — " avium multo rarior numerus." It is mentioned by Dr. Short that « during the four months Dant- zic was afflicted, in 1709, all kinds of birds, as swallows, crows, sparrows, &c. deserted the city." " A rubigo or mildew, i. e. a dew impregnated with highly corrosive powers, (see Hird on Pesti- lence, p. 91,) was anciently deemed one of the causes of epidemic diseases. The Romans, ap- prised of the pernicious effects of these mildews, instituted what they denominated festa rubigalia, and worshipped an imaginary God under the name of Robigo. Hoffmann mentions such a dew, ' ros valde corrosivus,' as having infested vegetables in 1693-4, whence the cattle died in multitudes. (Tom. i. de Temp. Ann. Insalub.) And Ramazzir.i ascribes an epidemic to similar dews; at wnich time the vegetables, corn, and fruit became black, being affected with a ' lues rubigalis.' The same year was remarkable for the scarcity of honey; and most creatures that live upon what they extract from vegetables died oi languished. Probably such occurrences led many of the ancient writers to mention the silence of the grasshopper, and the drooping inactivity of the bee and the silk-worm, among the presages of impend- ing pestilence. As to the spots, which are said to have assumed various forms, especially those of cruciculee or little crosses, and u> have appeared suddenly on garments, utensils, &c. as they are recorded chiefly on the authority of monks, whose writings are highly tinged with superstition, they are scarcely worthy of serious consideration." (Rees' Cyclop, ait. Epidemic.) Most of the writers who treat of the prognostics of pestilence refer to swarms of some of the insect tribes. Lord Bacon particularly remarks that " those years have been noted for pestilential, wherein there were great numbers of frogs, flies, locusts, &c." The plagues of Dantzic, Nimeguen, and Marseilles, and many others, afford illustra- tions of this fact. To give details of all the natural signs would not be compatible with our object. 2. To found a truth in science we must have recourse to general observations. Isolated facts are only valuable so far as they tend to establish general laws. There is no science in which what are called facts require to be viewed with more suspicion than in that of medicine; nor any de- partment of it where there is more room for error than in that which comprehends the invisiblo region of contagious miasms and atmospheric iiii purities. We have the following general observa tion of Dr. Mead in relation to the matter befoif. us: "Fevers of extraordinary malignity are th* 63 EPIDEMICS. usual forerunners of plague, and the natural con- sequence of that ill state of air which attends all plagues." This admission cannot but be consi- dered very important. It does not, however, depend upon the authority of Dr. Mead. The fact is con- firmed by a most ample induction. Fevers of extraordinary malignity, and other forms of mortal disease, have been observed to be the usual fore- runners of plague or epidemic pestilence in almost every country. (See Webster's History of Epide- mic Diseases ; and Researches into the Laws of Pestilence, by Thomas Hancock, M. D.) It was rather triumphantly stated that the plague of Malta in 1813 formed an exception to this rule, in order to prove the position that the disease was imported from Alexandria; in fact, that no pre- cursor fever ushered in that pestilence: and if we had no other accounts of it than those by Faulk- ner and Tully, we should have been left somewhat in the dark on this point. But the candid and enlightened Dr. Hennen informs us that " for four or five years preceding that in which the plague raged, sudden deaths were more frequent than or- dinary, and during the twelve months immediately preceding, and esp< cially for the last month of the period, the increase was still more remarkable, in- somuch as greatly to excite public observation." (Edinburgh Medical and Physical Journal, No. 104.) " Apoplexies (or sudden deaths) and other diseases were never so general or so numerous in the memory of man." " It is observable," says Dr. Heberden, (see his observations above quoted : p. 85,) " that at its first breaking out the disease has never been known to be the plague. It has moreover very generally been preceded by a severe putrid fever." The plagues of Venice in 1576, of London in 1625 and 1665, of Nimeguen in 1636, of "Naples in 1656, of Marseilles in 1720, of Aleppo in 1742 and 1760-3, of Holstein in 1764, and of Moscow in 1771, were all preceded by malignant fevers. Now if any one should inquire what are the effects of that peculiar state of air which ushers in an epidemic pestilence, the answer attested by long experience is, the occurrence of malignant fever. This is one part of the history of such events. But let us notice more particularly the observation which Dr. Heberden has annexed to the statement of this fact, viz. : that " at its first breaking out, the disease has never been known to be the plague." The simple reason of this extraordinary circumstance, and of the doubts and dissensions which have sprung from it, is the gradual and imperceptible change of the malig- nant fever into the true pestilential fever or plague, and the contrariety of this fact to the medical systems and authorities which have assigned dif- ferent forms of the same disease to different classes and orders in nosology. We may almost take shame to ourselves that we belong to a profession which, either from the imperfection of the science itself, or from the deficient observation of its fol- lowers, has exhibited so many instances within the last two centuries in different countries, of reproachful contention among the faculty, on the eve of pestilence, about its name and nature; and which hitherto has laid down so few solid data to •cure practitioners from future quarrels on the same ground. Leaving the disputes a 'out con- tagion out of the question, the disputes about names or nosological terms have agitated physi- cians in Italy and Franco, and Russia and Ger- many, and Spain and America, not excepting our own country, till the sober and impartial members of the profession are mortified, and legislatures are wearied and disgusted; for the latter know not what is really matter of fact, and the former are unwilling to ally themselves with such fierce combatants. Lord Bacon's aphorism, in its gene- ral signification, has been repeatedly confirmed since his time, that « the lesser infections of small- pox, purple fever, agues, &c. in the preceding summer, and hovering all winter, do portend a great pestilence the summer following; for putre- faction rises not to its height at once." Lord Bacon was too much of a philosopher to interpret the regular series of natural phenomena by his own fancies, and too little of a systematic writer on medicine to perplex himself with the trammels of artificial distinctions imposed by names. But some physicians have endeavoured to show that there was only a casual connection between the pestilential epidemic and the malignant fever, its forerunner ; and numbers have on such occasions involved themselves in keen disputes, whether the name of malignant fever or that of plague was the proper appellation of the epidemic pestilence itself. In this way they have too generally trod the thorny ground of contention instead of the simple path of faithful observation ; and the con- sequence is, that we have more of counter-state- ments than of unquestionable facts reported to us from the scene of every pestilential visitation. Nevertheless, all is not confusion; and there are some things on which medical science may repose with satisfaction in reference to this part of the subject. Two important observations be- long to it : the one is, that the malignant fever which precedes the plague, commonly reappears at its decline; and the other, that during the con- tinuance of the epidemic pestilence itself, at least during its active prevalence, all other forms of epidemic disease, such as those which are peculiar to the place and to the season of the year, are en- tirely extinguished. With regard to the former, it may be noticed, that one of the first and most evident signs of the epidemic pestilence being about to cease its ravages, is the appearance of another form of epidemic fever, generally of that which preceded, and sometimes of a new train of diseases; this new order of things indicating that the pestilential constitution is changed, or at least, the disposition in the air to foster and spread the principal disease, completely for the time removed. The second fact is interesting, both from the anti- quity of the observation and from its accordance with modern experience; that, while the tyrant disease is prevailing, it usurps complete, dominion, and suffers no other disease to appear of an epi- demic character. This was noticed in the plague of Athens, by Thucydides ; and every pestilence since that memorable period has verified the ob- servation. It was noticed particularly in the last plague of Malta. A fact recorded by Sauvages, (Nosol. Method, vol. i. p. 415,) places this cir- cumstance in a very strong light, viz. that when the plague was raging in the south of France in EPIDEMICS. 69 1720-21, no greater number of persons died of the disease in the town of Alet—and none died of any other disease—during the year of its visi- tation, than used to be carried off by other dis- eases, though the plague absorbed all others, or in fact put them to flight while it was prevailing. This is an incontestable fact, and a sufficient an- swer to those who deny the operation of any general cause. For it is perfectly clear that if a vessel from Sidon brought the plague to Marseilles in 1720, as was alleged, and that the contagion was conveyed from thence to Alet in Languedoc in 1721, as was asserted, this accidental circum- stance, upon that hypothesis must have exerted a most extraordinary influence on the atmosphere of the town of Alet, or rather on the constitution of every one in it, if it put every other form of mortal disease to flight for a whole year after. The general remarks above made, relative to the forerunners of plague and its insidious ap- proaches and dominion over other diseases, apply also to the pestilential fever of Spain, and to the yellow fever of America. "The occurrences," says Dr. Halloran, "which preceded the epidemic of Barcelona in 1821, correspond with the old and recent observations on a similar subject in other countries; it almost invariably happening that the yellow fever of Spain is preceded by unusual dis- eases of various form and force, more particularly by bilious remittent fevers, which are often so aggravated and malignant that physicians them- selves do not venture to define the line of demar- cation between them and the avowed epidemic." In the " Sketches of the Medical Topography of the Mediterranean," by Dr. Hennen, who closed his professional career at Gibraltar in 1828, and who observed and wrote with equal candour and ability, we find it stated that, "in 1813 bad re- mittent fevers preceded the epidemic which raged at Gibraltar, and that its true nature was disguis- ed, till it had made such progress as to be preva- lent in every quarter of the town. With regard to the transatlantic pestilence, Webster informs us that "the yellow fever never occurs in the temperate latitudes of America, ex- cept under a pestilential constitution of the air, manifested by other malignant diseases; and that it has been preceded by acute diseases, and follow- ed bv remittents, dysentery, and malignant pleu- risy." 3. We believe that the remark of Sydenham applies to the plague and the yellow fever, and the Indian cholera, and to every other form of epi- demic pestilence; that " all epidemics at their first appearance seem to be of a more spirituous and subtile nature, in other words, more violent and acute, as far as can be judged from their symptoms, than when they become older." These changes or varieties in an epidemic pes- tilence, during a few months' career, might be considered at some length under three heads, viz. the proportional mortality, the appearance of the symptoms, and the alleged difference in the con- tagious properties ; but a veiy brief notice of each must suffice. As to the first, it appears to be a universal fact, that at the first rise of an epidemic pestilence, the proportional mortality is always greatest; and, on the contrary, at the decline, whether a few months or weeks only comprise the who.e caieer, the disease loses much of its fatal character; putting entirely out of view the interference of medical art in either case. Knowing this to be the law, though we might not be surprised that, at the appearance of a new and formidable disease, when all is perplexity and alarm, medical men should be at a loss respecting the proper treat- ment, and should often witness the unequal con- flict of their science ; yet we can scarcely withhold a smile, when we see so much self-congratulation. and the numerous cases of recovery at the decline attributed to some improved plan of treatment. With regard to the symptoms or outward character of an epidemic pestilence, we believe the assertion may be safely warranted, that it has never happened that the appearances were uniform in its beginning, height, and decline. As to the plague, this is well known to be the case : Syden- ham, Russell, and others, note the fact. On the points of distinction between the varieties of the disorder we need not dwell; though it would be a work of no small practical utility to consider the usual periods in which the bubo, carbuncle, pur- ple spots, and milder features of the disease make their appearance. But if our limits allowed, it might be shown that even the quick or apoplectic nature of the attacks at the commencement, bears a near affinity to some of those precursor diseases, which, in London, Marseilles, Aleppo, and Malta, ushered in the pestilence itself; and at the decline the mild features and diminished mortality exhibit a striking contrast with its previous violence and malignity. It would scarcely be right to conclude this part of the subject without noticing an obser- vation of Sir James M'Grigor, showing the varie- ties which the same disease will sometimes assume under the influence of different localities and sea sons. " When the plague first broke out in the Indian army in Egypt, the cases sent from the crowded hospitals of the sixty-first and eighty- eighth regiments, were from the commencement attended with the typhoid or low symptoms. Those which were sent from the Bengal battalion, when the army was encamped near the marsh of El-Hammed, were all of the inttrmittent and re- mittent type. The cases which occurred in the cold rainy months of December and January had much of the inflammatory diathesis; and in the end of the season, at Cairo, Ghiza, Boulac, and on crossing the isthmus of Suez, the disease wore the form of a mild continued fever." With regard to the appearances of the yellow fever in Philadelphia in 1793, Dr. Rush tells us, that " the frequent absence of a yellow colour led to mistakes which cost the city several hundred lives ;" as the want of inguinal tumours at the rise of the plague of Messina in 1743, causeo thirty-three physicians out of thirty-four to deny the pestilential nature of the disorder, and to neg lect the proper means of checking it, till it was too late. It might appear that we were departing from the rule at first laid down, and entering upon dis- putable ground by taking any notice of conta- gion ; but the observations to be made being formed by decided advocates of that doctrine, they ought at least to merit due attention from all who do not deny it, especially from those who ascribe 70 EPIDEMICS. bo much more to contagion than to atmospheric influence. Dr. Russell informs us that at the be- ginning of an epidemic plague the contagion is so feeble, in other words, so many of the attend- ants escape infection, and such long intervals o> cur between the cases, as to cause serious perplex- ity respiting the nature of the disorder, (Russell on the Plague, pp. 19 and 261); and that the contagious property is nearly, if not quite extin- guished, at the decline, both in persons and clothes, must be obvious to every unbiassed observer who considers the facts; for the disease has never ceased in any place for want of subjects to act upon, (Researches, p. 156.) And the compre- hensive remark of Dr. Russell is a striking an- swer to those who can trace the extinction of an epidemic plague to no other means than police regulations. It is in these words: " From what has been said of London, Aleppo, and Marseilles, it would seem as if there was little observable dif- ference in the mode of its termination, in cities where purification was practised and where it was not." In all stages of the bilious pestilence of Amer- ica, its contagious property is so indistinctly mark- ed, that Dr. Rush felt himself obliged to confess that " the interests of humanity were deeply con- cerned in the admission of the rare and feeble contagion of the yellow fever." And although contagion is what popular opinion fixes upon the plague as its necessary attribute, yet there cannot be a shadow of doubt, that at all times this con- tagious property of the disease depends on so many contingencies to give it force, as to justify the remark of Dr. Russell, " that the dread of contagion from plague may, consistently with truth, lie moderated." Dr. Russell sums up the matter in these words, after stating that " the constitution of the air is the cause which heightens or lessens the suscep- tibility of the contagion."—" 1st. In the begin- ning of a pestilence the disease, though less con- tagious, appears in its most fatal form. 2d. On its increase and height, though manifestly more infectious, the malignity of the effluvia does not seem to be exacerbated, because milder forms of the disease are then more common. 3d. Several persons infected from the same subject are vari- ously afflicted ; some in a greater, some in a lesser degree, the disease being modified by difference in constitution. And lastly, persons in constant communication with the sick who have resisted infection in the most contagious stages of a pesti- lence, are sometimes attacked in its declining sute ; which seems to indicate some change in the habit of the individual, not the increased ac- tivity of the contagious effluvia," (Treatise on the Plague, p. 261.) "At Aleppo there were in- stances of persons who had exposed themselves two or three successive seasons, being attacked at length wher< the contagion was fast on the decline, and the distemper had become in all respects mild- er," (Treatiso on the Plague, p. 301.) In considering the progress of an epidemic pes- tilence from one country or city to another, it must be viewed as a remarkable fact, that a disease which has become so mild as to lose the power of iloir.g mischief in o.ie place, when transferred to •taofbrr should begin in the same insidious and destructive manner, and continue to rage with the same violence, and at last moderate its fury in the same way as it was observed to do in the former ; making due allowance for the variety of circumstances which must tend to modify the effects in different places. On the common ex- emption of strangers and others we have not time or space to enlarge. 4. The evidence wbxrh bears upon the connec- tion of pestilence witn filth, &c., is remarkable: it is both negative and positive. The negative is the absence of pestilence from those cities of Eu- rope, now for more than a century and a half, which have adopted a system of health-police, not by guarding against foreign contagion, but by do- mestic cleanliness. The positive is the devasta- tion of those where attention has not been paid to these points; and the immediate good effects which have resulted from sanatory regulation: wherever they have been adopted. " Dr. Heber- den," as was observed by Bateman in an able article on the subject, " has collected the most ample and satisfactory evidence of the connection of plague and of the malignant contagious fever, which usually precedes and accompanies it, (if, indeed, they be not modifications of one and the same disease,) with the filth of crowded, ill-con- structed large cities, in all ages and countries." London, Paris, and the cities of the Netherlands, which were formerly scourged by pestilence, when- ever untoward causes operated, such as wars, un- cultivated fields, famine, or unwholesome food, wretchedness occurring in a congregated mass of human beings, added to irregular seasons and in- temperature of the climate, have been compara- tively exempt from its visitations since their streets were paved and widened, and kept clean from animal and vegetable filth, which formerly lay in heaps under a scorching sun ; since sewers have been dug, and fresh water has been abundantly supplied to them ; since houses have been better ventilated, and built more for the purposes of health than of harbouring the greatest mass of people in the smallest possible space; and since all kinds of stagnant pools have been removed from their vicinity. And, besides the exemption from pestilence, the type and character of the reigning diseases in some of these cities have been much changed for the better; and the relative mortality has been wonderfully diminished. This is strikingly exemplified in London. But as it was always in the most filthy parts of those cities that plague " originated and main- tained its head-quarters," so, in other cities, which have been tardy in adopting such improvements, as Marseilles, Moscow, and other places, there was a corresponding liability to its invasion much later than the period above noticed. And now, if we turn our attention to the domestic sources of ma- lignant fever still subsisting in the cities of Spain, which have so often been scourged with it of late years; or to the present state of Constantinople, Cairo, and Alexandria, we need not wonder at the facts which experience has thus unfolded to us from time to time in confirmation of these princi- ples. -. AH the towns and cities (in Spain) which suffered from the yellow fever were, with the ex- ception of Cadiz, filthy in the extreme, dis-rust- ingly so, and very objectionable on the score of EPIDEMICS. 71 ventilation, situation, and form of construction; while the different towns of Arena, Matero, Bada- lona, Tarragona, Vimaros, Benicarla, Valencia, Alcama, Velez, Malaga, Marabella, Este-^ona, Vejer, Conil, Puerto Real, Rota Chipiona Orcos, and Medina Sidonia, all of which are in the vi- cinity of the sea, and which, it may be presumed, from their relative situations, communicate freely with the theatres of disease, were not affected by the malady. They seldom, indeed, suffered in any other years; because, independent of their localities being better chosen for health, they are comparatively clean." (Good's Study of Medi- cine, vol. ii. p. 81.) In the cities of the east which are still scourged with the plague, they nourish from year to year the seeds of the disorder in their own bosoms, in climates, too, the most favourable to the propaga- tion of pestilential epidemics; yet in these very places it is only in seasons when aggravated causes have been operating, that pestilence in an epidemic form appears; and when it does show itself, the phenomena of its beginning, and height, and decline, correspond with those which have been stated to occur in other places, allowing for the difference of climate. Sir John Webb notes the common epidemic, or rather endemic, preva- lence of plague in Egypt in these words : and the reader is requested to bear in mind the difference in the violence and symptoms of the disease in its beginning and decline. " The course of the dis- ease is nearly the same every year, and equally varies in different seasons of the year. In Egypt it commences in November, at which time it rages with its most deadly malignity ; and those who are affected by it sink into the grave almost with- out complaint. It continues its ravages with little abatement through the winter and the earlier part of the spring, when, as the weather becomes warmer by the approach of summer, its attacks are less frequent, its symptoms much milder, and it subsides into a manageable malady." Pappon, a late French writer, tells us, that even in Egypt, when it was formerly well cultivated, the climate was healthy compared with that of Rome in its decline. With regard to the indigenous causes adequate to the production of yellow fever or the transat- lantic plague, which Dr. Rush had frequently an opportunity of observing, he states, " Philadelphia must admit the unwelcome truth sooner or later, that the yellow fever is engendered in her own bowels; or she must renounce her character for knowledge and policy, and perhaps with it her existence as a commercial city." Although extensive marshes give rise to diseases of a febrile character every year among those re- siding in their vicinity, yet it is often found that, in seasons of uncommon intemperature, the ma- lignity and fatality of such diseases are much in- creased. And this cause, concurring with other circumstances, has frequently produced a destruc- tive pestilence. Diodorus attributes a pestilential disease which occurred among the Carthaginians at the siege of Syracuse to the following combination of circum- stances:—" the multitude of people confined with- in a narrow compass, the situation of the camp in a low and wet ground, and the scorching heats in the middle of the day, succeeded by cold and damp air from the marshes in the night." Fracastorius ascribes a malignant epidemic fever in Italy, in the sixteenth century, to an extraordinary inunda- tion of the Po, which, happening in the spring, left marshes, and, those corrupting, infected the air through the summer. Forestus remarks, that from the putrefaction of the water only, the city of Delft, where he practised, was scarcely ten years free from the plague or some pestilential distemper, (Rees' Cyclop. Art. Epid. Dis.) "At this day," says Assalini, " the lakes, the marshes, and the filthiness which one finds in the cities of Lower Egypt, are the principal causes of the fre- quent diseases to which they are subject, and which can never be eradicated until we have found means to purify the atmosphere of their environs. This important advantage may be obtained by draining off the water of the lakes, and filling them up ; by keeping the cities clean, paving them, and giving a free exit to the rain water, which, stagnating in different parts of these cities, becomes corrupted, and, conjoined with filth, infects the atmosphere. By similar operations several cities and provinces in Europe, America, and the Indies, have been rendered healthy. The inhabitants of the citadel of Cairo, which is favourably situated ou an eminence, during the plague of 1791 were exempt from the disease, which laid waste the lower town; with which, nevertheless, they con- tinued to hold constant intercourse." Bombay has been rendered much more healthy than it was formerly, by a wall built to shut out the sea, which formed a salt marsh, and by an order that none of the natives should manure their cocoa-nut trees with putrid fish. (Lind on Hot Climates, p. 207). According to Diogones Laer- tius, Einpedocles, the Sicilian philosopher, removed pestilential diseases from the Salenuntians, by con- veying two streams of running water into the stag- nating river round their city which gave rise to them. (Diemerbroeck de Peste.) Modena was subject to malignant fevers from a like cause; and by filling up the ditches and morasses which sur- round the citadel, these fevers have almost disap- peared. (See Assalini, p. 208.) 5. It is a singular illustration of the preceding views, that in none of the quarantine establish- ments on the continent, and in none of the stations appointed for the purpose in the British islands, along so great an extent of coast, engaged in such universal commerce, and for such a number of years, has there ever been an instance of a person suffering death in the process of expurgation or purification of goods imported from countries afflicted with pestilence. Evidence to this effect, so far as it relates to our own shores, was laid before a select committee of the House of Com- mons, in 1819. (Researches into the Laws of Pestilence, by T. Hancock, M. D. p. 233.) Professor Assalini, who has given us some interesting particulars concerning the plague of Egypt, communicates the result of his inquiries respecting the matter in question in these words: «It has often been said, that in breaking open a letter, or in opening a bale of cotton containing the germ of the plague, men have been slruck down and killed by the pestilential vapour. 1 have never been able to meet with a single eye- EPIDEMICS. witness of this fact, notwithstanding the inquiries which I have made in the lazarettos of Marseilles, of Toulon, of Genoa, Spczia, Leghorn, Malta, and in the Levant. All agree in repeating that they have heard of such an occurrence, but that they have never seen it happen. Citizen Martin, cap- tain of the lazaretto at Marseilles, who for thirty years has held that situation, told me that during that time he had seen opened and emptied some millions of bates of cotton, silk, furs, feathers, and other goods coming from several places where the planue raged, without having ever seen a single accident of the kind." The chief physician of the lazaretto at Malta informed Dr. Maclean that during the period of fifteen years in which he frequented the lazaretto, no cargo arrived, the expurgation of which infected a single individual in the establishment; and according to the testi- mony of the deputy-inspector Grieves, none of the persons so employed were affected in that island during the plague of 1813. If we go to the Levant, we have the evidence of Sir James Porter, that " all sorts of merchan- dise susceptible of infection pass through the hands of our English factors at Aleppo, Smyrna, or the places from whence they are shipped; they are examined strictly by them, or by their ser- vants ; and there is not upon record, nor has a single living witness ever related an instance of an English factor or servant dying of the plague, at any of the sea-port towns, or in any other part of Syria or Asia Minor, and but one only in Con- stantinople, in almost a century ; though the disease very frequently rages in that metropolis." (Russell on the Plague, p. 309.) In connecting together the preceding classes of facts and observations, it is necessary to premise that a mere sketch is only given, and very general conclusions only can be drawn; but we believe that no theory of epidemic diseases will be perfect which does not include a comprehensive survey of all these circumstances. As to the phenomena of the weather and sea- sons, it must be allowed that the physical signs deduced from their intemperature and irregulari- ties, such as blights, mildew, abundance of insects and reptiles, flight and death of birds, murrain among cattle, and pestilence among brutes, are uncertain in their development in different coun- tries, and even in the same ; and that some pesti- lential visitations have occurred without any very striking signs of this sort having been noticed. But though this may have been the case, it does not appear that extremes of some sort have ever been wanting in the air and seasons as accessories to the cause. The uncertainty, however, in egard to the outward visible signs of atmospheric impurity, as recognized in the manifest qualities of the air, has induced some philosophers to sup- pose that there were latent qualities which neither our senses nor chemical knowledge could detect, implicated in the causes of the mischief. Some, accordingly, have given reins to their fancy, if they have not also given occasion to the advocates of contagion to confirm their exclusive opinions, in seeking for the cause of epidemic pestilence in mineral exhalations from the bowels of the earth, emitted by volcanoes, earthquakes, and such-like <«nvulsions. But though we may have some persons admitting a corruption of the air by mineral vapours, and others a contagious semi- nium as being necessary to the effect ; yet a cor- rupt dr which cannot be detected, and a conta- gious principle which must be hunted for in a variety of channels, and is constantly eluding the search, may still leave the truth in as much ob- scurity as it was before. We are therefore com- pelled to leave such unsubstantial hypotheses, for they only remove the difficulty a step. The notion of Sydenham, however, " that epidemic diseases arise from mineral vapours from the inmost bow- els of the earth," comes somewhat nearer the truth, if we connect it with the effluvia and the effects of local filth and of animal and vegetable impurities in large, ill-constructed cities and marshy situations. In situations of this sort vapours do indeed, at times, rise from the earth, (if not mineral impregnations,) which are known to be highly destructive. Yet, on the other hand, if local causes like these are existing year after year, and a general pestilence is but rare, how are these to be considered the cause ? It cannot be doubted that local filth alone will not explain the circumstance. Like atmospheric intemperature it may contribute something, but it is not the cause. If, however, we add to the effects of unseasonable weather and of corrupting animal and vegetable materials, those of deficient or unwholesome food, and congregate the poor victims together in close sordid dwellings, surrounded and contaminated by local filth, then we fill up the range of pre- disposing causes which prepare the debilitated bodies of the wretched poor for the sudden inva- sion of acute disease, and lay them prostrate before the sweep of pestilence. But of famine, or unwholesome food alone, it may of truth be predi- cated, as of other individual causes, that it will not produce a pestilence. So that neither irregu- lar seasons and bad weather alone, nor the effluvia from putrefying animal and vegetable substances alone, nor vitiated bodily secretions, however con- centrated, alone, nor even diseased human secre- tions, the product of fever, however aggravated, alone, whatever marvellous stories may be attached by different authors to any of these particular cir- cumstances, will ever be likely to produce a gene- ral pestilence. This opinion is hazarded, not without being duly weighed, after a careful inquiry into the specific effects of these several causes, viz.: atmospheric vicissitudes; animal and vegetable putrefaction ; malaria, whether from marshes or the mouths of great rivers, or cities or camps ; famine or bad food ; and the concentrated poison of human filth and human disease. Yet the writer of this article is not the less assured that all these causes together have a powerful combined influence in occasioning that predispo- sition of body without which no epidemic plague will make any progress ; without which no con- tagion will spread ; and which, if in some few cases it require the assistance of a contagious principle to produce the disease in time of pesti- lence, yet in the majority of instances appears to surrender the multitude a prey to the common enemy without the medium of contagious inter- course. Nor is it, on the other hand, to be doubted that fear, wretchedness, fatigue, and excess, with other debilitating powers, hoth in an EPIDEMICS. 73 epidemic season and at other times, may co-oper- ate with some of the predisposing causes above mentioned ; and, perhaps, with contagion, to pro- duce the disease even in the bodies of those who, living in the comforts of life, have been subjected neither to the undermining effects of bad food, nor to the corrupting influence of a vitiated air and local filth. It is probable that a predisposition is formed, occasionally, to take the disease in this way ; but that it is very rare, and never has been the cause of general pestilence. As far as facts therefore enable us to form any general conclusions in regard to the circumstances Which conspire to produce a pestilence, the fol- lowing appear to be legitimate deductions, without having recourse to the obscure notion of a pesti- lential constitution of the air, except in so far as we may apprehend it as an ultimate fact, for it is in vain to inquire into the subordinate reasons, why an epidemic pestilence, in obedience to the laws of this constitution of the air, either observes certain seasons of the year, or a limited number of weeks or months to run its course, or a pro- gressive movement in families and neighbourhoods, and cities and countries. 1. Intemperature of the air, or a series of un- usual and irregular weather, lays the foundation for an acute disease in a congregated mass of hu- man beings. 2. Deficient or unwholesome food predisposes the bodies of the poor, especially, to be acted upon by this intemperature. 3. Local impurities, composed of effluvia from putrefying substances, in the vicinity of marshy situations or of large filthy cities, in proportion to their extent and to the concentration and viru- lence of the miasmata, aggravate the preceding causes by a partial pollution of the air. 4. Human secretions and excretions, hurtful in this state of the body even without actual dis- ease, but become virulent by accumulation, and poisonous when subjected to fever, acquire a de- gree of malignity which is proportioned to the congregated mass. Hence, if the air, and the soil, and the food, and the state of the animal secretions contribute each a part to the production of a pestilential fever, it cannot be said that the cause resides wholly in any one of them. From the combined effects of all, however, a predisposition is formed which makes some inhabitants of a town or city liable to pestilence sooner than others, some towns or cities sooner than others, some nations sooner than others, in proportion as they have been sub- jected to the causes before mentioned. If so many causes did not successively concur to this effect, pestilence would be much more common than it fortunately is. We do not depend, there- fore, upon the casualties of arresting contagious intercourse, or of expurgating imported fomites, but upon the rare occurrence of the several sub- ordinate causes, for our exemption. And if the prudent adoption of some salutary regulations should prove availing, even in the very time of a pestilential visitation, to lessen the mortality and to mitigate the disease, as they have been often found to do, much more should such measures prove availing, when practically adopted Vol. II.—10 g in any city, as the constant and habitual means of preservation. Now, unquestionably, the removal from close and filthy habitations and a vitiated neighbour- hood to a pure air, if such can be found ; and the separation from each other, and dispersion over a large space of healthy ground, of the distressed multitudes who are thus predisposed, and the sup- ply of sufficient and wholesome food to them; and cleanliness in their persons, clothes, and apart- ments ; have been fully ascertained to be the best prophylactics, even in time of pestilence, which human skill can devise, and the surest means of arresting this formidable evil. The citizens of the United States know well what security lies in these means ; the principles are not visionary. And here we must protest against the unscientific attempt to establish a specific difference between the Levant plague and the yellow fever, as to the former possessing a contagious property, and the latter none. It is astonishing that a physician with a mind so energetic as Dr. Bancroft pos- sessed, should have wasted his strength with so much pertinacity in that ineffectual labour. Too much stress has without question been laid upon contagion in both diseases. To take this quality, which is only incidental, from one of these dis- eases, in order to give it to the other in excess, when it is known that some deny it even to the latter, is not the way to advance our knowdedge of this subject. But it might appear invidious to place in contrast with means of preservation and precaution like those just mentioned, the modern European policy of keeping our fellow-creatures, when threatened or afflicted with pestilence, shut up in the hot-bed of disease; the sick and the healthy within files of bayonets, or in the hold of a vessel with a crowded and exhausted crew. Precautions like these, though in good truth their necessity is much to be doubted, we may not call barbarous and unenlightened, if they be sanc- tioned by a British senate, nor inhuman, though practised by Christian governments of the nine- teenth century, in direct opposition to the benevo- lent usages of Greeks 'and Romans, and even modern Pagans ! But we do call barbarous, and unenlightened, and inhuman, the conduct of those members of our own profession at Noya, who, through fear of ihe contagion, " carried a spear in their hands for the purpose of killing any patient (and the case really happened) who in a fit of de- lirium might attempt to seize the physician or attendants." (Quarterly Journal of Foreign Me- dicine, No. 5, page 7.) Our abhorrence of such cowardice and cruelty is scarcely to be expressed in any temperate form of words. No reasonable man can doubt that the sacrifice of human life from the unwarranted, and, in its effects, unfeel- ing dread of contagion, operating as it does throughout all its details of practical application from year to year, is and has been enormous. But, on the other hand, to maintain that indis- criminate intercourse may be allowed between the sick and the predisposed in their impure dwell ings, and that human beings may be cooped \.c together, in plague or yellow fever, or Indian cho lera, or malignant typhus, or dysentery, withju adding either to their own danger, or to that ol EPIDEMICS. their attendants, is to take that ultra view which is opposed to the experience of all ages. We do not want nice distinctions about a contagious and infectious atmosphere for practical purposes; they are terms which give occasion to many words and to little practical good. The effects of each have been overstated, and of none more than of conta- gion, when viewed apart from other circumstan- ces. Contagion of any disease can do but little harm at any time, in any country, unless there be a strong predisposition of body concurring with a pestilential season. The signs or indications of this pestilential season, and the way to remove this predisposition, are of far more consequence than the precaution against a foreign contagion. Judicious and moderate physicians are more and more tending to this view of the subject. Contagion is not a necessary incident of any disease; but some look upon it as constituting the very essence. A few brief remarks on this subject may perhaps be suitable in this place. The public are wearied with statements from me- dical men, that such and such diseases, of an epi- demic nature, are contagious, and that they are not contagious. They may well wonder at the imperfect state of a science which has not yet set- tled points of so much importance. What are thinking men to conclude when they see medical authorities thus opposed to each other ?—either that the opinion of the most eminent physicians is good for nothing, or that both parties are right —in fact, that under peculiar circumstances, these diseases are sometimes contagious and sometimes not. But it is a great misfortune that partial ob- servers allow their minds to be tinctured with ex- clusive opinions, of which they become as tena- cious as if these opinions could be verified by an undoubted demonstration. The consequence is, that little weight attaches to either side. It is too much the habit of all persons to look at pestilen- tial fevers of every kind, as if contagion was the quality which peculiarly characterized them. Butf called malignant fever, which has ushered in an a very simple view of the case should convince any one that the animal effluvia, or morbid secre- tion from a diseased body, which constitutes con- tagion, is not necessarily a poison to all who come within its influence. Small-pox contagion itself is inoffensive to thousands. In those who have had the disease the predisposition is destroyed. There must be a strong predisposition of body to receive the contagion of any other disease ; and this strong predisposition is what lays the multi- tude prostrate before an epidemic pestilence: .so that, in some cases, an intense dose of the poison ; in others, its protracted application ; in others, an exhausted state of the body from defective nour- ishment ; in others, extreme fatigue and watch- ing, with mental depression ; in others, the de- bility which follows a debauch ; proves, one or the other, to be the exciting cause which brings this predisposition into action while the epidemic constitution, whether this depends on the air, or the body, or the season, is prevailing. It is no fanciful idea that an epidemic constitution is thus limited; for how otherwise could it happen that cholera, like influenza, requires but six or eight weeks to run its course, to become, in fact mild and impotent, after it has raged with fury; while the Levant plague and the bilious pestilence or yellow fever take up three or four months ? If cholera halts days between the first few cases, pestilential fever halts weeks. Cholera observes precisely the same law as pestilential fever, when epidemic ; it is violent and fatal at the beginning, mild and harmless at the decline ; and, if its con- tagious nature were as well marked as that of plague, we should have the not less remarkable fact, that when it was most violent, and acute, and fatal, it was least contagious, except at the decline, when, as in plague, contagion is extinct. The preceding remarks have occurred in relation to the predisposing causes of pestilential diseases, which, perhaps, in most cases, go nine-tenths of the way in producing an attack of the disease, or only wait for some exciting cause while the body is already on the verge of pestilence. It remains to offer a few observations on the precursor dis- eases. That no pestilence comes alone, or without some heralds of its approach, seems to be a truth fully established in the unvarnished history of every such event. In most places it is the crisis of a series of fatal and uncommon diseases. The forerunner of plague is usually a malignant fever — of yellow fever, a fatal remittent; which often appear again at the decline. The difficulty of distinguishing between this malignant fever and the pestilence itself has never failed to excite dis- sension among the faculty, both as to the name of the disease and as to its contagious property. These disputes belong essentially to the present state of opinion on this most important subject; and until correct views prevail over Europe, there will not be a pestilential visitation without them. We can easily account for this difficulty ; for what nature has joined, both in series and affinity, man has attempted to disjoin. Physicians, therefore, have perplexed themselves with the most unac- countable dilemma that ever found its way into any science. They have acknowledged a disease epidemic pestilence, to be their own, or at least the product of the country where it appeared ; but as soon as a little change in its character has taken place — which amounts to nothing more than a change in degree, not nearly so great as that which takes place in the pestilence itself, in the short course of its career — which change in a few months is put off again, then it is to be accounted of foreign origin, and ships and goods are con- demned as the supposed channels of introduction; or it is well if even human life, as has often been the case, does not pay the penalty. The word contagion, with the fears attached to it, has been suffered to preoccupy the minds of statesmen and of many eminent practitioners to such a degree as to destroy all scientific research, to send them hunting after an ignis fatuus, which never yet was found, and to cause them to neglect those wholesome internal regulations which, if well observed, might bid defiance to all foreign conta- gions, supersede quarantine, and in great measure relieve commerce from its present injurious re- straints. J With respect to that law of pestilence above alluded to, according to which other forms of acute disease are banished while the epidemic pestilence continues to prevail, it is absolutely incredible ot EPIDEMICS —EPILEPSY. 7fc at least inexplicable on any sound principles, that one epidemic disease—whether plague, or bilious pestilence, or yellow fever, or cholera — which banishes a whole host of other epidemic diseases from any country while it is raging, and then suffers them to start up when it is about to disap- pear, should owe its origin to any other place than to that country. It is quite incredible that the for- tuitous importation of a foreign contagion should so entirely change the atmosphere of a country, on which its minor epidemics manifestly depend, as to drive them away in this manner, in order that it may exercise the power of destroying alone, until it shall withdraw itself to act the same tra- gedy in some other place; not only so, but that the presence of this foreign disease should restrain for the time the operation of the ordinary causes of mortality from the common acute and chronic diseases to which the inhabitants are liable, which is known to be in great measure the case during the rage of an epidemic pestilence. We might also lay some stress upon the fact that, with singular power of selection, an epidemic pestilence chooses its own season of the year, from which it is observed to vary but little in the same country or climate, both to begin and to conclude its ravages. If, in addition to these things, we consider the epidemic pestilence itself, and its varying features and character in its short career, we can arrive at no other reasonable conclusion than that it origi- nates entirely where it rages. We have seen that no pestilential epidemic is one form of disease, of unvarying type and destructive power, from the beginning to the conclusion; nor, by the admis- sion of the great advocates of contagion them- selves, of equal contagious property in its different stages, if indeed it be possible to ascertain this point, which is a question; and the question hinges upon the very slight degree of contagious property manifested at the commencement, when the disease is most malignant and most fatal, as well as upon the acknowledged extinction of con- tagious property at the decline. By these facts we are compelled to admit that such a change takes place in the air, or in the state of the miasmata from the soil, or in the human body, perhaps in all together—a change so extra- ordinary as to alter the type and character of a pestilential disease from a fierce to a mild state, and to expel it entirely, destroying every vestige of contagious property in it; but according to the doctrine of imported contagion, we must not admit that any combination of indigenous causes can produce it. We are called upon by the facts to admit that the precursor malignant fever, which is so nearly allied to plague that the most sagacious physicians have allowed their inability to distinguish them, is an indigenous disease; but, in condescension to common opinion, we must persuade ourselves that the disease which expels this native malig- nant fever, and that only for a time, is foreign ! It is marvellous that men of science could ever have been influenced to lend their sanction to such incongruous notions. But, in truth, the difficulty of ascertaining the real facts has been the cause of much erroneous opinion. Upon principles which allow of the domestic I origin of pestilence, we can more easily explain the singular facts so frequently recorded in the annals of epidemic diseases, relative to the exemp- tion of foreigners, as well as of the inhabitants of other cities, in a place visited with pestilence. Many facts seem to indicate that it is not the im- mediate state of things only which is to be taken into account, in order to explain the true causes of pestilence; but that the undermining effects of some remote causes, which have been some time in secret operation in certain communities, ought also to be considered ; for it is abundantly proved that a peculiar constitution of the air, on which the progress of pestilence in part depends, will not of itself induce the disease in strangers even hold- ing intercourse with the sick inhabitants, without a fit habit of body to receive it. And, on princi- ples like these, we can account for the escape of such inhabitants of the place as are living in clean secluded situations, enjoying all the necessaries of life, and but little exposed to the exciting causes — as in well-regulated hospitals and abbeys — far more satisfactorily than on the supposition that they have been guarded from the contagion. It is scarcely necessary to recapitulate the facts illustrative of the same views, and establishing the same principles, which belong to the exemption of those cities from the ravages of pestilence, where the wise regulations of cleanliness and at- tention to the poor have been adopted ; and, con' versely, the continuing liability of those in which these wholesome rules are neglected. If we wanted evidence of every other kind, the testimonies of those who have superintended laza- rettos and quarantine stations, furnish an argu- ment of no small weight against the doctrine of imported febrile contagion having in any case been a cause of general pestilence ; for the confused and contradictory accounts of the supposed channels by which contagion has been alleged to be con veyed into different countries, of which many ex amp'es could easily be furnished, might of them selves occasion serious doubts upon the subject. In conclusion, the separate points of evidence added together and weighed impartially, constitute a theory or system of connected observations and dependent results, tending remarkably to establish the opinion, with as much certainty as the case will admit, that the whole apparatus of an epi demic pestilence, from beginning to end, is th' production of the country where it rages. T. Hancock.. EPILEPSY.—Every one is aware of the dif culties with which the consideration of this disease is encompassed, especially with regard to its eti ology — difficulties which we have no expectation of removing ; nor can we hope materially to add to the information which is already before the public relative to the method of treating epilepsy ; but we are willing to put our mite into this trea- sury of medical lore: and being persuaded that those who are afflicted with epilepsy may often be made less wretched, by rendering its paroxysm* less frequent, even when the patient cannot be perfectly cured, we willingly avail ourselves of the present opportunity of urging physicians to re- consider this disease with care, and no longer, as many of their brethren have done, to pronounce 76 EPILEPSY. epilepsy, when unaccompanied with deformity of the cranium or imbecility of mind, incurable, un- til, first, they shall have endeavoured to correct in the patient every function which is disordered, and until, secondly, they shall have exhausted the whole armoury of the empiric. Indeed, it would seem that all those diseases which have been termed opprobria medicinse ought to be revised with care, were it only to seek for new and more effectual palliatives. Every year, by the industry and ingenuity of the naturalist, the chemist, and the mechanist, new agents or more refined expedients are discovered for abating the discomforts caused by infirmity and pain ; and nothing is more commendable in a physician than being familiar with all those resources of art by which incurable diseases can be alleviated. The euthanasia is a subject worthy of increased atten- tion. The name of Ferriar, who wrote a paper on the treatment of the dying, ought never to be mentioned without an honourable addition, on ac- count of the humanity which guided his pen upon that occasion. There exists yet another reason why epilepsy should be investigated with renewed attention. This disease has often brought candour and cun- ning, science and ignorance, into conflict: in the treatment of epilepsy, the empiric, ignorant and bold, and often confident in proportion to his igno- rance, is, in the estimation of the world, superior to the physician who is influenced by true princi- ples of science and morality. The physician ought to use all proper means of preserving epileptics from falling into the hands of the designing, whose nets are ever extended to catch the unwary. He ought to avail himself not merely of science and observation, of the advantage which he obtains from being enabled to prognosticate where an ig- norant person can only guess, but also of prudent reserve, time, and favourable contingencies; * and he ought not to forget that epilepsy will often spontaneously terminate, which favourable termi- nation nine-tenths of the community, educated and uneducated, patients and their friends, in spite of a disclaimer on his part, will attribute to the last medicine prescribed, according to that esta- blished aphorism of popular wisdom, post hoc, ergo propter hoc. Epilepsy, emX/i^lis, (from im' and XapfidvtaQai,) so termed from the suddenness of the seizure. Synonyms. Morbus divinus, M. herculeus, M. sacer, M. comitialis, M. caducus, falling sick- ness, mal caduc, &c. Many of these appellations prove the dismay with which the spectator is af- fected upon witnessing this frightful disease. When a person, with whom, perhaps, one was engaged in agreeable conversation, and who appa- rently was in perfect health, suddenly losing all sense, is thrown down and reduced in appearance to a state of hopeless agony, it is not wonderful that, in the days of ignorance, general amazement * The following are instances of these contingencies Puer decern annnrum, jam a tribus annis epilepticus frustra adhibitis mnltis, remediis, enrripitur febre epi- rlemica. pluribus inolestissyinptoniatibus stipata, et fell- citer superat huno morbum, et postea ab epilepsia ini- munis manet. Miscell. Cur. Dec. iij. Ann. 7 and 8 p. 298. Fuere quibus excilatus morbus, et nutrims opipara ac dw-udiosa vita, subila fortunarum jactura per ouinem vit'nm, hand conteninenda plane conipensatione, silue- ri* tie Haen, pars v. Rationis Med. cap. v. should have been the consequence ; nor that, du. ing the reign of superstition, the frightful scream and struggle of epilepsy should seem to argue the interposition of an offended deity, in this empha- tic manner testifying disapprobation of passing events. Thus did the most politic nation of an- tiquity interpret the occurrence of epilepsy during public business, nor did they hesitate to dissolve a meeting the moment that so apparently porten- tous an eruption took place. Even now, when the mind is strengthened by true religion, which, by calming the spirit, adds to the powers of observation and of reasoning, and is destructive of superstition, and which, moreover, imparts just views of the divine govern- ment, the occurrence of epilepsy is productive of awe in those who are gifted with reflection; not as manifesting any disturbance in the established order of nature, but as a striking and salutary evidence of the uncertainty of health, a gift gene- rally prized by mankind above all others. Paroxysm.—The scream with which epilepsy usually commences is one of the most startling sounds that can be uttered. In female auditors it has produced an hysteric fit, abortion, or as it has been said, eclampsia. We have known it pro- duce in an animal an effect which, although not without something ludicrous in its nature, is cal- culated to exemplify its astounding harshness. A young lady, white in the drawing-room of an eminent physician, waiting the assembling of a consultation summoned to consider her case, was suddenly attacked with epilepsy. She uttered a scream so piercing, that a parrot, himself no mean performer in discords, dropped from his perch, seemingly frightened to death by the appal- ling sound. When, horror-struck by the scream, we turn to the patient, we often find him labouring under a general spasm, more especially of the extensor muscles ; his eyes may be discovered fixed and staring, his eye-brows contracted and lowering; he appears to draw back from the beholder with a fixed and threatening look, which, however, it immediately becomes apparent, is but a senseless gaze. The complexion in some epileptics is leaden, in others it is flushed even to duskiness ; the mus- cles are in alternate relaxation and vehement con- traction, the spasms being what are called clonic. In a girl who was for some time under our care, so violent were the muscular contractions, that her arm was found dislocated after every fit, until, by a proper bandage, which she always afterwards wore, this accident was prevented. Burserius describes a similar accident, and tells us that he once attended a young lady whose jaw was found dislocated at the end of a paroxysm ; and several authors have observed the teeth fractured by the violent contraction of the muscles which elevate the jaw ; the tongue is often protruded, and is then almost always bitten, sometimes nearly through; frequently the sides of the tongue, aftei the fit, are found ragged and bleeding, having been gnawed by the teeth; from the wound in the tongue, the frothy saliva which is forced from the mouth is often tinged with blood ; the neck ap- pears swollen; the eyes roll, or are fixed in a hide- ous squint, which sometimes continues after the paroxysm is over, and even has been perma- EPILEPSY. 77 nent ;* rapid nictitation takes place, and the mouth is sometimes strangely distorted. The abdomen is distended with flatus productive of borborygmi. The diaphragm, abdominal muscles, and muscu- lar coat of the bladder, overcoming the resistance of the sphincters, expel the fieces and urine with violence, nor is a discharge from the vesiculce seminalcs uncommon. The pulse is rapid espe- cially at first, but varies much ; it is generally full and strong towards the end of the fit, when sweat flows, especially from the head and neck. The breathing also varies ; sometimes it is sibi- lous, sometimes stertorous; sometimes the lips are puffed out by every expiration ; at last the breath- ing becomes full and uniform. The violence of the convulsions gradually abates, and the strong muscular contractions give way to subsultus ten- dinum ; and at last the patient, perhaps previously heaving a sigh, is restored to a degree of recollec- tion ; soon after which, exhausted by the violence of the struggle, he drops into a profound sleep, from which he awakes unconscious of his illness, unless admonished of having had an attack by a severe headach ; by the state of the tongue; by discovering that there has been some involuntary discharge, which experience has taught him to connect with the fits to which he is subject; by extreme exhaustion, which may continue for seve- ral days ; or by discoloration of the skin from ecchymosis similar to that which often occurs in hooping-cough. Death has taken place unexpectedly in a pa- roxysm of epilepsy, occasioned, as it is thought, by respiration being suspended by spasm of the glottis, or by congestion of the vessels of the brain. [This, however, is not common.] The attacks of epilepsy are not always attend- ed with so horrible a struggle as that which we have described. Sometimes the patient is seized with sickness or great faintness; his sight becomes dim and uncertain, and recollection is lost, toge- ther with all muscular power, so that he slips from his chair or falls from his horse, and when his friends run to his assistance, they find him pale and bedewed with cold perspiration, perhaps in- sensible, but not convulsed. Occasionally he ob- tains great relief from vomiting; but generally he continues sick, languid, and confused during the remainder of the day. These attacks may often be traced to indigestion, and sometimes re- quire nothing more for their removal than atten- tion to the state of the stomach. There is yet a slighter paroxysm to be described, indeed so slight that its nature is generally over- looked by the patient and his friends. It takes place thus : the eyes of the patient suddenly be- come fixed and vacant : if he be in conversation, sometimes he tries to prolong it in a slow, mono- tonous, gibbering manner. This attempt, narrowly scrutinized, would seem merely an abortive effort to articulate the last word which he had uttered, and which he mumbles for half a minute or a minute, and then recovering, he takes up the thread of his discourse, being soon aware of an interruption of consciousness, which interruption * Oculorum bulbos incredibili celeritate sub palpebris clausis rotari observatur. unde in musculis oculorum moventibus magna distractio fit, et incurabiles saepe tota .ita oculorum distorsiones manent. V. Swieten Coram. § 1077. we have sometimes seen an artful attempt to con ceal. Some individuals have described this state as one of great mental distress, of perplexity and depression, like a frightful dream; they have an imperfect reminiscence of some overwhelming calamity, or a sense of remorse for which they cannot assign a cause. This paroxysm is like a short mood of extreme melancholy, at least such an impression the countenance of the patient, which is full of sadness, makes upon the spectator. The returns of these attacks are frequent; they occur several times a day with some. They who are thus affected seldom escape for many days. That this slight and transient attack, which has been called by some French writers " vertige epilep- tique," is truly an epileptic paroxysm, we are of opinion, from having observed the chain of thought completely broken; from having seen it in per- sons who had been affected with falling sickness in its severest form; from having known falling sickness affect patients who had suffered under these slighter fits, and from a recollection of the slighter and more severe attacks being alternate in the same individual. This affection is alluded to by Burserius, (Burserius, vol. iv. § 264,) as well as certain other attacks, in which a clonic spasm of only some parts, as of an arm or only of the face, takes place, or in which all the senses are not overwhelmed, in the following terms : " There are, moreover, certain degrees of approximation to epilepsy in which the senses are interrupted only for a moment, and scarcely any convulsive motion, or only a very slight one, takes place, the patient not falling to the ground, but continuing to stand. These I should rather name epileptic attacks than actual epilepsy. But if they are ne- glected, a transition first to eoilepsy, and next to that which is severe and perfect in general gradually takes place." Heberden briefly describes this affec- tion as follows : " Postremo animal defectio levis, quae modo antecedit justam epilepsiam, modo quasi vicem ejus implet, dum nihil aliud seger sentit prater oblivium quoddam, et delirium adeo breve ut fere ad se redeat priusquam ab adstantibus ani- madvertatur." (Heberden, Comm. cap. xxxiii.) The following case of this sub-epileptic seizure was written by the patient herself, (C. S. st. 37,) and is highly illustrative. " Even when a girl, I was very nervous, sometimes losing all my strength. I have also been liable to a complaint in my liver, for which I was rubbed with mercury. I have had working and uneasiness in my feet, which was quite painful. Now, at times while speaking, or while any one is speaking to me, I get a confusion on the subject about which we are conversing, which used to last for some time, but does not now for more than a minute, and when it is gone I have a most violent palpitation. I have it now much oftener, but it does not last so long. I am told I grow pale round mv mouth and look rather melancholy for the time, and fix my eyes upon the person with whom I have been talking. I at the same time work my hands, from having a most uncomfortable feeling in them. I am told I always make a noise in my throat, and moan; but of this I am not conscious, and I seem to be in a tremble, my hands shaking. I am tor- mented with a pain which goes from my chest to my back-bone, and prevents me from drawing mv 78 EPILEPSY breath, and gives me an inclination to sigh. From my head to my feet I am at times in pain, and I feel as if there were a heart beating in every part of my body. A numbness conies in my hands, particularly at night, and then I have no feeling in iny fingers, till by rubbing I get it back. Occa- sionally I have had numbness and coldness in my tongue. A lump came in the outside of my throat, which often returns with violent throbbing. This I have every evening."* In this patient there was great irregularity in the uterine function. In truth, this was a specimen of uterine epilepsy in- termingled with hysteria, which was aggravated by continued anxiety of mind and a diet much too stimulating. In the much greater number of patients parox- ysm of epilepsy occurs without warning,f but some are admonished of its approach by symptoms rc- ferrible to a disturbed state of the brain or of the external senses, similar to those which are premo- nitory of apoplexy ; as for instance, excitement of the mind; throbbing in the temples; turgescence of the veins of the neck ; flushing of the face, with cold extremities; giddiness, weight, headach, drow- siness, forgetfulness; disturbed rest, frightful dreams ; irritability of temper, despondency ; in- articulate speech; flashes of light or sparks of fire seen in the dark; tadpoles, motes, flies, chains, or cobwebs, appearing before the eyes; coloured areola? around the candle, or any other luminous bodj'; dimness of sight, or, only one portion of an object distinctly visible ; hissing, ringing of bells, roaring of the sea, or other discordant noises heard ; strange and unpleasant odours smelt; dis- agreeable tastes occurring; numbness in the course of a nerve, or tremblings or convulsions in a limb mounting upwards. Watching or delirium some- times precede a fit, during which ghosts and appa- ritions are supposed to appear; and as the fit does not always follow the illusion, many of our ghost stories and supposed visions doubtless have arisen from threatenings of epilepsy or of apoplexy. We knew an individual subject to epilepsy who be- lieved that his mother had visited him after her death. Disorders of the digestive organs fre- quently precede epilepsy, as pain in the abdomen, salivation, sickness, vomiting, looseness. Some- times the paroxysm follows hysteric symptoms, sometimes obstructed or painful menstruation; or, lastly, the attack follows the aura epileptica, which is a sensation as if a current of air, stream of water, or slight convulsive tremor ascended from a part of the body, or of the extremities to the head ; when the aura reaches the head, the patient falls down in convulsions. This sensation has first been felt in, and seemingly has arisen from, various parts of the body ; from the toe, foot, leg, groin; from the finger, hand, arm ; from the bot- tom of the spine, uterus, loins, abdomen, and chest. * Perhaps we may be allowed to observe that a swell- ing of the thyroid gland, which is often a symptom of hysteria, has not, as far as we know, been sufficiently attended to. This swelling sometimes disappears and returns, but is more commonly permanent; in its ex- 'ernal character it is not distinguishable from broncho- cele. t Sir cent malad<>s, on en trouve a peine quatre ou imq ilont les ailaques soient preced6es et annoncees par des symptomes precurseurs. Chez les quatre vinirt quinze, (hi quatru viiigt seize autres, l'invasion de I'attaque est moite. Gcorget, Diet, de Medecine, Art F.pilcpsie. Here we would observe, that the epileptic fit does not always take place when the patient u thus menaced with it [and, very frequently, it is wholly absent]. Premonitory symptoms of epi- lepsy often occur; not only vertigo, headach, false perceptions, but convulsions in a limb, or in one side of the face, similar to those spasms to which Burserius alludes, with weakness, headach, and a degree of stupor; after which the patient recovers, without the convulsions becoming universal, or insensibility being complete. Dr. Prichard con- siders these as attacks of partial epilepsy, under which head they are described by that eminent pathologist. To us it would rather appear that, like the aura, they are mere threatenings of a fit. In some patients epilepsy is congenite, in others it commences in childhood, in others in youth, manhood, and even in age. Sometimes, when previously established, it subsides at puberty; and sometimes, especially in females, the disease com- mences at that important epoch. There is much variety and uncertainty with respect to the return of the paroxysms. The attacks have been peri- odic, but much more generally they are irregular in their recurrence. Months, nay years, may in- tervene between the severer attacks ; while the slighter may return daily .j- We have preserved no list of the epileptic patients by whom we have been consulted, and cannot state the proportion of males to females, but our impression is that we have seen many more of the former than of the latter ; hence the observation of Heberden, distin- guished for his accuracy, is, we presume, true with respect to epilepsy as it occurs in the upper and middle ranks of society, " Femins tamen rarius quam viri in earn incidunt." (Heberden, Comm. cap. xxxiii.) We have known individuals subject to epilepsy preserve their intellect unimpaired in old age. A very dear friend who was liable to epilepsy, died a few months ago in the seventy-fourth year of his age, whose comprehensive, well-stored, and active mind remained unclouded till within a few weeks of his death. But it is often otherwise; many become corpulent, indolent, dyspeptic; others are affected with paralysis, apoplexy, 01 veternus, or sustain gradual inroads on the intel- lect, which lead to amentia, the relations of things being no longer perceived or recollected by them: like mere machines, they act as they are induced to do by external influence; no longer able to originate anything, when they receive an impulse they are carried on as it were by mere habitual training, the power of modifying their conduct by circumstances as they arise being lost. They generally sit all day long staring and drivelling, inattentive to the calls of nature; so that at last their most sanguine and affectionate relatives, des- pairing of their recovery, become anxious for their death as a release from suffering and degradation. The change which takes place in the expression of the countenance cannot be better described than in the words of M. Esquirol. « Les traits de la face grossissent, les paupieres inferieures se gon- flent, les levres deviennent epaisses; les plus jolies visages enlaidissent, il y a dans le regard quelque 1 Hfberde" rp,atPS a case in which there was an in ™llh,rleen yeafS belwecw tbB «'« ?nd second EPILEPSY. 79 chose d'egare, les yeux sont vacillans, les pupiles dilatees. On voit souvent des mouvemcns con- vulsifs de quelques muscles de la face." (Diction. des Sciences Med. vol. xv. Art. Epilepsie). While we transcribe from Dr. Cooke's valuable work on nervous diseases the following descriptive passage from Aretams, we would have the reader take note that it is applicable chiefly to the extreme cases of the epilepsia cerebralis. " If the disease be of long duration, patients suffer from it even in the intervals of the paroxysms; they become torpid, languid, and dejected ; they avoid the sight and society of men; time does not afford any mitiga- tion of their sufferings; they are often oppressed with watchfulness, and when they do sleep they are terrified with horrible dreams ; they loathe food, and digest with difficulty; their natural co- lour disappears, and changes to a leaden hue; they have a difficulty of comprehension on account of torpor of mind and of sense ; they are dull of hearing, are affected with a ringing of the ears, and a confused sound in the head ; the tongue is unable to do its office, either on account of the nature of the disease, or from injuries which it may have received in the paroxysms ; they are agitated by convulsions, and sometimes the mind is so disturbed by the complaint, that persons la- bouring under it become fatuous or idiotic." (Dr. Cooke on Nervous Diseases, vol. ii. p. 24.) Species of Epilepsy.—This disease has been divided into the idiopathic and sympathetic spe- cies, the former embracing the cases which depend upon an affection of the brain, the latter the cases which depend upon an affection of parts remote from the brain — the epilepsia cerebralis and the epilepsia sympathica. With respect to the epilep- sia occasionalis, which is the third species of Cullen, most of its specimens may be considered merely as convulsions symptomatic of other dis- eases. Thus the epilepsia traumatica, e veneno, e scabie retropulsa, a hsemorrhagia nimia, a debilitate febricosa, ab hydrocephalo, &c. ought to be treated of under the head of wounds, poisons, &c. or if consi- dered not as symptomatic, they ought to rank under the head of eclampsia, an acute disease, of which the paroxysm may never be repeated, and not under epilepsy, which is a chronic disease and recurrent. It must not be denied that it is not always an easy matter to distinguish between the epilepsia cerebralis and the epilepsia sympathica: the rules for discriminating the one from the other, laid down by authors, are by no means implicitly to be relied upon ; and, as the decision of this point is not always practicable, the physician, in the course of an attendance, will sometimes have to change his opinion, for which he ought to be pre- pared. A dictum of the celebrated Cullen, namely, that in the epilepsia cerebralis there are no pre- monitory symptoms, while the epilepsia symathica is generally announced by an aura frigida, has not been confirmed by our observation. In our endeavour to determine the species to which a case of epilepsy belongs, we may proceed as follows :—First, we may inquire into the state of the natural functions—the state of the appetite, digestion, and nutrition, and into the condition of the secretions and excretions; then into the state of the nervous system : tnd lastly, if the patient is a female, into the functions of the uterus, espe- cially with respect to menstruation. If we are unable to detect any affection of the nerves, any local irritation, or disorder of a part remote from the brain, we may with probability consider the case as a specimen of the epilepsia cerebralis. In this conclusion we may repose with more confidence, if we discover that the disease is inhe- rited ; that the patient has been liable to vascular congestion in the brain from determination of blood to the head, increased action in the arterial system within the cranium, or obstruction in the system of the veins, to be inferred from flushing of the face, throbbing in the temples, epistaxis, vertigo increased by stooping, dulness or weak- ness of intellect, tightness across the forehead, headach, false perceptions; that there is anything peculiar in the form of the head, or expression of the countenance; and that the habits of the pa- tient have been such as to produce considerable or long-continued excitement of the brain. Pa- roxysms of epilepsy which occur late in life ii: persons who have had apoplexy, or whose diathesis is apoplectic; rank under the epilepsia cerebralis ; as also do those cases of not unfrequent occur- rence, in which epilepsy almost invariably leads to an attack of insanity; cases which differ in two respects from the more common form of periodic insanity, 1st, in commencing with an epileptic fit; and, 2dly, in the mind being much sooner restored to sanity — derangement continuing sometimes only for a few days. It may, however, be worth while to observe, that white differing in these respects, the mental disturbance which follows epilepsy, and mania periodica, require the same method of treatment. Of the epilepsia sympathetica there are five species, viz. that in which the brain sympathizes with a disordered state of the stomach, of the liver, of the nervous system, of the uterus, or with any part of the body suffering from pain or irritation. The following, then, is our arrangement of the subject : — I. Epilepsia cerebralis. II. Epilepsia sympathica. Sp. 1. Epilepsia stomachica. — 2. — hepatica. — 3. — nervosa. — 4. — uterina. — 5. — a dolore. 1st species. — In addition to many of the com- mon symptoms of indigestion, such as a loaded tongue, unpleasant taste, acid or rancid eructations, cardialgia, heavy breath and perspiration, high- coloured urine, fulness of the hypochondria, and foul discharges from the bowels ; the appetite in the epilepsia stomachica is extremely irregular and capricious ; sometimes it is defective, often canine, and a sense of distension of the stomach takes place after meals. Even white the demand for food is exorbitant, it will often lie in the sto- mach undigested for two" or three days; this \» frequently the case about the time of a paroxysm, shortly after which we have known an enormous quantity of half-digested food vomited, part ol which had been eaten at least two or three days before. " Epilepsia stomachica ea est quam fovel et excitat crapula ; cardialgiis, ructibus, anorexia, dyspepsia, nauseis, vomitione, pragressis." San I vages, cJ. iv. c xix. 2d species. — The liver more than the stomach would sometimes appear to be the organ in which this disease originates. Cases have been reported to us in which paroxysms of epilepsy were inva- riably preceded by change in the complexion, and pain and tenderness of the right hypochondrium ; and in which by great attention to the liver, when its function became disturbed, attacks of epilepsy have been averted. We learn from Burserius, that, in certain cases, epilepsy is preceded by pain in the region of the liver, icterus, and symptoms of calculi in the gall-bladder; and from Dr. Prichard, that he has witnessed several cases of epilepsy wherein the symptoms which point out the existence of chronic diseases of the liver were clearly discernible. The following is a brief case of the epilepsia hepatica. " May 6, 1827. Mr.------, of a highly scro- fulous diathesis, has been affected with epilepsy for several years. The fits commenced at the age of thirteen, and were for some time very frequent in their recurrence; what remedies were employed at first does not appear, but of late he has tried a variety of quack medicines. About twelve months ago, after a rapid succession of paroxysms, he consulted Dr. Casey, of Cork, who found him complaining of pain and soreness in the right hypochondrium, his complexion being at the same time sallow, and his stomach disordered, and by whom small doses of a mercurial medicine and bitters were prescribed, by means of which these symptoms were removed, and there was no return of epilepsy for some months ; after which, in November, symptoms of great hepatic disorder returned, of which two paroxysms of epilepsy ap- parently were the consequence. Since which he has had no paroxysm in a perfect form; but he has experienced symptoms which formerly had forewarned him of an attack, and which he de- signated a " nervousness," namely a sudden tre- mor with a momentary but slight convulsion, at which time there was always more or less disorder of the hepatic function ; when these symptoms occurred, a brisk mercurial purgative was given, and under this simple treatment he has enjoyed a longer exemption from convulsions than since the commencement of his illness." 3d species.—In pursuing our investigation, we ought next to endeavour to ascertain whether the patient, if a female, is labouring or has laboured under hysteria; whether she has been liable to rapid palpitation of the heart, sudden failure of strength, faintings without loss of consciousness, entire loss of voice, anorexia, or any of the more palpable symptoms of hysteria, as the globus or clavus hystericus. Nay, although there be no symptoms of hysteria, causes which produce that affection may have been in operation prior to an attack of epilepsy, as sedentary occupation in a close and cold apartment, insufficient food, de- pressing passions; and if so much light may be thrown on the case, through a knowledge of the diathesis of the patient. Nor ought the inquiry respecting the symptoms which characterize hys- teria to be confined to the female ; for symptoms which no one would hesitate to call hysterical, if occurring in a female, may frequently be detected EPILEPSY. ~\v~e mav include both sexes, this species ought to be called epilepsia nervosa rather than epilepsia hysterica, hitherto the term which has been ar> plied to it. In patients liable to epilepsia nervosa, there may sometimes be observed preceding a paroxysm, an excessive irritability with jactitation, weakness, tendency to deliquium, suspirious breathing re- quiring a constant supply of fresh air; or tinni- tus aurium, vertigo, and the wildest hysteric de- lirium. 4.th species.—An inquiry into the condition of the uterine function will sometimes discover the nature of an attack of epilepsy, which may be connected with obstructed menstruation or dys- menorrhcea. The epilepsia uterina arises and re- turns at or about the period of menstruation; sometimes for the first time at puberty, and often in consequence of those causes which check men- struation, as damp and cold feet, excessive fatigue, great anxiety of mind, or alarm. In our opinion this species ought to stand apart from the third species, with which it is generally identified, but from which it differs both in its causes, exciting and predisponent, and in the method of treatment which it requires. 5th species.—To this species of the disease be- long cases of epilepsy originating in injuries, in which the nerves are wounded or lacerated, or arising from diseases of the nerves. In the Edin- burgh Medical Essays and Observations, (vol. iv. art. 27,) a case of this nature is related, in which epilepsy was caused by a cartilaginous tumour of the size of a large pea, which was situated on a nerve. Upon the excision of the tumour the fits ceased. In the same work there is an account of convulsions being caused by a concretion of the size of a nut pressing upon a branch of the sciatic nerve. One such neuralgic affection we have witnessed, but we rather think the convulsions in that case were not strictly epileptic. To this spe- cies, also, belong the affections described by La Motte, in which epilepsy was caused by calculus in the pelvis of the kidney : one epileptic, after a violent paroxysm of the disease, voided five cal- culi, and had no return of the fits. (Yol. ii. p. 20.) As these cases, however, are rather within the province of the surgeon, we shall not revert to this species of the disease when we come to explain the treatment of epilepsy. It must be acknowledged that the symptoms which, in distinct groups, give a specific character to a case of epilepsy, are in some instances con- fusedly intermingled, whereby the symmetry of our attempted arrangement is disturbed, and what is of much more moment, the remedial p\oce>s rendered difficult by contra-indications : thus it would not be easy to say to which of the forego- ing varieties the following case belongs, which is presented, not to discourage the student, who with increasing experience will see more clearlv that our division of this important subject is founded on just observation, but to show him that there are difficulties which it will require persevering study as well as the most attentive observation to conquer. "In the latter end of harvest, 1829. a young lady, an. 17, who had not begun to menstruate, of in males subject to epilepsy, who are of a nervous temperament or hypochondriacal; and hence, that [ a very strumous habi^ an^much^fflteted'wi"! EPILEPSY. 81 psoriasis labialis, having a dry, scabrous, branny skin, and being liable to hysteria in an aggravated form, was visited for the first time by a physician just as she was recovering from a paroxysm of epilepsy, several attacks of which she has since had at the intervals of one, two, or three months. After the first attack there was a sense of fulness and tension in the head, with symptoms of hepa- tic congestion and torpor, all of which yielded to a moderate bleeding from the arm, together with the use of calomel and pulvis Jacobi, followed by a draught of the infusion of senna and the com- pound decoction of aloes; and subsequently the shower-bath, and diet of easily digestible materials, together with tonic medicines. Her tongue had usually been coated, the digestive function deprav- ed, as appeared from anorexia and a very capri- cious choice of food ; the alimentary canal very torpid, requiring the continued use of various ac- tive purgative medicines. The paroxysms appear- ed some of them to be averted by a pill of calomel over night and a purgative draught in the morn- ing, so that indigestion seemed to be the chief ra- dix morbi." Pathology of Epilepsy.—That there will in general be found, on dissecting the bodies of those who have laboured under falling sickness, some exemplification of diseased structure in the cra- nium, subjacent membranes, cerebrum, cerebel- lum, or spinal canal, works of morbid anatomy, and treatises on epilepsy, have taught us to expect; they show that after death we may count upon finding a part of the contents of the cranium affected through the operation of some irritating cause. In some dissections is discovered exosto- sis, or thickening of the bone, which indeed may be a consequence rather than a cause of disease ; in others, inflammation or ulceration of the mem- branes of the brain, of its surface or substance ; in others vascular turgescence ; effusion of various fluids—bloody, serous, gelatinous, purulent; in- duration or softening of the brain; tumours some- times are detected, whether scirrhous, fatty, or sarcomatous; and lastly, tubercles or hydatids : but what may be disclosed by any one dissection about to be performed, whether an appearance connected with some change in the structure of the bone, membranes, or the brain itself; nay, whether any morbid change will be discovered, a cautious physician would not venture to predicate. The following is one of many quotations which we might produce to show that dissection hitherto has given us but little aid in ascertaining the cause of epilepsy : " Sed et fessi fuerent summi in arte viri, atque in rebus anatomicis peritissimi, quod in cadaveribus hoc morbo defunctorum nihil invenerint saspe quod culpare poterant." (Van Swieten, Com. s. 1872.) Even the brothers Wenzel, who have produced a monograph on thjs subject of the highest order, in which we recognize just principles of investi- gation, ability, and zeal, after an inquiry continu- ed for a good many years, and the careful dissec- tion of above twenty epileptics, confining their observations to idiopathic epilepsy, to the exclu- sion of those cases, " en qui cette maladie peut elre produite par des vers ou autres causes exte- rieuret et materielles," and arriving at a conclu- sion that the disease is seated in the sphenoidal Vot. II.—11 bone, in the pineal gland, and the pituitary gland, but chiefly in the latter, have added but little to the pathology of epilepsy. Admitting their conclusions to be just, it will not satisfactorily explain the nature of the disease, nor lead to any practical improvement, the great objects to be obtained from the cultivation of mor- bid anatomy. There seems to have been the greatest diversity in the appearance and condition of the pituitary gland.* Its colour was not uni- form, nor yet was its consistence. In some cases it was very soft, and in others preternaturally hard ; and in respect of its size and structure there was also great diversity. The Wenzels, we conceive, have merely opened up a new path—a path which ought to be explored by future inqui- rers notwithstanding the discouraging remark of M. Esquirol, " de toutes ces recherches, particu- lierement de celles de Bonet, de Morgagni, Bailie, Greding, Meckel, Wenzel, que pouvons-nous con- clure ? Rien, sinon que ces memes alterations ont lieu ches des individus qui ne sont pas 6pileptiques, comme Wepfer, Lorry l'ont prouve. Avouons franchement que les travaux de 1'anato- mie pathologique n'ont jusqu'ici repandu aucune * As it would appear from a paper placed in our hands by Dr. Tweedie, which was written by his friend Dr. Sims, of London, that in the French Translation of the work of the Wenzels by M. Breton, ann. 1811, the Ger- man word hirnanhang, which ought to have been trans- lated gland pituitaire, has been rendered cervelet, we are induced to lay before the reader in this note an extract from Dr. Sims'spaper, in which an accurate account is given of the labours of the German pathologists. "The Wenzels regard as a pathological circumstance a peculiar thinness of the sphenoidal bone and of this part of the base of the skull, when compared with the ordinary thickness of the other bones; variations in the position, curvature, and size of the clynoid apophyses ; which destroy the natural symmetry of the bones of the basis, and occasion changes in the. capacity and form of the sella turcia. These have an influence on the brain and pituitary gland. "The pineal gland, in several cases, was altered in colour; in ten it was a pale grey ; a brownish yellow vesicle on its upper surface is noticed; in all it was softened; in nine it was much smaller, in two much larger than natural. "In the pituitary gland the principal changes were observed, some of which certainly would require the close inspection of a practised eye to discover : an une- qual and furrowed appearance of the upper surface—in two instances a muscular appearance as in old people; excavations, or loss of substance of the upper surface ; depression along the anterior margin ; alterations of colour, as various shades of red verging to black, pale grey, yellow, brownish yellow, and pale white. In three cases it was very soft; in five, firm, compact, and of un- natural hardness, considerably enlarged, with an effu- sion of thick lymph between the two lobes. In seven of prodigious size. The most important alterations ex- isted in the interior: in ten cases, at the point of union of the two lobes, there was a yellow, solid, friable mat- ter, which might be raised in bits ; this substance almost always (independent of the separation of the lobes) oc casioned a loss of substance. In five cases there was a viscid semifluid lymph between the two lobes. Patches of white, or brownish solid lymph on the superior sur- face of the gland ; the anterior lobe enlarged, and con- taining a substance resembling pus; the lobes joined without intermediate surface ; the lobes separated from each other, the upper surface inflamed. " In some instances the infundibulum was firmer than natural ; in one instance an effusion of lymph resem bling false membrane was deposited around a portion of it; in another part it was red and inflamed. "Several other morbid appearances are noticed. Ex crescenceson different parts of the basis of the cranium caries of the bones; effusion on the internal surface of the dura mater, and on the arachnoid lining; varia tions of the convolutions of the brain, of its magnitude and colour; in the ventricles, corpora striata, thalaini nervorum opticorum, tubercula quadrigemina. In fifteen of the dissections, the cerebrum and cerebellum were perfectly healthy. 62 EPILEPSY lumiere sur le siege immediat de l'epilepsie. (Diction, des Sciences Medicates, Art. Epilepsia) [Recent writers —MM. Bonchet and Cazau- vielh—whilst they accord with MM. Forille and Delage in their view, that mania consists in acute or chronic inflammation of the cortical substance of the brain, are of opinion, that epilepsy consists in chronic inflammation of the medullary neurine.] Proximate Cause* — Nothing can be more obscure than the proximate cause of this disease. As convulsions similar to those which attend epi- lepsy may be produced by the application of an irritant direct to the brain ; as every part of the frame is agitated during a paroxysm—all the ex- ternal senses often being morbidly affected just before the paroxysm, the whole muscular system agitated during it; and as not only the animal but the vital functions are universally perturbed, the proximate cause must be seated in the sensorium commune, as being the only part capable of exer- cising such an influence over the whole body ; but the nature of the disorder upon which the epilep- tic fit depends will probably never be discovered. It cannot be vascular distension, since convulsions are often a consequence of loss of blood, (no other cause at the same time operating,) and may be removed by stimulants. It cannot be vascular collapse, since convulsions sometimes depend upon plethora, and are relieved by spontaneous hemor- rhage or by bloodletting. In this disease we are unable to lay hold of the first link in the morbid catenation. It is generally thought that the aura epileptica is an irritation which first takes place in the sentient extremity of a nerve, and is thence conveyed along the af- fected nerve to the sensorium, which is thus thrown into disturbed and irregular action, influ- encing the whole body ; but to us it would appear that the aura epileptica is not an irritation of a nerve in the part from which it seems to arise, for then it would take the course of the nerve instead of passing along the integuments; but that it is a reflex sensation, caused by a morbid process going forwards in the brain, or a part of it—that it is a false perception — a mere symptom of an unex- plained disorder of the sensorium, as much as tin- nitus aurium, or muscae volitantes, or numbness in a nerve, or pins and needles, as a certain prick- ling sensation is called by paralytic patients. It would be vain to investigate the essence of a dis- ease, in which there is the utmost uncertainty even in the first stage of our inquiry ; in which dissec- tion, instead of affordinnr assistance, rather per- plexes us by the multiplicity and diversity of the changes of structure which it discloses. Moreover it would appear that so long as we are ignorant of the nature of the healthy function of the brain, in what manner its influence over the body arises and is maintained, the deviation from the healthy exercise of its function which constitutes the proxi- mate cause of epilepsy must remain sub judice. Predisponent Cause. — According to sys- tematic writers, the predisposition to epilepsy is supposed to depend on " great mobility," on " a peculiar liability to excitement and collapse;" on •• a liability to be influenced by those causes which are applied to most persons with little or no ef- fect." This condition connected with " a greater degree either of sensibility or irritability, it is con- ceived, is generally derived from original stamina and mav more particularly depend either upon debility or upon a plethoric state of the system. We must, however, observe that we have known epileptics, who did not give way to strong emo- tions upon slight impressions, who were with dif- ficulty excited, and who pursued every purpose with a manly constancy ; and hence, without de- nying that a state, not easily definable, of mobili- ty, is a predisposing cause of epilepsy, we con- ceive that it is by no means the only predisponent to that disease. An opinion on this subject which we hold, we think will probably not obtain favour; and yet, as it has not been hastily formed, we con- sider it a duty to put it forward, that it may be verified or disproved by future observers. We conceive that epilepsy is as certain a manifestation of the strumous diathesis as tubercular consump tion, psoas abscess, hereditary insanity, or certain congenital malformations or defects of organization which are inherited only from scrofulous parents. Epileptic patients are of the habit of body in which scrofula occurs. We have no recollection of a case of cerebral epilepsy in a patient, who, when due inquiry was made, did not appear to inherit a strong disposition to scrofula. It must be admit- ted, however, that there are many epileptics in whom there exist none of the more common symptoms of scrofula. That epilepsy is a hereditary disease is gene- rally admitted. If, when consulted by an epilep- tic, we make diligent inquiry, we shall find that, although direct progenitors, father or mother, may have escaped, yet some member of the family (uncle or aunt, grandfather or grandmother,) has been subject to fits. As Boerhaave has observed, " silente ssepe morbo in genitore, dum ex avo deri- vatur in nepotem." If epilepsy for the first time occurs in a family, it has appeared to us that it has been in consequence of the strumous diathesis having been exalted by the intermarriage of two persons inheritors of that condition or tendency of the constitution, and which it has been in a yet more remarkable degree if the parents were of the same blood and nearly related—we may then ex- pect, if an epileptic patient has several brothers and sisters, that his case will not be a solitary one in the family. [YV e have no adequate statistics to enable us to settle the question as to the hereditary nature of epilepsy.] Occasional causes.—Patients, especially those who have had only two or three attacks of epi lepsy, are ever ready to consider them as acci- dental. One attack is brought on by a fright, probably the most frequent exciting cause of the disease; another by over-fatigue ; one by confined bowels; another by a strong purgative; one by fasting, another by a surfeit; and it cannot be de- nied that very many attacks of epilepsy may natu- rally enough be traced to some inattention to the organs of assimilation, especiallv in the form of excess in the use of fermented liquors. There was lately in Steevens's Hospital, Dublin, a patient who some twelve or fifteen years ago had a frac- ture of the skull, which left a depression of the bone. After the accident occurred, he was sub- ject to epilepsy whenever he indulged in the use of intoxicating liquors: at last he was induced to EPILE lay them aside, and ever since he has been with- out an attack of epilepsy, and is now an able- bodied watchman. " I have observed," says Fo- thergill, " that epileptics are often extremely incau- tious with respect to diet; that children highly indulged are liable to the disease; that in every other period of juvenescence, and in middle-aged adults, if they were attacked with the disease, it was when they had either committed some ex- cesses, or by one means or another were plethoric; and that in habits subject to epilepsy, the disease seldom recurred without either an habitual indul- gence in eating, or a neglect of necessary exercise." The occasional causes of epilepsy may be divi- ded into two classes. 1st. Joy, anger, suppressed discharges, repelled diseases, elevated temperature, bodily over-exertion, drunkenness, prolonged sleep, surfeiting, congestion of the bowels, obstructed or painful menstruation. 2. Opposed to these are terror, grief, disgust, exhaustion of mind from in- tense application to business or study, vigilance, inanition, hypercatharsis, venereal excesses, he- morrhage. " Parmi les causes excitantes de l'epilepsie la frayeur tient a-coup sur le premier rang. La colore et un chagrin profond, la mas- turbation, et les exces veneriens paraissent, apres 'a frayeur, tenir le premier rang parmi les causes Je l'epilepsie." (Diction, de Medecine, Art. Epi- lepsie.) We read of epilepsy being caused by imitation. An attack of epilepsy, when witnessed by a number of unmarried females in a church or school, has often led to convulsions spreading from one to another, till a great many are affected. Dr. Whytt describes this affection in the following words : " There is a disease very common in the islands of Zetland, which is known there by the name of the convulsive fits. It begins with a vio- lent palpitation of the heart; soon after which the patients fall to the ground, unless they are sup- ported ; their arms and legs are alternately con- tracted and relaxed ; and in some cases their joints become so rigid that they cannot be bent. Their respiration seems to be difficult, and they cry ter- ribly white the fit lasts, which is generally less than a quarter of an hour. This disorder seldom attacks married women ; but young women, and even girls of ten or twelve years of age, are liable to it. Some boys and two young men in these islands have also been affected with it. In the church or other public meetings, as soon as one is seized, all such as have formerly been subject to the distemper are attacked with it, which often occasions great disturbance." These attacks, there cannot be a doubt, are not epileptic, but, like cer- tain more recent exhibitions in churches, are clearly referrible to sympathetic hysteria. [A recent writer, M. Meyer, has published some cases of what he terms epidemic epilepsy, occur- ring in schools. In consequence of a girl being attacked with epilepsy, numerous others became affected. Most of the girls were approaching the age of puberty, and they were all of a highly ex- citable temperament. It is probable, indeed, as the writer has stated elsewhere, (Practice of Me- dicine, ii. 230,) that these were cases of hysteria rather than of epilepsy. Many cases, however, are on record, in which the disease appears to have been produced by the sympathy of imitation from witnessing a paroxysm in another. IPSY. b3 An idea has long existed, that the paroxysms of epilepsy may be connected with the condition of the moon ; but there does not seem to be any sufficient reason for this belief] Of the occasional causes of epilepsy, it is justly observed by Dr. Cooke, that " some are stimulants producing an increased action of the brain, while others are sedatives, operating so as to diminish its energy." When there is a predisposition to epilepsy, a cause of either kind, productive either of excessive or defective action, may interrupt the equable transmission of the sensorial power by means of the nerves, and thus occasion a fit; and hence it would appear desirable to retain every patient who is subject to epilepsy in a state equally distant from plethora or from undue emptiness of the cerebral vessels. [Perhaps disorders of the digestive canal, while a predisposition to epilepsy exists, are the most common exciting causes; and, accordingly, we often find the paroxysms recur as certainly as ali- ment, improper by character or quality, is received into the stomach. In such case, the disease is " eccentric" epilepsy.] Diagnosis.—We have reason to think that not only eclampsia, but hysteria ; cataleptic hysteria ; sympathetic hysteria, the disease of religious sects among whom enthusiasm is permitted to usurp the place of sobriety; catalepsy; catalepsis deli- rans; extasis, have been considered as specimens of epilepsy. The student, therefore, must acquaint himself with these diseases, as also with the his- tory of feigned epilepsy, which, not merely in the military hospital but in private practice, he may be called upon to distinguish from the genuine disease. Let him bear in mind that if a fit com- menced with a scream, if it was characterized by insensibility, convulsions, and foaming at the mouth, if it ended in sopor, and if the tongue were wounded or even gnawed at the edges, there can be but little doubt that it was epileptic. Prognosis.—The prognosis in epilepsy em- braces two heads of inquiry, viz. first, the danger to be apprehended from the paroxysm; and se- condly, the probability of a return. As epilepsy sometimes proves suddenly fatal during a paroxysm, our opinion must be delivered with a salvo in reference to such a contingency. To form a judgment of the amount of danger, we must, first, endeavour to ascertain the species of epilepsy to which the case belongs; cerebral epilepsy being attended with more danger than nervous, nervous than gastric or hepatic, and these again than uterine: but we must not forget that the sympathic species of epilepsy may, by repeti- tion, acquire the character of the idiopathic, and be attended with equal danger. Secondly, we may oftentimes judge of the danger of the attack by the symptoms which precede it; thus, in the cerebral species, danger may be apprehended when the preceding symptoms indicate a fixed disease of the brain, as intense pain, vigilance, delirium ; when inroads have been made upon any of the mental faculties ; and when there have been threat enings of paralysis. Thirdly, we are influenced by the violence and duration of the paroxysm. Those severe paroxysms which continue many hours often terminate in fatal exhaustion, or in an apoplectic state. Hence coma, after the -onvul 64 EPILEPSY. sions, is truly alarming, as it shows that apoplexy has actually begun. The probability of the return of the fits will, in like manner, be greatest in cerebral epilepsy, than in nervous, next in gastric and hepatic, and least in simple uterine. In cerebral epilepsy the fits will with most likelihood return in the cases in which the disease is inherited, in which the patient has a peculiarity in the configuration of his head and expression of his countenance, and which have been long established. Of the epi- lepsia stomachica and hepatica, the cases will pro- bably be most obstinate which exist in connection with habits of self-indulgence and with weakness of character. Of the epilepsia nervosa the stami- na of the patient will in general decide our opin- ion both in respect of danger and repetition; indeed, in every species of epilepsy recurrence will be more probable in a constitution defective in point of original vigour, or impaired by excess. In the epilepsia uterina we have most hopes of ultimate recovery, inasmuch as epilepsy will fre- quently cease when a change takes place in the function of the uterus; as, for example, at the appearance or reappearance of the menses, at marriage or during pregnancy. We are inclined to think that epilepsy will be found more inveterate when it occurs in patients who are affected with chronic cutaneous affections. To lepra, psoriasis, ichthyosis, and porrigo, epi- leptics are peculiarly liable. Treatment.—In general, a physician now-a- days may unreservedly explain his views, to such patients as are possessed of good sense and tem- per, of the nature of their malady and the reme- dial process about to be employed,—nay, in some instances, may explain the doubts which are sug- gested by the former, and the uncertainty of the latter, while at the same time the solid ground on which he builds his hope of achieving a cure is clearly pointed out. But such a procedure with nervous patients would be highly injudicious. Not only are such patients, by constitution, infirm of purpose, but by disease are they often rendered additionally irresolute, and, in consequence of the fears which disease engenders, they are a prey to every pragmatical relative or acquaintance or vol- unteer prescriber, who may choose to insinuate doubts and apprehensions, suggest the necessity of changes, and damp and disconcert the medical attendant. When he undertakes the treatment of a case of epilepsy, the physician ought in the first place to study the patient's disposition, in nervous ill- nesses it being generally of as much importance to distinguish the shades of character as the shades of disease ; and, having penetrated into the inte- rior of his patient's mind, he must there obtain an ascendency not merely by knowledge of dis- ease, but in virtue of that influence which is gen- erally obtained by calmness of manner and con- sistency and decision of conduct. We venture to hazard an observation with respect to physicians of equal skill in the medical treatment of nervous diseases, that they who are not communicative will be more confided in and more successful than they who think aloud and explain all their views ■nd plans. I: would lead us away from our subject, other- wise we could easily show the necessity that the physician is under of acquiring and retaining a complete control over the mind of bis epileptic patients, and of inspiring them with hope. We may be permitted to state, in support of this ob- servation, a fact which we have often witnessed, namely, the temporary advantage which is gene- rally derived from a change of measures. When an epileptic patient is placed under the care of a confident empiric, or of a physician who is in great repute, the disease will often be suspended for a considerable time, and to the eye of a san- guine person appear cured; while on the other hand, after a long suspension, when the disease returns, such disappointment is produced as to fill the patient with the gloom of despair, a state of mind which would seem to renew the energy of those causes upon which the fits depend, and hence they occur at shorter intervals and with greater violence than ever. The empiric, well knowing how much depends on confidence, has various methods of fixing un- stable minds; he cajoles and blusters, and with equal power of fulfilment he promises and threat- ens ; he knows that he may draw upon the ima- gination of his patient to any amount, and that his draft will be honoured ; that the mystery with which he clothes all his measures is often the cause of his success, and hence he provides his own remedies* and invests them with suppositi- tious activity. Give a patient a few grains of liquorice-powder, and let him he told that he has just swallowed part of the skull of a malefactor, (which once was considered a sovereign remedy for epilepsy,) or that this powder contains a sub- stance of which, according to the German dream- er, a thousandth part of a grain is the proper dose, and you often may thus cure a disease which is any thing but imaginary. In Ireland, epilepsy has often been cured by the priest, who is sup- posed by the credulous of his own communion to be gifted with the power of working miracles of healing, a power claimed for the Roman Catholic Church, even by her most enlightened members. Uneducated adherents of the Church of England, and even the presbyterian, both in such matters equally credulous, often successfully apply to the same functionary to be cured of fits. He some- times begins the curative process by giving two or three very powerful emetics; but he chiefly relies upon obtaining dominion over his patient's mind, an art in which he is often eminently skill- ed, and which he is the better able to practise, as probably he implicitly believes in his own super- natural power. If the epileptic be a Protestant, the priest signifies that the prayers which he offers up, the virtue with which he is endowed, are his, only for the benefit of the members of his own church; the patient, over-persuaded probably by his friends, goes to mass with reluctance, as a tem- porary expedient to qualify him for the interces- sion of his spiritual physician, by which means the latter gains an advantage over the disease. A struggle has taken place in the patient's mind, in which conscience is laid prostrate; a great and permanent moral impression is made, which, espe- cially if the disease is nervous epilepsy, sometimes ends in the fits being suspended, and the patient becoming a devoted adherent of the Church of EPILEPSY. 85 Rome, to whose interests, by his belief in the su- perhuman power of her clergy exercised in his behalf, he becomes more attached than if he had been born within her pale ; and confidence in the agency through which he has obtained relief, we doubt not, sometimes renders it permanent. Such is the nature of modern miracles, and such the principles by which even protestant clergymen have leen enabled to take a part in a farce equally dis- gusting to all who are able to distinguish between true religion and superstition. A successful empiric, who by various practices had for a long time sustained the hopes of a young lady who was afterwards under our care, one day observed her, while under a sense of faintness, having recourse to sal volatile ; this he eagerly snatched from her, and throwing up the sash he violently dashed the vial upon the pave- ment, at the same time declaring, with well-affected displeasure, that if he ever heard that she had any medicinal substance in her possession which was not given to her by himself, he would never see her again, as his remedies were so delicately com- bined, that, by admixture with any other drug, their efficacy would be completely destroyed. When the extrinsic occasional causes of epi- lepsy are removed or guarded against, the parox- ysm, as depending upon associations established within, will often return with equal violence. Against epilepsy thus become habitual and almost periodic, well sustained hope, whether rational or but a « fair fallacy," as were the amulets employed of old, will be found more efficacious than any other condition of the mind. Sudden alarm, indeed, has been called into assistance as an anti- epileptic remedy; but, with Dr. Cooke, we agree in thinking that terror cannot be employed in the treatment of epilepsy, as being a remedy not suf- ficiently under control. From the annals of medicine we learn that there were other influences formerly much in vogue, which, acting upon the mind alone, must have produced permanent feel- ings of disgust; as for example, the following medicines, which may be considered as a curious specimen of the articles of the Materia Medica which, in former times, were derived from the animal kingdom: — Cineres talpae, muris, corvo- rum ; heputa ranorum ; testicula et urina apri; dentes humani pulverisati; hepar hominis comes- tum; sanguis hominis recens occisi; sanguis patris ; secundina humana; stercus humanum : There are other abominations of the same kind, unnecessary to specify, the use of which, Erastus alleges, was taught to mankind by the devil; but without calling in question the active malignity of our great enemy, we are of opinion that man, when left to his own inventions, is fully equal to the discovery of these and a multitude of other therapeutic agents of equal ineptitude. We have known regular physicians, aware of the advantage which may be derived from keeping the imagination under the agreeable excitement of hope, practise upon the credulity of their patients, as we conceive, very unworthily. We once pos- sessed a prescription written by a physician of some name in Paris, in which the chief remedy prescribed by him was a polished piece of jasper or jade, which he ordered to be inserted under the skin of an epileptic patient's arm. Had he ordered u the words of power which were supposed, by believers in the art magic, to be inscribed on the ring of Solomon, or any other talismanic charac- ters of equal value, to be engraved on this anti- epileptic fossil, his charlatanry would have been more perfect. The regular physician must not practise deception even to forward the interests of benevolence, but he may practise reserve, which will often answer better than all the mystifications of the empiric. Let it be matter of agreement, when he undertakes the treatment of a case of epilepsy, that the patient shall not know the nature of the medicines to be prescribed. Were we, in certain cases, to send our prescriptions to the apo- thecary sealed up, the medicines so ordered would produce effects which would surprise even the prescriber himself. It would be superfluous to dwell upon the import- ance of diet in the treatment of chronic diseases. In such diseases great improvement will sometimes arise from mere change of diet, how unobjectionable soever the diet may have been formerly. If, how- ever, a change is recommended when the indi- vidual first comes under our care, it behoves us to explain the reason of the change; let us not, as some have done, change a patient's diet in such a manner as to abate his confidence in his former physician, who may have treated his case with judgment.* It is needful to stipulate that our patient shall no longer yield to his appetite or inclination. He must move by fixed rules. He must eat only what is placed before him by order of his physi- cian, not asking to have his food varied or en- larged. We do not exaggerate when we affirm that not one individual in ten, labouring under chronic illnesses, strictly observes the rule of diet which is appointed for him by his physician. Drunkenness, in the middle ranks of society, is much less prevalent than formerly, but epicurism in eating much more so. The affected delight with which some popular writers have expatiated on the refinements and indulgences of the table has been, we fear, supposed real, and has given a stimulus to sensuality much to be deplored, espe- cially among young men, many of whom now put no restraint upon their appetite for rich and sa- voury food, while on the pleasures of the table they descant as shamelessly as if they were fit only for the society of Apicius. In general there is no difficulty in persuading patients to relinquish intoxicating liquors, which, as almost every sen- * Some practitioners living in a thoroughfare, or in towns in which the population is constantly fluctuating, thinking that the character of their professional brethren at a distance is a matter in which they have no concern —thinking, moreover, that any means of advancement is lawful—abruptly change the measures of their prede- cessor in attendance, as it would seem, to obtain confi- dence it his expense. If, fur example, a dyspeptic pa- tient i.as been permitted to take animal food only once a day, they will order it to be taken at every meal Change of air, of occupation, a mild purgative regulariy taken, and perhaps even, for a limited time, a full diet after a restricted one, will often produce a sense of great improvement, which it is generally thought by the pa- tient himself might have taken place earlier had his former physician been more skilful. The patient re- turns home full of erroneous opinions relative to diet, soon to experience an aggravated return of his suffer- ings, and fondly imagining that there is but one physi- cian in the land who understands his case. Innumerable are the phases of quackery, inasmuch as it is applicable to every species of credulity and mode of folly. 86 EPILEPSY. sualist is aware, seldom fail to produce painful exhaustion in proportion to pleasurable excite- ment, and which are well known to unfit those who habitually indulge in their use for animal gratifications which are more prized ; but very great indeed is the difficulty which we encounter in securing a strict acquiescence in our injunctions with respect to food; and if this cannot be accom- plished, it would be well that the physician at once should decline the care of an epilectic patient. Having paid some attention to the proceedings of empirics, foreign and indigenous, regular and irregular, we venture to say that we may some- times be taught by them useful lessons; and we ought not to decline assistance even from such sources : in this case the end will justify the means employed. There was some years ago, in Dublin, an outlandish person, said to be from Ger- many—a high German doctor, although by some it was alleged that he was a native of Ireland, and born in the kingdom of Kerry—who professed to cure epilepsy. His appearance was such as to strike a vulgar mind with awe, while one who had pleasure in the grotesque or fantastical, or a taste for the antique, could scarcely help being amused by the public exhibition of an individual who ap- parently belonged to an earlier and more rude and credulous age of the world. With measured pace and serious aspect he paraded those parts of the city which are most frequented, displaying what the refined taste of our youth has rendered no longer a novelty—a beard like that of an adult goat; behind him, almost in lock-step, there marched a tall fellow in a gaudy livery—light blue, abundantly tricked out with silver lace. Jan Stein, the shrewd observer of water-doctors and mountebanks, never painted a more characteristic pair than the solemn leech, whom we have slightly sketched, and his self-important follower. At first, trade was brisk with this adventurer; but he soon left Ireland, having discovered, to borrow an illustration from the agriculturist, that ground made to yield too rich a crop is thereby soon im- poverished ; and probably he also found that in no community is there a keener perception of the ludicrous or a juster estimate of character than among the more respectable part of the inhabitants of Dublin. He held some of the opinions of the Nazarite, for he told his patients that they must not cut their hair, «in which," he generally added, '• lay the strength of the body," and he in- hibited the use of wine and all intoxicating liquors, a restriction not calculated to advance his reputa- tion in Ireland. But to have introduced this ori- ginal to the reader would be mere impertinence, were it not that there was a point in the regimen which he prescribed worthy of adoption. He ordered his patients to walk, those who were not enfeebled, twelve, fifteen, or even twenty miles a day. They were to begin by walking a moderate distance, and they were gradually to extend their walk according to their ability. In some of his patients a great improvement took place, both with respect to digestion and muscular strength, and this was so apparent in a short time, that ever since this luminary shone upon the metropolis of Ireland, most of our patients, affected with epilepsy, have, by our advice, been peripatetics. We re- commend those who are subject to this disease to walk as far as they can without much fatigue. We do not prescribe one long walk, but several in the course of the day, of moderate length. Deli- cate females have thus been trained to walk eight or ten mites, by making them sit or recline when they were fatigued, and again move on when rested. Females of the hysteric diathesis, who are liable to epilepsy, must pass as much of their time as possible sub dio, driving, boating, or even sitting in a sheltered place, if they are unable to walk without being fatigued, muscular exhaustion be- ing generally hurtful to them. In prescribing a rule of diet suitable to all epi- leptics, moderation in quantity and simplicity in the preparation of food are indispensable points. If the diet of an epileptic has been either too high or too low, it ought to be changed. We conceive the diet which would best preserve an individual liable to scrofula from an attack of that disease, would be best suited to a patient liable to epilepsy. Fermented liquors, however, should be in general altogether withheld. Flesh meat ought to form the principal part of one if not two meals in the day ; and milk, if it agrees, that is, if it does not retard digestion, which it is less liable to do when fermented liquors are laid aside, is the article next in value. The epileptic ought to be trained so as to be in good wind, or, in other words, his mus- cles ought to be in a state of the utmost strength and firmness. If we permit ourselves to take a lesson from empirics, we may surely avail our- selves of such information as may be derived from a brotherhood at least as respectable, namely, the gentlemen of the fancy, as they are called, or we may have epileptics trained as were the athlete in ancient times. When the patient leaves his bed in the morn. ing, he may have a rusk or a slice of toasted bread with an egg beat up in a teacupful of warm milk and water; then let him dress, make all needful arrangements, and walk three or four miles. Two hours or more after he has left his bed, let him have his second meal,—milk, or cream in water, or cocoa, with bread a day old and good butter. It may be observed that wheaten flour is very generally adulterated with bean and potato flour, both of which injure the quality of bread, and that butter is much oftener rancid than good. Let the patient rest for three hours after breakfast, and this will be the best time to devote to business or education. Then he must again walk, if an adult possessed of sufficient vigour, from five to eight mites. At from five to six hours after his second meal let him have a third, consisting of meat of the best quality, — mutton excluding fat, poultry, game, or very tender beef, roasted or boiled, of which an adult must not eat more than six ounces; bread, and one moderate helping of tender well-boiled vegetables; of drink—not more than j> common tumblerful must be taken, distilled water, Seltzer water with a little milk, or toast and water, being equally proper. Then the individual may rest for two hours, but we would not have him lie after meals as some have recommended, this having appeared to us to retard rather than to promote digestion, probably by disturbing the circulation: he may stroll in* a garden, read an amusing book, or chat with an agreeable friend. only such occupation being permitted as will not EPILE raise the pulse by one beat; he may then resume more active exercise for an hour or two. In five t or six hours after dinner a light supper may be taken, consisting of not more than four ounces of ;. meat with bread, or a cup of milk with a water- biscuit The rest of the evening may be spent in cheerful society, in a large airy room, not over- lighted nor overheated, but sufficiently warm to prevent that chill which in the latter part of the day often follows very active exercise; and every occupation by which the mind is depressed, or is excited and thereby subsequently exhausted, must be avoided. The patient must be in bed at eleven and up at six, nothing in general being more hurtful to epileptics than sleep unnecessarily pro- longed. The scalp in all epileptics ought to be shaved once a week, (a few ringlets at the temples and in front being permitted to grow,) and daily well rubbed with a flesh-brush after the tepid shower- bath, or what answers nearly as well and gives less trouble, after pouring a flagon of tepid water on the head inclined over a large basin. The hat or cap worn must be of the lightest kind, a straw hat, or a light foraging-cap of cloth, which may be replaced, when within doors, by a nightcap of woven silk worn single. The patient may gra- dually bring himself to sleep without a nightcap, and without curtains, both of which lead to effe- minacy ; with his shoulders and head raised and his feet well protected from the cold, in a chamber as large and airy as possible, and without a fire ; there may, however, in winter, be a fire in his dressing-room, or his bed may be warmed. The temperature of his extremities must always be supported by means of exercise, friction, or proper clothing. A patient liable to epilepsy must not be per- mitted to ride, or to hold the reins in a carriage. The grates in all the apartments which he fre- quents ought to be guarded by a deep and strong fender ; he ought to avoid the streets of a crowded city, in which the whirl of carriages, the tide of human beings, the stunning confusion of sounds, and the multiplicity and distraction of objects, produce a vertiginous hurry of thought, which to him is ever dangerous. He ought not to walk near water. One of our earliest patients, a fine young man of twenty, came to an untimely end in his own garden, by falling into a runnel, in which he was drowned, although the water was not more than four inches deep. Lastly, if his circumstances admit of his having an attendant, the epileptic ought never to be alone. His compa- nion ought to be provided with a nervous draught, consisting of camphor mixture and ether or am- monia, by taking which there is reason to think that the paroxysm may be averted in the gastric or nervous species of epilepsy ; with a wedge of soft wood to interpose between the teeth ; with a piece of broad tape to be applied to the superior part of the limb, if the paroxysm should commence with the aura in the extremities ; and with an air- pillow to inflate, and place under the patient's head, when he is attacked in the open air. If the attack takes place in his chamber, the patient ought to be laid on his back on a French bed, with at least one attendant standing on either side to prevent him from injury during the struggle. 1PSY. 87 If he is much flushed, his head and shoulders ought to be elevated, the warmth of his extremities sup- ported, while at the same time air is freely ad- mitted into the room. All attempts to make him swallow, or to stimiJa^-e the nostrils, are improper. A medical practitioner ought to be sent for and ought to remain in attendance while the struggle lasts. In a first attack, if the fit is severe, blood ought to be procured from the temporal artery, a precaution which will also be necessary in patients of an apoplectic diathesis, whensoever they labour under a prolonged fit of epilepsy. [Compression of the carotids has likewise been found serviceable, not only in the way of preven tion, but during the paroxysm.] Most of the foregoing observations apply to every case of epilepsy. Having endeavoured to determine the variety to which the case belongs, a point in general overlooked by the nostrum mongers, we have now to point out the specifii treatment which will be required. We are in the first place to ascertain whether there exist any symptoms of present danger; and, secondly, to apply ourselves "to the more continued treatment required in the disease considered as a chronic af- fection." (Prichard.) Epilepsia cerebralis. — If the case belong to cerebral epilepsy, we must endeavour to discover the condition of the vessels with respect to in- creased action or congestion ; if in a state of ex- citement or turgescence, they must be relieved without delay, by means of general or local bleed- ing, or by antimonials, with mercurial purgatives, and the antiphlogistic regimen. At every pa- roxysm, as soon as the patient awakes from that sleep which is part of the crisis, he ought to be examined with care by a medical practitioner. We conceive, were this uniformly done, and the necessary treatment immediately adopted, that in many instances the subsequent attack would be milder and more distant, the faculties of the mind would be less endangered, and the probability of ultimate recovery would be greater. Many chronic affections are merely a series of imperfect reco- veries from attacks of acute diseases. This we have seen exemplified on a large scale in the House of Industry in Dublin, which in formei times was filled with paupers, the victims of pover- ty and intemperance, mostly labouring under chronic disorders of the viscera. Many of these outcasts from society passed much of their time in the subsidiary hospitals, to which they were sent when they were affected with febrile attacks, of which a considerable portion of them died; each recurrence of fever assuming a darker com- plexion in consequence of recovery from its pre- cursor being incomplete. In epilepsy, if due at- tention were paid after every return of the convul- sions to establish the fact of perfect recovery, we are persuaded that the patient might often preserve his place in society, instead of becoming from chronic disease of the brain, originating in or ag- gravated by the severe paroxysms, a mere driveller, as is the lot of many an epileptic in the latter part of his life. And this view is strengthened by the fact that some patients are reduced to idiot- ism, not so much by the natural course of disease as by vicious habits in which they indulge, which not only confirm the predisposition to "pilepsy EPILEPSY. but injure the brain and nervous system : " L'abus des liqueurs alcoholiques, les exces vene>iens, et la masturbation aggravent l'epilepsie et precipitent la perte de la raison." (Georget, 1. c.) The paroxysms of epilepsia cerebralis chiefly occur, to use an expression of Fothergill's, " in the plenitude of health;" and when this is the case, we may pursue the plan about to be recom- mended with more confidence. In treating this form of epilepsy we apply the principle of revulsion, explaining that term, not as the driving back of the fluids from one part to determine them to another, but simply as expres- sive of the relief to be obtained for an organ in which a morbid process is going forward, by in- ducing a more vigorous state of the circulation in other organs, or by the establishment of a process of counter-action in a remote sympathizing part. With this view we have to recommend, first, once a month the cupping-glasses and scarificator to be applied to the nucha, and a few ounces of blood to be by that means taken away ; secondly, dry- cupping to be practised between or over the scapula every third or fourth day, two cupping-glasses to be allowed to adhere for a quarter of an hour; thirdly, a caustic issue (which is less troublesome and painful in dressing than a seton) to be made in the back of the neck where the seton is usually inserted ; and, lastly, once in the week, a moxa, or a blister, not larger than a crown-piece, to be applied to the back of the head, behind the upper part of the ear, where there is space for a succes- sion of four such blisters. If a blister be preferred to a moxa, let it be put on at noon, and it will be ready to be dressed before bed-time, by which means the patient's rest will not be broken, as it generally is, by a blister, however small, applied at bed-time. There is abundant evidence of epi- lepsy being moderated while a discharge has been maintained, from a sore either accidentally occur- ring or designedly produced, and being aggravated almost immediately after such discharge has been dried up. In epilepsia cerebralis we wish to promote a more active circulation in the muscular tissue, and in the integuments, especially of the limbs, which is to be done by champooing and frictions, while the head is kept cool and the shower-bath taken daily. Our hope of cure in this form of epilepsy chiefly rests on persevering attention being paid to diet and regimen, and on topical means; yet although our confidence in the use of internal medicines is not so great in this as in the other species of the disease, they are not to be dis- pensed with, when the functions of the cuta- neous, gastro-hepatic, or nervous systems are d'.s- oidered Antimonials are requisite when the skin is in- active, and we have known signal benefit afforded by antimony to those persons who, in advanced life, have laboured under the apoplectic epilepsy, as it has been called. The preparation of anti- mory which we prefer is James's powder, the pulvis Jacobi veri, and the following is the method of exhibiting it which we recommended a good many years ago, and which has often been adopted since with advantage. (Dublin Hospital Reports, vol. 1. p. 315.) The patient is to begin with a v-^ry moderate dose of the powder, not more than two or three grains at bed-time, and to increase the dose by half a grain every night, till some sensible effect is produced on the skin, stomach, or bowels. Should the stomach at any time be affected with sickness, the dose may be lessened by a grain on the following night. By the addi- tion of a few grains of rhubarb, a larger quantity of James's powder may be administered than the stomach could otherwise bear. If the skin be affected, the dose should not further be increased, but it must be repeated every night for about three weeks; it may then be reduced as it was aug- mented by half a grain every night, the course occupying a period of at least six weeks. We have known eighteen or twenty grains taken every night for a considerable time without inconve- nience, and even when not productive of any sen- sible perspiration, it has often allayed the heat and restlessness which so often accompany irregular determinations of blood. In very cold weather we have directed the patient to make some addi- tion in point of clothing, but have not confined him to the house even when the snow was on the ground ; as we do not consider the system to be more susceptible of catarrhal or rheumatic affec- tions while under the influence of James's pow- der. To this course of medicine the tepid bath will prove a valuable addition. If there be any of those scaly affections of the skin to which epileptics are so liable, a draught as follows may be taken : R Radicis sarsaparillae concisae, gi. Radicis glycyrrhiza? concisae, gii. A qua? calcis, uncias x. Macera in vase clauso, subinde agitans, per horas duodecim, dein cola. Divide in haustus sex. Sumat unum ter quotidie. When the eruption is not attended with inflam- matory heat or itching, the aqua picis liquids; may be given to the extent of from half a pint to a pint in the day, or as a substitute the pilulse piceaj. In indigestion with a loaded tongue, the nitrc- muriatic acid may be deserving of a trial, two or three minims of the nitric acid, with four or five of the muriatic, in three ounces of distilled water, may be sucked up through a glass tube or a reed, at least three times a day. Where the breath is heavy, the following powder may be given. R Pulveris recentis carbonis ligni, gr. xv. Pulveris rhei, gr. ii. Pulveris ipecacuanhas, gr. i. M. F. Pulvis e cyatho vin. aqua? cinnam. bis quoti- die sumendus. If the urine be scanty, with a red sediment, a drachm of Brandish's alkaline solution in water, or an a'kabne bitter draught, may be taken every forenoon and evening. We do not object to the occasional use of mercury, but we have never, in this form of epilepsy, willingly given that mineral so as to affect the mouth. If the bowels are con- be"d time" ^ f°'l0Wing pi"S *»' be P™ - R Extracti aloes, G. galbani, sing. gr. ii. Saponis duri, gr. i. ]yfp Or the following powder, which was thP f„™ •* EPILEPSY. 89 R Sulphuris loti, J)i. Sulphatis potassa?, j»r. x. Pulveris rhci, gr. v Pulv. nucis moscbxta?, gr. ;i. M. Lastly, if the nervous system be irritable, the patient desponding and apprehensive, the treat- ment to be recommended under the head of Epi- lepsia Nervosa will probably afford relief. Epilepsia Stomachica.—We once had a patient who, in the early part of his life, had been under the care of the celebrated Dr. Cullen. Dr. Cullen kept him in a state of unceasing nausea for a very long time, — our impression is, for more than a year, — and without the slightest relief. It is not so that we would have emetics employed. We conceive that attacks of epilepsy may sometimes be parried by giving emetics at stated periods, and we have been accustomed to prescribe the follow- ing emetic in this form of epilepsy, once in the week : R Pulv. ipecacuanha?, gr. xv. Sulph. zinci, gr. v. M. Two cases of the epilepsia stomachica were successfully treated by giving, once a week, a calo- mel bolus at bed-time, and on the following morn- ing a draught containing castor-oil and oil of tur- pentine in the following doses : R Olei ricini, giii. Olei terebinthinse, gii. Mucilaginis acacia? ^iii. Aqua? mentha? viridis, ^vi. M. To the best of our recollection, both patients had a pill of aloes and soap every second day, took bitter medicines, and had their diet regulated with great care, more especially with regard to quantity. In this form of epilepsy, the bowels ought to be completely emptied, every second day, by means of a dinner-pill, and the use of the injec- tion syringe.* The dinner-pill may consist of two, three, or four grains of the pilula? aloes com- posite, or the pilula? aloes cum myrrha, or of the pilula? stomachica? Mesues, now by an altered name, contributing to the medical fame of Lady Webster, and which owes its efficacy solely to the aloes which it contains, and to its diffusion among a mass of solid aliment. A pilula ante cibum ought not to contain more than a grain and a half or two grains of aloes, or to be taken every day. The injection may consist of a pint or more of tepid or cold water, with or without two or three drachms of the muriate of soda. Once every week the bowels ought to be fully evacuated by giving at bed-time a medicine act- * When the bowels refuse to act regularly without the assistance of medicine, which is the case with many persons advancing in life, it is an error to order a purga- tive every day ; the evacuation procured by medicine is generally so complete that a longer time elapses before the bowels fill than after a natural stool, therefore the purgatives resorted to, whether aloetic pill in the even- ing, or a saline aperient before breakfast, ought to be taken only on each alternate day. Their contents ought to be permitted sufficiently tf> accumulate before the bowels are again urged to discharge themselves of their load; by this means the cathartic being more completely incorporated with the ftecal residuum, irritation and mucous stools will be avoided. If a purgative he taken when the bowels are comparatively empty, more fre- quent discharges will be obtained, but they will be less consistent and satisfactory ; and griping and tenesmus, and perhaps hemorrhoidal irritation, will be the conse- quence. Vol. TI---2 h* ing upon the iiver, stomach, and small and great intestines : R Hydrarg. submuriatis, gr. ii. Pulv. ipecacuanha?, gr. i. Pulv. rhei. gr. iv. Extr. aloes, gr. ii. M. F. pilula? ii. hora somni sumenda?; and the following morning before breakfast, a sa- line aperient draught. At the same time the patient must have a tonic medicine, twice in the day, containing half an ounce or six drachms of the atramentum Heber- denii, now introduced into the Dublin Pharmaco- poeia under the designation of mistura ferri aro- matica, or an ounce of the mistura ferri composita, or the following draught: R Sulph. ferri, gr. iii. Sulph. quinina?, gr. i. Infusi calumba?, ^i. Ac. sulph. dil. m. iii. M. It is in this species of epilepsy and in nervous epilepsy, that benefit may occasionally be obtained from the nitras argenti and cuprum ammoniatum. In the cerebral species we have repeatedly tried the former medicine, in the dose of nine or ten grains a day, for a sufficient length of time, with- out the slightest benefit. Among the means most likely to improve the state of the digestive system, there is not any which is so uniformly beneficial as change of resi- dence and travelling, and the improvement is often felt for many weeks after a movement. Journeys, in the case of the epileptic, who naturally dis- likes to expose his infirmity to strangers, ought to be undertaken shortly after an attack, as a con- siderable period of time generally elapses before the fit may be expected to return. It would ap- pear from the following observation, made by De Haen, that changes of residence and long jour- neys have sometimes cured the disease. " Etiam mutatione domicilii, diuturniore peregrinatione, vita? genere prorsum permutato, quidam legun- tur se etiam ab ipsa gentilitia labe pra?stitisse im- munes." Epilepsy has sometimes arisen from ta?nia. When this takes place the treatment will not be attended with much difficulty, as the disease may be removed either by means of rectified oil of tur- pentine, or by tin in powder given in large doses, and followed by cathartics. We have found in some individuals, that after worms, especially as- carides, have been expelled, so that there was no vestige of them for several weeks, they have re- appeared within two months, as if a nidus had been left behind. In such patients, worms may be permanently destroyed by exhibiting proper anthelmintics before the expected period of recur- rence, which may easily be ascertained. Epilepsia hepatica.—When hepatalgia, biliary colic, icterus, or any other symptom of biliary congestion, precedes or follows an attack of epi lepsy, local bleeding, an issue over the region of the liver, and mercurial purgatives will be requi- site, and afterwards alternate courses of dilut« nitro-muriatic acid and of taraxacum, the lattei exhibited as follows: R Extracti taraxaci, ^ii. Extracti gentians?, gr. x. Olei cinnam. min. ii. M. et divide in 90 EPILEPSY. pilulas xii a?quales. Sumat tres ter quotidie su- perbib. haustum decocti taraxaci R Taraxaci, 5;ii. Extr. glycyrrhiza?, ^ii. Aqua? ferventis quod satis sit ut colen- iur uncia? decern. Coque per hora? tertiam par- tem et cola. Colatura? adde supertartratis potassa?, giss. Divide in haustus sex. Epilepsia nervosa. — The chief indication in this species of epilepsy, after the removal of the exciting cause, is to allay the irritability of the stomach and to strengthen the system. The sto- mach is ever disturbed, the disturbance evincing itself not in anorexia but in despondency, in irri- tability of mind, in the animus, nee sponte, vari us et mutabilis, in depression of strength, unre- freshing sleep, and often in that most distressing sensation which has been called " the fidgets;" in palpitation, in acute pain in the mamma, and in the existence of various other symptoms of hysteria. In neither males nor females, is this variety of epilepsy connected with the state of the generative system, unless when the attacks pro- ceed ex onanismo. In nervous epilepsy our chief reliance is upon diet, regimen, attention to the state of the bowels, proper regulation of the mind; and on such medi- cines as valerian, camphor, snake-root, and castor. The following draught we have often known to re- lieve the irritable state of the nerves which attends this species of epilepsy. R Radicis Valeriana?, Radicis serpentaria?, aa. gii. Aqua? ferventis, ^ vii. digere per horam, et liquorem frigefactum cola. Colatura? adde Sp. ammonia? aromatici, gii. Tinctura? serpentaria?, gvi. M. et di- vide in haustus sex. Sumat unum meridie et vesperi. Tonics are also applicable to this affection, as cinchona and iron, especially the former when epilepsy is periodic. We have known moderate doses of nitrate of silver given with advantage in aggravated hysteria, and hence, although we have not successfully prescribed it in nervous epilepsy, unless in one instance, there are many cases of this variety of the disease in which it would pro- bably be of great use. Much may be expected from agreeable occupation, variety of scenery, the bracing air of the sea, and tepid and cold sea- bathing. All kinds of fermented liquor, tea, and also coffee, ought to be given up, together with the use of tobacco, if unhappily the patient should have addicted himself to the use of that poisonous and demoralizing weed.* * Tobacco is an enemy to domestic economy and per- sonal cleanliness; it taints the brea'h permanently, in- jures the digestion, impairs the intellect, and it even shortens the life of some of its votaries. Cullen says it produces loss of memory before the usual period. Snuff keeps a great many of the females, engaged in lace-mak- ing, in this neighbourhood (Newport Pagnell), under the continued influence of hysteria, and gives them an early stamp of age ; at thirty a snuff-taker looks as if she were forty years old. It is the sole cause of a variety of dys- pepsia, of which we have witnessed a vast number of instances—the symptoms being a painful sensation of a lump at the stomach — of a hard undigested substance pressing, as it were, upon a tender part of the stomach, which sensation is, for the time, relieved by taking food ; remarkable depression of spirits, every thing seen through a medium of gloom and distrust; and tremors »f the nerves. " Upon an accidental interruption of muff-taking for a few days, the pains do not occur, upon Epilepsia uterina.—H the attacks of epilepsy precede the menstrual period or accompany it, the effort of the constitution being imperfect, relief must be sought for in venesection, purgatives, and the antiphlogistic regimen. In the interval be- tween the periods, those emmenagogues must be employed which moderately act upon the intes- tines, and at the same time give vigour to the cir- culation ; as, for example, pills of myrrh, sulphate of iron, and aloes; or pretty full doses, two or three times in the day, of the carbonate of iron, with a moderate dose, every second night, of the decoctum aloes compositum. The tepid pedilu- vium, or hip-bath, with friction of the back and limbs at bed-time, more especially just before the menstrual period, may be practised ; and in this species of epilepsy also the patient ought to have the benefit of sea-bathing, and frequent changes of residence. There is a point from which our attention ought never to be withdrawn in the treatment of epilepsy, namely, the exciting cause of the first paroxysm. If the paroxysm have been caused by mental impressions, not only ought the causes of fear, anxiety, and displeasure, to be as much as possible removed, but endeavours ought to be used to strengthen the mind. If from excess of any kind, then every method of renovation must be employed. If from inanition, proper restora- tives must statedly be exhibited. If the disease be periodic and connected with dysmenorrhcea, after evacuations, if they are indicated, anodynes, even in large doses, will be necessary; of which the fol- lowing will be found one of the most efficacious :— R Camphora?, (ope sp. vini rect. in pulv. red) gss. Extracti hyoscyami, gr. xv. Extracti opii, gr. iii. M. et divide in pil, xii a?quales. Of these compound camphor pills two may be taken on the very first accession of pain, two in an hour after, and even a third dose may be taken after a second hour; if relief is not obtained, some- times a double or even quadruple portion of opium must be given; it being an established point of practice that the pain which attends dysmenor- rhcea is to be subdued without loss of time. We apprehend that the efficacy of full doses of cam- phor on painful menstruation is not so generally known as is desirable. To propose a regimen of diet which would ap- ply to every variety of epilepsy, as we have already hinted, would lead to a disproportionate extension of this article. The directions, therefore, which we have given, are of necessity general, and may be departed from should the paroxysms return with unabated frequency. Eminent physicians, as for example Lv. Fothergill, have recommended abstinence from all kinds of animal food and fer mented liquors. He tells us that, « In the form of epilepsy, which may be supposed to proceed from disorder of the digestive organs, evidenced in craving appetite, and supported by inattention to IT^I to4rVJB1 tobacco will produce the same affection Smoking produces anorexia and emaciation. I,. «'•e,f,eVH1, howcvrr'in tl,hac'-°. taken in any way, .s that ,t leads myr.ads upon myriads to the habitual use of ardent spirits and opium the ruin of soul, body, and estate. and consequently to EPILEPSY —EPISTAXIS 91 diet, laxatives, with a light chalybeate interposed and steadily continued, together with a course of diet consisting of milk, vegetables, fruits, and things prepared from them, and in moderate quan- tities, seldom fail of removing the disorder." In Heberden's Commentaries we have the fol- lowing pithy illustration of the importance of diet: " Duo epileptici ab omni cibo animali abstinue- runt, et sanati sunt." And Dr. Abercrombie, no mean authority in this or in any practical point, is of opinion that the only remedies of real efficacy in such cases are purgatives, a strictly vegetable diet, and total abstinence from strong liquors. According to our experience it would not be easy to overrate the importance of diet in epilepsy, at the same time we admit that many changes may be necessary before the full advantage is obtained which diet is capable of yielding; one rule alone, in our opinion, being established, namely, that food ought ever to be taken in great moderation ; in other words, that there is danger in a full meal, however unexceptionable the materials may be of which it consists. When, in medical works of respectability, we meet with a variety of remedies, many of them possessed of dissimilar qualities, recommended for the cure of the same disease, we must conclude that its species are dissimilar in their nature, and require to be treated differently. In examining the anti-epileptic remedies recommended by au- thors, we may discover four classes, viz. evacuants, tonics, nervines, and emmenagogucs: first, those which reduce vascular congestion or action, vena?- sectio, hirudines, fonticuli, setacea, cauterium, ve- sicatoria, irritantia, emetica, purgantia, antimoni- um, mercurius: secondly, those which invigorate the body and improve the digestion — aeris et dieta? mutatio, balneum frigidum, cinchona, amara, acida, zincum, argenti nitras, cuprum [artemisia vulgaris] : thirdly, medicines which relieve disor- ders of the nerves — serpentaria, cardamomum, Valeriana, castoreum, moschus, camphora, guaia- cum, hyoscyamus, belladonna, stramonium, opi- um : fourthly, emmenagogues — ammonia, galba- num, assafostida, aloes, ferrum, oleum terebinthina?, ruta. A consideration of the foregoing catalogue would justify the division of the subject which in this article has been adopted. [Of late years, indigo given in very large doses, has been extolled by many practitioners. The writer witnessed numerous trials with it in the Philadelphia Hospital; but its efficacy was not marked. (See his New Remedies, 4th edit. p. 363, Philad. 1843.) Where epilepsy has been caused by an external injury of the head, the ope- ration of trephining has been practised; and in some cases the results have been happy. The operation is, however, of a serious character, and ought rot to be had recourse to, unless there is every ^inspect that the cause of the disease is seated in parts which can be removed by the tre- phine.] If the necessity of more diligently studying epi- lepsy, of more carefully attending to its specific differences; if the inapplicability to some cases of epilepsy of the treatment which has succeeded in others, be admitted and acted upon, happier prac- tical results will probably be the consequence. But, lest the reader should suppose that wr are j too sanguine in this our expectation, he shall have the concurrent testimony of the venerable com- mentator on Boerhaave produced, to whose au- thority he will more readily yield : " Illis observa- tionibus sic collectis et in ordinem digestis, sedulo expendat medicus omnia, et facile deteget regulas agendorum et vitandorum, sed in singulari tantum hujus a?gri casu. Nam generates in omnibus epi- lepticis curandis regula? haberi nequeunt; quod enim uni prodest, sa?pe nocet alteri. Ubi hoc factum, tota difficultas evanuit, nam reliquum est tantum facilis executio bene perpensarum rerum. Certum est, medicos, luculenta praxi obrutos, sa?pe deficere in cura hujus morbi, cum tempus ipsis non sufficiat, ut singulari a?gro tantam curam impendant; verurn et doluerunt toties, a?grorun. custodes observasse ilia, qua? ipsi neglexerant, non sine fama? damno. Credo firmissime, si omnem animi attentionem adhiberent his medici, quod sanarent plures epitepticos, et levamen adferent fere omnibus."—Sect. 10S0. T „ J. Cheyne. EPISTAXIS, (derived from lm and crd^s. stillatio, from ardfa, stilo,) a flow of blood from the nose. This is one of the subdivisions of the natural class of disorders termed hemorrhages, to which article in this work (in order to avoid un- necessary repetition) we refer for a general expla- nation of the circumstances under which it takes place. Bleeding from the nose is a physical phenome- non too common and conspicuous to have escaped notice at any period ; and from the earliest times its consequences, together with the conditions of the body which have accompanied and preceded it, have been objects of medical observation. The word epistaxis has, also, from a very early period, been applied to this affection under whatever cir- cumstances existing ; but it is evident that Hip- pocrates, who has left us several observations on the subject, used its original always to signify an oozing, and a'tpo^ayia, a rush of blood: we make, however, no such distinctions. Of the various hemorrhages, epistaxis is the most common; and so often is it attended with salutary effects, that its encouragement and sup- pression equally require the consideration of the medical practitioner. Its frequency is readily ac- counted for when we reflect on the structure of the Schneiderian membrane; its extreme tenuity, and the number as well as proportionate size of the ramifications of blood-vessels which traverse it in every direction, forming a complete net-work, with a comparatively smaller portion of interstitial cel- lular substance and thinner lamina? of membrane enveloping it than is to be found in any other part of the body. The blood-vessels of this membrane being for the most part supplied by the internal maxillary artery, and inosculating with some of the extreme ramifications of the internal carotid, any increased impetus given to the latter, or to the trunk of the former, is less resisted in this part; and, in consequence of the rupture which is very frequently occasioned, an escape of blood is effected, with relief of both these systems of ves- sels, and, in a very essential manner, to the ad- vantage of the brain. As in hemorrhages from every other part, it is important to observe that in epistaxis there ar« 92 EPISTAXIS. two opposite conditions of the blood-vessels, in- duced by corresponding states of the body under which it occurs : in the one the extreme vessels are ruptured by the increased activity of the cir- culatory system, general and local ; in the other, from debility and relaxation their elasticity is de- stroyed, and, incapable of distension as well as of propelling their contents, their parietes readily give way ; or, from the same condition, red blood insinuates itself through the exha'ents, instead of the thinner and colourless part of this fluid proper to them. We shall proceed to consider epistaxis under these two conditions, adopting the common language of pathologists in applying to the former the term active or entonic, and to the latter pas- sive or atonic epistaxis. [Like other hemorrha- ges, epistaxis may arise from mechanical hypere- mia—in other words, from some physical obstacle to the return of the blood from the mucous mem- brane to the heart.] Entonic epistaxis occurs occasionally in very young children, most frequently before or about the age of puberty, and in persons of a plethoric or sanguine temperament; the latter are not un- frequently the objects of it until the advances of age effect a change on the constitution, and the balance of power is transferred from the arterial to the venous system. Thus we find in early life that this hemorrhage is almost always from the arteries, and in old persons, when it does occur, that the blood flows from the venous sys- tem. The habits and exercises of males render them more liable to epistaxis than females; but on the other hand we find in the latter that it is very often vicarious with the suppression of the menstrual discharge, and occasionally occurs with the same periodical exactness. Even in the male sex the influence of habit is often evinced in the occurrence of epistaxis, and, after other causes have been removed, it is sometimes with difficulty that its power is resisted. Local injury, inordinate exercise, exposure to heat, or increased temperature of the atmosphere; hot drinks, stimulating diet, suppressed discharges, either natural or artificial; and all other circum- stances which increase the quantity of blood, or the impetus by which it is distributed to the dif- ferent parts of the head, may occasion the occur- rence of epistaxis. In addition to these causes, it has been fre- quently preceded by various emotions of mind, terror, anger, and even a single excitement of the imagination ; hence, says Mason Good, we may •eadily trace by what means the philosophers and poets of the eastern world, and even some of those of the western, were led to regard the nose as the seat of mental irritation, the peculiar organ of heat, wrath, and anger; and discover how the same term f]X (ap or aph) came to be employed among the Hebrews to signify both the organ and its effect, the nose, and the passion of anger to which it was supposed to give rise. In some individuals it is probable that there is an extraordinary delicacy of the Schneiderian membrane and its vessels, which renders the latter peculiarly easy of laceration : there appears also to be a degree of correspondence between this ex- pansion and the integuments of the face with which it is continuous, the phenomenon of blush- ing being ofte? remarkable in persons subject to epistaxis, a cii cumstance which is doubtless also in great part te be referred to the identity of tem- perament predisposing to both of these affections. Excitation of the olfactory nerves, in persons of peculiar irritability of the organ of smell, has occasionally induced epistaxis; an example of this kind has been recorded by Bruyerin, in which it was induced by smelling an apple : and another by Rhodius, in which the odour of a rose appeared to be the exciting cause. Coughing, sneezing, singing, and reading aloud for any length of time, stooping also, and particular postures of the body, have not unfrequently occasioned it. The secre- tory office of the Schneiderian membrane is liable to material interruptions from the vicissitudes of temperature to which it is necessarily exposed in the act of respiration ; and any check by cold to its natural or inordinate secretion will occasionally lead to the rupture of blood-vessels in this part. The febrile disorders which are attended with determination of blood to the head are often the precursors of epistaxis ; and this affection, from the days of Hippocrates, who pronounced it criti. cal, an expression which has been adopted through succeeding ages to the present day, has been wel- comed as a salutary effort of nature, either to relieve or bring the disorder to a favourable issue. Some nice distinctions have been drawn, by the great authority just mentioned, of the different in- dications from the occurrence of epistaxis on different days of the progress of fever ; but inde- pendently of their being inapplicable to the fevers of this country, more extended experience has shown that this is to be regarded as only one of an assemblage of symptoms from which our judg- ment of the issue of such diseases can reasonably be drawn. Epistaxis has sometimes been observed to be synchronous with the periodical returns of inter- mittents, taking place at the accession of the hot stage, when in this, as in other disorders in which fulness of blood in the vessels of the brain has been one of the morbid conditions, the greatest danger of injury to that organ, and its conse- quences, has been averted by the escape of blood from the nose. In congestions of blood in other organs of the body, whether of an acute or chronic character, as in the lungs, but particularly in the liver; or in mechanical obstructions to the free course of blood, occasioning its determination to the head, or an impediment to its free circulation in this organ, the same effect has been attended with the same salutary consequences. The suppression of the natural secretions of the body is a frequent cause of epistaxis. We see it occurring very com- monly in amenorrhcea; in those diseases in which the secretions of the other mucous or serous mem- branes are suspended ; and not unfrequently when the natural function of the skin has been checked partially or generally. Morgagni has handed down to us the record of an extraordinary, and, as far as we know, a singular instance of the simultaneous occurrence of epistaxis in a number of persons :- it is stated that in the year 1200 there was a great mortality of men in the space of twenty-four hours, frZT"y T-i Rom*ndi°la' by * flux of blood from the nostrils; and Morgagni has remarked EPISTAXIS. 93 that Clcmentini, the historian of Rimini, had noted that in the same year a great number of deaths from hemorrhage had occurred within four-and- twenty hours at Rimini, Ravenna, and in other cities of the Roman province; but from what part of the body is not mentioned. Various conditions of the atmosphere, it is well known, have a power- ful effect on the expansive quality of the blood, as well as of other fluids: besides the effect of the stimulus of heat, the plethora ad molem is induced by the same cause; it not unfrequently happens that passing from a cold into a heated room occa- sions this kind of hemorrhage ; and a sudden transition in the natural atmosphere occasioned, it is probable, the endemic we have just noticed. The same expansive quality of the blood is evinced by alterations of the atmospheric pressure ; and in the ascent of high mountains an early physical consequence has been a flow of blood from the nose, increasing in proportion to the altitude, and succeeded by hemorrhage from the ears and lungs, as well as by other very alarming symptoms. We have an interesting example of this in the enter- prising traveller Saussure, on the occasion of his celebrated ascent of Mont Blanc. The passive or atonic epistaxis takes place only in those extreme states of depression of the vital powers, which occasionally occur after the inflam- matory stages of fever have passed by, or in such as have been considered of a putrescent tendency, as in the advanced state of eruptive fevers, parti- cularly of malignant small-pox and scarlatina. In cachectic diseases, such as the purpura hemor- rhagica, scorbutus, and certain broken-down states of the constitution, consequent to visceral disease of a chronic kind, particularly that of the liver, arising from the long-continued influence of a hot climate, or the habitual intemperate use of spirituous liquors, the atonic epistaxis is occasionally a very troublesome and dangerous symptom. Instances have been recorded of the loss of al- most incredible quantities of blood from the ves- sels of the nose. Ten, twelve, and upwards of twenty pounds have been known to flow away before the hemorrhage has ceased. " Bartholin mentions a case of forty-eight pounds, Rhodius another of eighteen pounds lost within thirty-six hours; and a respectable writer in the Leipsic Acta Erudita, a third, of not less than seventy- five pounds within ten days, which is most proba- bly nearly three times as much as the patient pos- sessed in his entire body at the time the hemorrhage commenced." In the Ephem. Nat. Curios, is a case " in which the quantity indeed is not given, probably from the difficulty of taking an account of it, but which continued without cessation for six weeks." (Good's Study of Medicine.) The active or entonic epistaxis is usually pre- ceded by a sense of weight and fulness in the forehead and face, frequent flushing in the latter, with heat and itching in the nose; a remarkable degree of throbbing is often experienced in the temporal arteries, a ringing in the ears, and some- times a dull or indistinct sense of hearing; but in many instances no precursory symptom is ob- served, and the blood issues forth suddenly, with various degrees of force. Passive or atonic epistaxis occurs, in general, without any preceding indication peculiar to it; and in many instances, particularly in the ady- namic states consequent on fevers, it is not unfre- quently accompanied with entire insensibility. In the cachectic states of the constitution giving rise to this kind of epistaxis, inordinate and uncontrol- lable losses of blood from the nose have most commonly taken place, and therefore have been more frequently the objects of attention in advanced than in early life. Entonic epistaxis is always to be regarded as ar> indication of the urgent necessity for the systerr- of the blood-vessels of the head to be relieved ol a superabundance of this fluid; and so long at this condition lasts, it ought to be encouraged, o> at least on no account restrained by direct suppres sion. It is often observed that the evacuation ol a small quantity of blood from the vessels of thb organ is the spontaneous cure of a severe head ach, or relieves an oppressed state of the brain dependent on preternatural fulness of its blood vessels; and it is probable that apoplexies and other dangerous diseases of this organ have not unfrequently been stayed, if not entirely prevent- ed, by this natural method of. cure. In advanced life, however advantageous this hemorrhage proves under an immediate threat of such forms of dis- ease, we must bear in mind that it is an indication of an altered condition of the blood-vessels of the head, which pathologists have observed progres- sively to increase in the majority of persons after the middle period of life, and that it is often, on this account probably, the precursor of fatal apo- plexies, epilepsies, palsies, and other cerebral dis- eases. In a practical view we may consider epistaxis, in reference to the condition of the various organs of the body, and the positive disease (if any) with which it is accompanied, in the same light as arti- ficial bloodletting, always remembering the im- portance and delicacy of the organ to which a determination is already established, or probably would be, if the exit of blood from the ramifica- tions of the vessels supplying the nose were pre- vented : such diseases and conditions will require their peculiar kinds of treatment, and the avoid- ance of the exciting causes which produce this particular affection. It occasionally happens, how- ever, that this evacuation is oxcessive at a single occurrence; or that by its continuance a passive state of the vessels is induced ; or sometimes, in- dependently of plethora, the evacuation becomes, by frequent recurrence, habitual, and, if not ar- rested, would be productive of consequences dan- gerous to life. The particular treatment necessary to prevent an excessive or habitual epistaxis of the entonic kind is founded on two principles; 1st, diverting the determination of blood from the vessels of the head to other parts of the body; and, 2dly, the direct application of those means which are cal- culated to act on the extremities of the vessels themselves; which means consist of astringei. substances and mechanical compression The former includes the various remedies which are comprehended in the antiphlogistic regimen. those being selected which are adapted to restoie the particular function which may in each cate have been suspended, and to produce a counter balancing excitation in a system of vessels at « 94 EPISTAXIS, distance from the already overloaded vessels of the nares and head: hence the use of purgatives is particularly indicated; and in very plethoric habits a combination of such as stimulate the tract of the alvine canal, as well as excite its watery secre- tions, will be found advantageous. Bleeding, also, from a vein in the arm or foot, or topical bleeding by leeches applied to the head, or by cupping on the nape of the neck, will be requisite in some cases in which the hemorrhage from the vessels of the nose may have been so small as to point out only the necessity of such an evacuation, but not sufficient to remove the occa- sion of it, and the symptoms with which it is ac- companied. In habitual epistaxis, also, we shall find the necessity often of thus artificially changing the distribution of blood, and, by anticipating the periods of the return of this morbid disposition by proportionate bleeding, may at length be enabled altogether to prevent it. Emetics have been occasionally of service, and are recommended by Stoll, on the principle of relaxing the capillaries; but unless epistaxis should appear to depend on an inordinate fulness of the stomach, impeding the due course of the blood in the large vessels, we should be wary in having recourse to them, for the very action they induce is an impediment to the free circulation of blood in the vessels which it is our object to relieve, and has occasionally been the cause of the affection which -is to be removed. Sprinkling cold water on the face will often have a powerful effect in the suppression of this kind of hemorrhage, and even immersion of the whole head has been successful when other remedies have failed. A striking in- stance illustrative of this is recorded by Dr. Dar- win, in his Zoonomia ; the patient was a lady who had epistaxis for several days from a part of the nose to which the attempt to apply mechanical compression had failed, and in whom, from a pre- ternatural sensibility of the pharynx, it was found impossible to stop up the posterior nares: vene- section and the other usual remedies had been tried in vain : but by immersion of the head in a pail of water, rendered colder by the liquefaction of some common salt, the hemorrhage was checked, and did not return; but hardness of the pulse continuing, loss of blood from the arm on the fol- lowing day was resorted to as a requisite precau- tionary measure. Dashing cold water on the genitals has some- times had an instantaneous effect in the suppres- sion of epistaxis. In the same manner, the popu- lar remedy of applying a large key or other piece of cold metal between the clothes and the surface of the back has caused it to cease. The exposure of the face to cold air, the observance of an erect position, with an inclination of the head back- wards, cold drinks, and the application of cold water or ice to the nose, will often be sufficient to terminate this hemorrhage. If these means, however, should fail, the nostril from which the blood issues should be stopped with a piece of lint or other soft substance, so that the retarded blood may coagulate, and thus pro- duce pressure against the ruptured vessel: if this should not succeed, recourse must be had to astringents in preference to methods of compres- «i'T. to be presently described, and which, though perhaps more certain, are extremely disagreeable in their application, and need be resorted to only under urgent circumstances. Astringent applica- tions may be used in the form of an injection with a syringe; or that of powder, carefully blown into the nostril through a quill: the method of inhaling them by an inspiratory action, as commonly ad- vised, is apt to disturb any portion of coagulum that may be already formed, or to increase the excitation of the ruptured vessel itself. A variety of astringent applications have been recommended for the suppression of epistaxis; those most in use are vinegar and water, dilute mixtures of sul- phuric acid with water or spirits of wine, spirits of wine alone, tincture of benzoin, solutions of alum, of the metallic salts, &c.; the two last men- tioned are chiefly to be relied on, and should always be preferred. Two drachms of alum, or from two scruples to a drachm of sulphate of zinc, dissolved in half a pint of distilled water, or the solution of the acetate of zinc of the Edinburgh Pharmacopoeia, or a drachm and a half of the muriated tincture of iron, diluted with six ounces of water, will be suitable injections for this pur- pose : the common solution, also, of the acetate of lead, or the same salt in a much less diluted state, may also be used for the same purpose, after which a piece of lint, imbued with whichever of the solutions may have been preferred, should be passed up the nostril with a probe, or some such instrument, so that firm compression may be effected. The powders to be used in the manner we have already stated, ought to be finely levigated; but even in this state the irritation they are apt to excite may be productive of consequences which would more than counterbalance the advantages to be expected from their astringent quality. The sulphate of alum and powder of galls have been usually preferred; a powerful styptic has also been found in charcoal, either used in the form of powder, or mixed with water and applied as a paste on a tent of lint. An instance of the suc- cessful use of the powder of gum acacia blown into the nostril in a case of epistaxis, which had continued for two days, and had resisted the other means generally adopted, has been transcribed from Hufeland's Journal into the 27th volume of the Medical Repository. As this substance is not only free from the objection we have mentioned to astringent powders, but congenial to the sensibility of the Schneiderian membrane, and probably pro- duces its good effect simply by increasing the tenacity and adhesive quality of the blood on its issue from the extremity of the bleeding vessel, it appears to us that in some cases it may be an eligible application. Should the practitioner be baffled in his at- tempts with the means above suggested, or should the unsuccessful use of one astringent give little promise of advantage from another, direct com- pression may be made by passing a long piece of catgut from the anterior aperture of the nostril which is the source of the hemorrhage, so far into the pharynx, that by a pair of forceps it may be drawn into the mouth, in order that a piece of cotton or lint may be attached to it, of sufficient thickness to press against the parietes of the canal when the catgut is again rttracted ■ this being EPISTAXIS. 95 done, it is to be separated from the lint or cotton, which is allowed to remain in the canal until fur- ther means shall have had the effect of suppressing the hemorrhagic tendency. Such is the method generally recommended by surgical writers, but the irritation excited on putting it into practice, and, when effected, the aversion expressed by patients to its endurance, are so great, that, what- ever the danger may be, they will rarely submit to or suffer its continuance for a sufficient length of time; and it must be acknowledged that there is some hazard that its removal may prove a fresh cause of excitement. A great surgical authority (Mr. Abernethy), with his accustomed humour, has told us that he knew that such a method could be adopted, for he had seen it done ; but that whenever he had tried to do it he always failed, finding an obstacle in the excessive irrita- tion produced in the muscles of the pharynx : but the same authority has observed that he had never seen an instance of epistaxis which could not be suppressed, (and that he had seen a great many instances,) by the introduction of a cylindrical plug of lint through the anterior nares, made suf- ficiently large to fill the tubular part of the nostril, being first wetted and wound round a probe, so as to give it the form of a bougie, long enough to allow it to be passed along the floor of the nose from the anterior to the posterior aperture, but not into the throat; the probe being withdrawn when the lint has been thus disposed of. This plug should be allowed to remain in three or four days, white the proper means are taken to remove the causes of the occurrence of the hemorrhage. The after treatment, which is usually of more importance than the immediate suppression of nasal hemorrhage, for the latter will frequently cease as soon as it is desirable that it should do so, consists in the pursuance of the antiphlogistic regimen to a degree commensurate with the ur- gency of the general symptoms and state of the body. It is necessary to consider how far it may be safe to regard the recurrence of an attack as the salutary consequence of the impeded function of a particular organ, or other co-existent disease; and how far, also, it may be reasonable to anticipate the practicability of the restoration of the one or the cure of the other, on which the hemorrhage may depend, without the hazard of a further loss of blood, if it should happen, exceeding the neces- sity of the system, or being otherwise disadvan- tageous to the circumstances of the patient. We deem it superfluous to enter into a detail of the antiphlogistic means to be adopted; the general condition of the system affording the best indication of the extent of reduction which may be necessary. It will be evident that the causes which excite the attacks in the first instance must be avoided as those likely to promote their recur- rence. The observations already made as to arti- ficial bloodletting, purgatives, and emetics, will also be applicable to the state we are now con- sidering. It may nevertheless be necessary to diminish the action of the heart and arteries fur- ther than it would be prudent to attempt by greater abstraction of blood, as well as to oppose the re- active tendency which may existwhen this remedy has been adopted. In digitalis, or nauseating doses of tartrate of antimonv, the suitable mean* will be found : one or both of these may be com- bined with the common diaphoretic saline draught and nitre, or other excitants of the skin and kidneys. When this hemorrhage, either from long con- tinuance or habit, has induced an atonic state of the blood-vessels, and a disposition to its inordi- nate or frequent recurrence is manifested, the in- ternal use of diluted sulphuric acid, or superace- tate of lead, may be advantageously had recourse to; and whether the hemorrhage be combined with an entonic or atonic condition of the body, if it have been excessive, or there should be rea- son to apprehend that it may prove so, experience has shown that either of these astringents will be a powerful adjuvant whether to the antiphlogistic or tonic plan of treatment, whichever may be directed to establish the contractility required in the ruptured end of the bleeding vessel from which the effusion may have taken place. This consi- deration leads us to notice a remedy,—the ergot of rye, which, from its powerful effect of exciting the natural action of the uterus, has been applied to a corresponding condition of the blood-vessels of that organ productive of hemorrhage, and, as it appears, with the desired effect: on the same prin- ciple it has lately been used in epistaxis ; (Med Chir. Rev. July 1831,) and as it was followed by its cessation, further experience may determine it to be a valuble remedy in this as well as in other kinds of hemorrhage in which the bleeding vessejs are reduced to an atonic state. Our present ex- perience of it, however, in cases of epistaxis is too limited to enable us to decide on its eligibility. In passive or atonic hemorrhage it is scarcely necessary to observe that those means which con- stitute the antiphlogistic regimen are inadmissible. The general treatment must be adapted to the dis- ease, whatever it may be, which exists with this affection ; and on some occasions, when the he- morrhage is excessive and exhausting, powerful stimuli will be required ; a large dose of laudanum, with carbonate of ammonia and camphor mixture, may be given with advantage under such circum- stances ; brandy and water, brandy^gruel, wine, strong animal soups, and jellies will also be necessary to recruit the exhausted strength of a patient, weakened as he must be by the continued or repeated drain of this vital fluid, under circum- stances of disease in which debility is a fearful, and in many instances an irremediable condition. The local treatment consists of the application of astringents and the use of compression or stop- page by the insertion of lint or cotton, as advised in the local treatment of entonic hemorrhage; and must be immediately adopted, unless in some pe- culiar states of the blood-vessels of the brain, in which it is possible that the balance of advantages may preponderate in favour of a slight evacuation of blood from the vessels of the nose, even though they should be in a passive or atonic state; but as this occurs in the advanced stages of continued and eruptive fevers, or purpura hemorrhagica, 01 of scorbutus, accompanied with every other symp torn of exhaustion, the oozing of blood should be restrained as soon as possible. It too often happens, however, under such circumstances, that the work of death is already begun, and that the arrest of the hemorrhage by mechanical and not vital powp* proves but a feeble obstacle to its completion. tJ6 ERETHISMUS MERCURIALIS-ERYSIPELAS. [Of late, a mechanical agency has been pro- posed for arresting the flow of blood, which, it is affiimed, is a popular remedy for epistaxis in the United States. (Amer. Journ. of the Medical Sciences, Jan. and April, 1843.) It has been strongly urged on the attention of the profession by M. Negrier, and has been made by him the subject of different communications to the Aca- demie des Sciences, of Paris. The patient is made to stand up with the head elevated. The nostril whence the blood flows is compressed with the finger, and the corresponding arm is directed to be raised perpendicularly, and to be kept in that position for about two minutes. The hemorrhage is soon arrested, owing, M. Negrier thinks, to a less vigorous circulation through the carotids, re- sulting from the increased force required to carry on the circulation through the upper extremities when raised. Cases have been published by others than M. Negrier in which this plan has been suc- cessful. M. Negrier has found it equally service- able in encephalic hyperemia, and in cephalalgia with somnolency,—whenever, in other words, it has been desirable to diminish the flow of blood to the head. (Revue Medicate, Juin 1843 ; or Amer. Journ. of the Med. Sciences, April 1844, P- 446<)] W. Kerr. [EQUINIA. (See Glanders.)] ERETHISMUS MERCURIALIS, mercurial erethism. The word erethismus (from tpeOifa, to excite or irritate,) is obviously a generic term which may be applied to any kind of morbid sen- sibility or irritability ; but it has hitherto been al- most exclusively confined to that species of ere- thism which sometimes arises from the use of mercury, and to which the appropriate name of erethismus mercurialis was given by the late sci- entific John Pearson, to whom we are indebted for the first notice of the disease. Prior to the period at which that distinguished surgeon was elected to the charge of the Lock Hospital, a year seldom elapsed without the occurrence of two or three sudden deaths, without any assignable cause, among the patients who were undergoing a mer- curial course. These were, in truth, cases of mercurial erethism, the nature of which was not then understood. Mr. Pearson has well described the disease as characterized " by great depression of strength; a sense of anxiety about the pra?cor- dia ; irregular action of the heart; frequent sigh- ing ; trembling, partial or universal; a small, quick, and sometimes intermitting pulse ; occasional vo- miting ; a pale, contracted countenance; a sense of coldness : but the.tongue, (Mr. Pearson adds,) is seldom furred, nor are the vital or natural func- tions much disordered." This affection appears to arise from mercury acting as a poison. So great is the danger attending this affection in its severer form, that any sudden or violent exertion may prove immediately fatal. Happily, however, its first appearance may be readily detected, and, by prompt measures, effectually removed. A tre- mulous motion of the tongue, a slight trembling in the limbs, or a sense of fluttering within the chest, are among the earliest indications of its ap- proach. The pulse becomes feeble, hurried, and irregular, sometimes intermitting for several se- conds, and then beating with great rapidity. On applying the hand to the left side of the chest, the heart will be found to act with extreme irregularity, This peculiar irritation may arise from the ad- ministration of mercury in any form; and may occur during any period of a mercurial course, though most commonly at its commencement. The exact circumstances which favour its occur- rence in the particular individuals attacked have not hitherto been ascertained. The writer of this article, while resident medical officer of the Lock Hospital, has seen it produced by the inunction of a single drachm of mercurial ointment, arid re- produced, in the same individual, after the discon- tinuance of the medicine for a whole month, by three frictions, each consisting of only one drachm of the ointment. It is remarkable, however, that in the greater number of instances, a full and ade- quate course of mercury has been afterwards borne, without any recurrence of erethismus, by the very persons who had suffered from it during the com- mencement of the course. The treatment of the mercurial erethismus is as simple as it is effectual. The open air is the grand antidote. As soon as the slightest intima- tion of the disease is perceived, the patient should be carried into the open air, with as little exertion to himself as possible, and there he should remain as long as may be practicable. To use Mr. Pear- son's words, " he should live there." Mercury, in every form, must be immediately discontinued, and a mercurial atmosphere carefully shunned. If in- unction have been used, the skin should be tho- roughly cleansed from any adhering ointment The subcarbonate of ammonia, either with oi without camphor, is an important auxiliary, and may be given in rather full doses, at moderate in- tervals, until the circulation becomes more steady, and the general power of the system revives. It is an important and encouraging fact, that from the time at which this treatment was adopted by Mr. Pearson, not a single death occurred from ere- thismus at the Lock Hospital. After an attack of mercurial erethism, great cir- cumspection will be needful both as to the time of recommencing, and the mode of conducting, the mercurial course. In the slighter cases, the dis- ease entirely subsides in five or six days, and even in the severer forms the mercurial treatment may often be safely resumed within a fortnight. Still the most watchful care must attend every remain- ing step of the course. The reader may consult with advantage Pear- son's Principles of Surgery, and the observations, by the same author, of the different articles on the Materia Medica which have been employed in the cure of Lues Venerea. m tt t-> P. H. Burder. ER\ SIPELAS. This term is derived, accord- ing to some authors, from Iptta, to draw, and *&*?< adjoining,- implying that a disease has a tendency to spread to the adjoining portions of the skin. Various other derivations have been suggested, but that now adopted appears to be the more correct. It was termed by the Greeks ipvoiniXa?, by the Romans Ignis Sacer, and is known in popular language by the name of the Rose, from the colour of the skin, and by that of St. Anthony's fire, from the burning heat with which it is accom- panied. ERYSIP ♦ Erysipelas may be defined inflammation of the skin, either alone, or combined with that of the subjacent cellular tissue ; generally, though not always, accompanied with vesicular eruption, the local affection being attended by symptomatic fever. The confusion and contradiction which have existed among practical writers respecting the na- ture of erysipelas, have in some measure arisen from attempts to found a correct classification of its varieties on some unimportant circumstances in its progress. For example, Cullen places ery- thema and erysipelas, which are certainly only modifications of the same disease, under different orders. He classed the former among the Phleg- masia?, the latter among the Exanthemata or rashes. It is evident, however, that he was aware of their identity, as he laid down their diagnosis with great accuracy in the following passage. " When the disease is an affection of the skin alone, and very little of the whole system, or when the affection of the system is only symptomatica! of the external inflammation, I shall give the dis- ease the name of erythema ; but when the external inflammation is an exanthema, and symptomatical of an affection of the whole system, I shall then name the disease erysipelas." (First Lines of the Practice of Physic, sec. 274.) If Cullen intended to apply the characters of his order Exanthemata to ery- sipelas, it must be observed that it does not corres- pond in its most important features with this order. Willan (On Cutaneous Diseases, Order iii. Ge- nus 6, and Order iv. Genus 1,) and Bateman (Practical Synopsis, pp. 117 and 124,) classified erythema and erysipelas according to their occa- sional external characters. Thus erythema is placed among the Exanthemata, and erysipelas among the Bulla?. This classification would be less exceptionable were vesication an invariable accompaniment of the cutaneous inflammation; but when we consider the occasional absence of this symptom in erysipelas, it is clear that any no- sological arrangement founded on an appearance which is not invariably observed, can only lead to confusion and misapprehension. J. P. Frank (De Curandis Hominum Morbis, Lib. iii,) has adopted Cullen's classification as to erysipelas, but includes erythema among the Im- petigines, while Rayer, (Traite des Maladies de la Peau,) after grouping together erythema and ery- sipelas, places them among the Exanthemata. Mr. Lawrence (Med. Chir. Trans, vol. 14,) con- siders erysipelas to be inflammation of the skin, but that like other inflammations it varies in de- gree. When it affects the surface of the skin, which is red, not sensibly swollen, and without vesication, it constitutes erythema. When the inflammation is more violent, so as to produce swelling of the skin, or in still more severe cases, when the cellular and adipose membrane, as well as the skin, become inflamed, he designates the disease erysipelas. Varieties of erysipelas.—The various forms of erysipelas depend on the degree of the local in- flammation, the type of the accompanying fever, and on particular circumstances with which the case may be complicated. A full account of the varieties of this disease will be found in the article Ertthema. Various divisions of erysipelas have been pro- Vol. II.—13 i ' E L A S. 97 posed. Some writers, as Burserius, have founded distinctions on its supposed causes. This author divides it into three species : 1. primary or idio- pathic ,- that is, arising spontaneously from an internal cause, not preceded by any other disease; 2. symptomatic or secondary, supervening on another disease, by which its progress is influ- enced ; 3. accidental, when it is excited by some obvious external cause. Others, again, have divided the disease into idiopathic, (from an internal cause,) and trauma- tic (from an external wound.) Later writers have introduced subdivisions from differences in the degree of local inflammation. This seems to have been the ground of Willan's and Batcman's classification : viz. 1. phlegmonous; 2. edema- tous ; 3. gangrenous; to which they add, 4. erra- tic, (migratory.) Another distinction has been made, according as the disease appears on different regions of the body, viz., erysipelas of the face and head, of the trunk, and of the extremities. We shall describe three forms or varieties: 1. simple erysipelas ,■ 2. phlegmonous erysipelas ,- 3. osdematous erysipelas; and afterwards point out some differences depending on its situation on the several regions of the body. 1. Simple erysipelas.—In this, which is the mildest form of the disease, the inflammation is confined to the skin, which is hot, smooth, red, and shining ; the colour varying from a bright scarlet to the more deep rosy or livid tint. The swelling is either so inconsiderable as to be scarcely perceptible, or, when the inflammation is in a greater degree, an evident tumefaction is felt on passing the finger over the inflamed sur- face. When the inflammatory action is still more considerable, effusion takes place into the subjacent cellular tissue ; and when this happens, the swell- ing is proportionably increased. The accompa- nying pain, which varies according to the intensity of the local disorder, is of a pungent burning kind, very different from the throbbing or pulsatile pain of phlegmon. About the third or fourth day after the appearance of the disease, vesications form on different, parts of the inflamed skin, after which there is a sensible diminution of the local suffering. The vesicles are sometimes small and numerous; occasionally they are of a larger size, and in a day or two either break and discharge their contents, or the fluid dries into hard yellow crusts, which fall off, leaving the subjacent skin sound, or some- times abraded. In very mild cases the local symp- toms disappear without vesication or even desqua- mation of the cuticle; more generally, however, when the inflammation ceases, the cuticle becomes detached, and falls off in successive portions. Al- though in by far the greater number of cases the disease is thus terminated, in some instances its disappearance from one part of the skin, more par- ticularly if sudden, is followed by its appearance on some other part. When erysipelas shows this tendency to metastasis or translation, it constitutes the erratic form described by Willan and othei authors. In such instances it is important to watch the condition of the internal organs, more particularly if the recession of the erysipelatous inflammation be followed by symptoms which in dicate visceral disease. ERYSIPELAS. Swediaur (Nov. Nos. Meth. Syst. vol. ii.) gives the case of a robust plethoric man, 55 years of age, who had for many years laboured under paroxysms of gout, which returned at stated periods. He had been free from his gouty attack for a longer period of time than usual. The eyelids became suddenly swollen; two days after, the oedema dis- appeared from the palpebra? ; he then complained of pain in the throat and difficulty in swallowing. This was soon removed by the use of gargles, when the oedema of the eyelids returned: in a few days afterwards the fingers of the right hand became in succession red and swollen, and subse- quently ulcerated. The man then recovered. After the lapse of some months the disease re- turned, and assuming the same migratory course, fixed in the feet, where it produced ulceration, on the healing of which the patient's health was com- pletely restored. Frank (De cur. Horn. Morbis, vol. ii.) relates the history of a woman in whom erysipelas mi- grated from the face to the feet, thence to the hip, and afterwards re-appeared on the face. After it disappeared from the face, the intestines became affected ; soon afterwards she was seized with dis- ease successively in the chest and in the brain. Willan gives the only case of erratic erysipelas which had in his experience proved fatal. A labouring man, aged 44, after much fatigue and exposure to cold, became affected with cough, shortness of breath, and febrile symptoms. Five days afterwards an erysipelatous patch appeared on his left shoulder, and another on the left leg. On the seventh day, similar patches appeared above and below the knees. On the eighth day the eyelids became tumid and red. About this time the other swellings assumed a livid hue, the febrile symptoms increased, and were attended with deafness and coma. On the ninth day the tumour of the right eye extended to the temple, upon which small phlyctena? soon after formed. On the eleventh and twelfth the patient seemed totally insensible; his pulse became feeble and irregular, and he died on the following day. (Wil- lan on Cutaneous Diseases.) 2. Phlegmonous erysipelas---In this form the inflammation affects the skin and the subjacent cellular and adipose tissues, and generally termi- nates in suppuration, and even sloughing of the affected parts. It generally occurs in young ple- thoric persons; those in more advanced life, how- ever, are not unfrequently the subjects of it, though its progress is more rapid, and its duration shorter, in young than in elderly people. Phlegmonous erysipelas appears more frequently on the extremities than on any other part of the body. The fever with which it is accompanied is of the inflammatory character ; and occasionally symptoms of gastric disturbance arise, either at the beginning or during its progress. The redness of the skin is of a deep tint, and, as in other forms of erysipelas, disappears on pressure. The pain is severe, and accompanied with <% sensation of burn- ing heat, while, in consequence of the effusion which takes place into the subcutaneous cellular memurane, the affected parts communicate a pecu- liar feeling which has been expressed by the term brawny. When the disease has gone on for four or five days, vesications appear, and go through the same changes as in simple erysipelas; or sometimes, instead of this process, desquamation of the cuticle takes place. The redness then declines, the skin assumes a yellow tinge, the swelling and febrile symptoms gradually subside, and the disease may thus end in resolution. This favourable termina- tion is by no means common. Phlegmonous erysipelas more commonly ends in suppuration, and even in gangrene, the purulent matter in the former case being either confined in small ab- scesses, or diffused in the cellular membrane. When gangrene takes place, the cellular mem- brane becomes completely disorganized, and, ac- cording to the description of Mr. Lawrence, appears like a dirty spongy substance filled with turbid fluid ; then losing its vitality altogether, it is con- verted into more or less considerable fibrous shreds of various size and figure, which come away, soaked with matter like a sponge; while the inte- guments, being deprived of their vascular supply, become livid, and often lose their vitality. When these changes take place, the tension of the pre- vious inflammatory stage is succeeded by a pecu- liar softness; the sensation thus imparted has been compared to that excited by a quagmire or morass, and hence the term boggy has been given to it. When an entire limb is affected with phlegmon- ous erysipelas, the inflammation and subsequent disorganization of the cellular tissue is not con- fined to that portion which is immediately under the skin, but extends to the intermuscular stratum. Should the patient survive such an attack, the skin, fascia, muscles, tendons, and bones, as stated by Mr. Lawrence, are so agglutinated and fixed, after the extensive destruction of the connecting cellular tissue, that the motions of the part are permanently and seriously impaired. Various morbid appearances in the internal organs have been discovered in fatal cases of phlegmonous erysipelas. These organic inflam- mations, which were evidently the more immediate cause of death, have been often unaccompanied by symptoms by which their existence during life could be ascertained. 3. QSdematous erysipelas.—This species, which may be said to be intermediate between the simple and phlegmonous, is observed chiefly in persons of impaired constitution, or in those who have a tendency to dropsical effusion. The skin, which is of a pale red colour, inclining to a yellowish brown, is smooth and shining, but less hot and painful than in the other forms. The inflamma- tion is of the sub-acute kind, and gives rise to serous effusion; the swelling extends slowly and gradually, leaving the impression of the finger as in anasarca, from which circumstance this form has received its distinctive appellation. In the more acute cases thin purulent matter is often mixed with the serosity. Vesications are less commonly observed in cedematous erysipelas, and the vesicles are smaller, less elevated, and more numerous than in either the simple or phlegmon- ous forms. It is very liable in some situations to terminate in gangrene; this is announced by the redness changing to a livid hue, and by the cessation of pain. Hence, when erysipelas appears on the genital organs, or on dropsical limbs, when the ERYSIP skin is much distended, or when punctures have been made with the intention of allowing the fluid to drain off, gangrene frequently supervenes. When, therefore, it is deemed advisable to punc- ture dropsical parts, the best mode of preventing such consequences is to insert a fine couching needle under the skin at short distances. This mode has been found preferable to making small incisions with the lancet, in so far as it is seldom followed by erysipelas. 4. We shall next advert to some differences in the local and general symptoms of erysipelas, de- pending in some measure on the situation of the part on which it appears. It is a matter of daily observation, that when erysipelas occurs on the extremities, it is less severe than when it appears on the trunk ; it is almost invariably confined to one limb, and seldom attended with danger, un- less, from its proximity to any of the larger joints, articular inflammation arises, which may termi- nate in effusion, or some other consequence of sy- novial inflammation. In no region of the body is erysipelas more for- midable and dangerous than on the face and scalp. The severity arises chiefly from the inflammation of the brain or its membranes, which almost inva- riably supervenes. Erysipelas of the face or scalp (to which the name sideratio has been given) is preceded by two or three days' smart febrile indis- position. The redness appears on some part of the face, from which it gradually spreads: it is sometimes confined entirely to the side of the face in which it first appeared ; but more generally it is diffused over the whole face, forehead, and scalp ; and occasionally creeping down the neck, extends to the shoulders and trunk. In other cases it first appears round some slight wound, such as those made by leeches or by the cupping scarificator, or around the margin of a blister : sometimes it succeeds to an external injury of a more severe kind, a lacerated or contused wound of the scalp. As the disease advances, the face, and more particularly the eyelids, become swollen ; the vessels of the head pulsate strongly; delirium, at first transient, but afterwards constant, comes on, succeeded by drowsiness, or coma; vesications or desquamation oi the cuticle take place about the fourth day, after which the local and general symptoms abate : in more severe cases, however, the symptoms in the brain increase ; the delirium increases; the patient either becomes furious, or falls into a state of perfect insensibility, and after lingering till the tenth or twelfth day, dies from the effects of cerebral inflammation. In other in- stances, in which the brain affection has been less intense, external abscesses form, most frequently on the eyelids : occasionally the matter becomes diffused in the cellular tissue of the scalp, or when the inflammation has terminated in gangrene, sloughing of this membrane takes place, the peri- cranium being often detached, to some extent, from the cranial bones. The parotid and cervical glands become inflamed in severe cases, and not unfre- quently abscesses form in the cellular tissue in which they are embedded. It is necessary to notice a form of pharyngeal inflammation which has been observed when ery- sipelas is prevalent at certain seasons, or appears in some localities as an epidemic. Some have de- 'ELAS. 9 112 EUTROPHIC—EXAXTHEJ certainly passes into the mass of blood, and doubtless, like eutrophics in general, modifies the condition of that fluid, so as to exert dyna- mically a new action on secretion and nutrition ; but as to the precise mode in which this is ac- complished, we know no more than we do of the modus operandi of other articles of the class, or, indeed, of any of the classes of therapeutical agents. It is impossible to depict every case in which this valuable agent is capable of affording benefit. It seems to be adapted for all cases in which it is desirable to induce a change in asso- ciated actions, and hence is an invaluable revellent in many febrile and inflammatory affections. As a eutrophic, it is chiefly indicated in chronic affec- tions, that are characterized by morbid depositions, or hypertrophies. The preparations of iodine are, likewise, admi- rable eutrophics; well adapted for cases in which it is desirable to modify the state of the fluid of the circulation. Hence, they are much used in the various cachexia?, and for the removal of dif- ferent morbid growths. The reputation of iodine is most decided in goitre. In scrophulosis it has attained great celebrity; and in certain of the constitutional forms of syphilis has supplanted mercury. Burnt sponge, cod-liver oil, animal charcoal, chloride of calcium, chloride of barium; the pre- parations of arsenic, of gold, and of silver, of pla- tinum and of iron ; as well as alkalies, and the mineral acids ; chlorine and chlorinated prepara- tions ; sulphur; the free internal use of sugar : sarsaparilla; guaiacum-wood; mezereon ; the root of aralia nudicaulis; bark of sassafras root; dul- camara, &c., are the chief eutrophics now used. For the precise cases to which they are respec- tively adapted, and for the forms of preparation of these and other eutrophics that are most advisa- ble, the reader is referred to another work—(Gene- ral Therapeutics and Mat. Med. ii. 290, Philad. ) Robley Dunglison.] EXANTHEMATA.—The word exanthemata, derived from the Greek term e^av8iu>, to effloresce, or break forth, was applied, by the Greek writers, to cutaneous eruptions generally. By modern authors its application is confined to cutaneous eruptions accompanied with fever, arising from specific contagion. In the nosology of Cullen, the exanthemata constitute the third order of the class Pyrexia?, and we find he has included ten different genera, viz. variola, varicella, rubeola, scarlatina, pestis, erysipelas, miliaria, urticaria, pemphigus, and aphthae, It is evident, however, he has included not only the eruptive fevers, strictly so called, but those diseases in which a vesicular efflorescence occasionally appears in their progress. Plenck, Frank, and others have fallen into a similar error. Willan and Bateman classify the exanthemata, according as the eruption agrees with their defini- tion of an exanthema or rash, viz. " superficial red patches, variously figured and diffused irregu- larly over the body, leaving interstices of a natural colour, and terminating in desquamation of the cuticle." They therefore, comprehend, under ex- anthemata, rubeola, scarlatina, urticaria, roseola, purpura, and erythema. EXPECTORANTS. In the article Fever will be found the classifi- cation of fevers we propose to adopt in this work, viz. into 1. continued; 2. periodic; and 3. erup. live. The eruptive fevers comprehend those dis- eases which we submit should alone be included in the exanthemata, viz. variola (and its modifica- tions), rubeola, and scarlatina. In those diseases which bear a strong analogy to continued fever, we find that a certain order of febrile symptoms is followed by a particular eruption ; that the fever and exantheme run a definite course ; the efflores- cence going through a regular series of changes, and terminating in desquamation of the cuticle; that these eruptive fevers occur only once during the life of the individual; and lastly, that they are communicated by contagion. The regularity of the eruptive fever and the progress of the efflorescence are most precise. The eruption of small-pox appears on the third day from the commencement of the febrile indis- position, and maturates on the tenth; the rash of measles appears on the fourth, and declines on the seventh day ; and the efflorescence of scarlatina is visible on the second day, and begins to disap- pear on the fifth ; the progress of the fever being thus fixed and regular, and apparently keeping pace with the series of changes which the erup- tion successively undergoes. The circumstance that eruptive fevers occur only once in the course of life, though correct as a general rule, is liable to occasional exceptions. These, however, are comparatively so few, that they tend much to confirm this principle. Per- sons, on the other hand, occasionally escape one or more of the eruptive fevers; more frequently, however, scarlatina than either sinall-pox or measles. The last characteristic of the exanthemata — that they are communicable by contagion — ad- mits of positive proof as to small-pox, in the com- munication of this disease by inoculation. Dr. Home (Clinical Experiments) succeeded in communicating measles by introducing the blood of a patient affected with the disease into the sys- tem of another individual; and the evidence of the contagious nature of scarlet fever is so strong that no one in the present day ventures to im- pugn the doctrine. (See Measles, Scarlatina, Small-Pox, and Varicella.) A. Tweedie. EXPECTORANTS, (from ex and pectus; expectoro, expectorans, Expectorantia,) are medi- cines intended to promote the exertion of mucus and other substances from the trachea, its branch- es, and the bronchial cells. In offering this defi- nition, it is proper to mention that the existence of any substances capable of unloading the pul- monary tubes has been doubted; but experience has demonstrated that not only substances applied in the form of vapour or of gas to the parts now mentioned, promote expectoration, but that sub- stances taken into the stomach produce the same effect. The mucous membrane of the air-tubes of the lungs is the part intended to be influenced by ex- pectorants. This membrane, which lines the whole of these tubes, from their origin through their trunk, the trachea, and all its ramifications, ATA — EXPECT ORANTS. 113 to their termination in the bronchial cells, se- cretes a lubricating bland mucus, in appearance not unlike a thin solution of gum, intended to mitigate the action of the air on a highly irritable surface. When this mucus is accumulated, or becomes viscid and adheres to the sides of the bronchial tubes, or when it is inspissated or ren- dered acrid by inflammation excited in the mem- brane, so as to impede in any manner the function of respiration, then expectorants become useful by contributing to its removal. In effecting this, they operate in two distinct ways; 1. they either diminish the action which has produced the pre- ternatural secretion, and thereby enable the natural effort of coughing to remove the morbid matter already existing in the air-tubes, or, 2. they di- rectly operate on the respiratory nerves, and pow- erfully excite those muscles, the sudden simulta- neous action of which is necessary for expelling the morbid matter. It is easy to conceive in what manner gaseous substances introduced into the lungs may promote this expectorant effort; but the question naturally suggests itself, do the sub- stances taken into the stomach proceed to the lungs, and there exert their influence ? Many substances, when introduced into the system through the stomach, escape by the lungs. Thus, various odorous matters, oil of turpentine, ether, alcohol, phosphorus, and camphor, soon after they are taken into the stomach, become per- ceptible in the breath ; and this is the case, also, when they are introduced into the system by other channels. M. Breschet and Dr. Edwards having injected oil of turpentine, in small quan- tity, into the crural vein of a dog, found that it was soon afterwards strongly exhaled from the lungs, although no odour of it was perceived on exposing the peritoneum.* From these and other facts it is evident that the lungs afford exit to sub- stances which have entered the circulation: now, in admitting this, it is not unreasonable to suppose that some of the medicines administered with the intention of promoting expectoration also enter the circulation, and proceeding to the lungs, ex- cite there the expectorant effort. But, although this conclusion be highly probable, yet it must be admitted that it is not susceptible of demonstra- tion. All expectorant substances may be arranged under two heads.—1. Those which effect the ex- cretion by topical means; 2. those which effect it by general means. 1. Topical Expectorants.—These may ope- rate in two ways: a. they may directly stimulate the nerves regulating the action of the respiratory muscles, and, by exciting these to sudden action, may effect the excretion by coughing; or, b. they may compress the thoracic viscera by producing vomiting, and thus induce a sudden and forcible expiratory effort so as to effect the expulsion of matters from the lungs. a. In explaining the manner in which the first kind of topical expectorants operate, it may be useful to consider briefly the nature of coughing. The act of coughing is a short and forcible expi- ratory effort, frequently repeated, the inspirations, * During this experiment, if a portion of the surface was denuded and a cupping-glass applied over it, the odour was not then perceptible in the breath. Vol. II. —15 k» in the intervals, being trifling in comparison with the expirations. Any irritation affecting the glot- tis, and acting upon a branch of that series of nerves which supply the respiratory muscles, ex- cites involuntary coughing; but the action thus excited may be moderated, if it cannot be wholly checked and terminated, by the will of the indi- vidual. Coughing, whether voluntary or invol- untary, is the result of the irritation of a Certain set of nerves, and is intended to relieve the bron- chial system of some offending cause; it is, there- fore, a salutary phenomenon. In those debilitated by disease or other causes, the difficulty of excit- ing the act of coughing with force sufficient to produce the salutary effect, is so obvious as to strike the ordinary as well as the professional ob- server. The distress arising from this circum- stance, the uneasiness caused by the irritating matters which coughing forcibly would readily remove, and the feeling of suffocation experienced from the accumulation of mucus obstructing the free passage of the air to the bronchial cells, are very considerable. In such states of the chest, the topical application of a stimulant to the bron- chial nerves may so far rouse the exhausted excita- bility as to enable the muscles to perform the ne- cessary effort; whilst, at the same time, the sub- stances employed to produce this effect may be of a nature to prove also beneficial, by imparting a renewed healthy action to the diseased mucous membrane. The whole of the substances arranged under this head, it must be recollected, stimulate so much as to require the utmost caution in their administration; but as the atmospherical air is the vehicle by which they are conveyed into the lungs, there is no difficulty in apportioning the degree of dilution so as to regulate the quantity of stimulus required or admissible. The substances employed for the purpose of stimulating the mucous membrane of the bron- chial system by direct application, and through it stimulating the respiratory organs, are few, and of these a small proportion only are in use. Benzoic acid may be employed either in its separate pure form or at the instant of its extri- cation from benzoin. In either case it requires to be largely diluted with atmospherical air, and combined with aqueous vapour. If the crystal- lized acid be employed, half a drachm should be put into an inhaler, and volatilized by the heat of a spirit-lamp ; or if the crude benzoin be prefer- red, half an ounce of it should be broken into small morsels and treated in the same manner. In the first instance, the diluted acid is the stimu- lating agent; in the second, the volatile oil, mixed with a small portion of the acid, rises with the aqueous vapour. Both are said to have proved beneficial in phthisis, even after the existence of suppurating tubercles had been clearly ascertain- ed. The writer of this article has never employed these stimulants in phthisis; but he has seen much advantage derived from them in spasmodic asthma, in shortening the paroxysm and promot- ing expectoration. Acetic acid acts nearly in the same manner as the benzoic. It is the oldest of the topical reme dies of this torder, is more manageable than the acid of benzoin, and does not require the aid o boiling water for its elevation. It is usually ex 114 EXPECTORANTS, tricated from diluted vinegar; but as this contains sulphurous acid, distilled vinegar should be em- ployed. Chlorine is of very late introduction as a topi- cal expectorant. It may be breathed by mixing it with the common air of the apartment of the patient, at the moment of its extrication from chloride of lime or of soda; or from a mixture of one part of peroxide of manganese and four parts of muriatic acid.* The former is to be preferred when a moderate stimulus only is required ; but in general, for expectorant purposes, chlorine is obtained by expelling it from its saturated solution in water by the aid of gentle heat. If an attempt be made to breathe chlorine in its undiluted state, it does not enter the lungs, but produces a powerful spasm of the glottis; and, if this be not immediately relaxed, suffoca- tion ensues. When it is diluted with a mode- rate portion of air, it excites violent coughing, irritation in the bronchial cells, great dyspnoea, and a painful, anxious sensation in the chest, which continues for several days. When largely diluted it operates as a salutary stimulus to the mucous membrane. In its largely diluted state, chlorine gas was first proposed as a topical expectorant by Dr. Fa- vart of Marseilles in 1804. Soon after that pe- riod the writer of this article became accidentally acquainted with its value as a topical expectorant, from witnessing its beneficial influence in a severe case of epidemic catarrh, when extricated as a fumigation to check infection ; and he has em- ployed it occasionally from that time in pulmo- nary diseases. But it was scarcely used either in this country or on the continent, until a report of Dr. Cottereau, of the Faculty of Medicine of Paris, again brought it before the profession. Sev- eral trading chemists, in particular M. Gannal, had remarked that phthisical persons, who en- gaged themselves to work in the manufactories of bleaching liquor, in which chlorine is largely ex- tricated, were gradually but evidently improved in health : to confirm his observations, M. Gannal constructed an instrument for inhaling it, and ac- tually administered it as a remedy in phthisis. The success of his experiment surprised him; but not being a medical man, he mentioned his views of the subject to Dr. Cottereau, who pur- sued the same plans as M. Gannal, and with a degree of success sufficient to merit the attention of the profession. The same influence of chlo- rine in pulmonary diseases has been observed by Mr. Tenant, of Glasgow, who informs us that all the men who engage themselves to work in his manufactory, if they have coughs, are rapidly re- lieved when gradually introduced into the chlorine * In this process the muriatic acid, which is a com- pound of hydrogen and chlorine, is partially decompos- ed; and decomposition of the peroxide of manganese also takes place. The liberated hydrogen of the muri- atic acid unites with one equivalent of the oxygen of the peroxide of manganese, and forms water; whilst the chlorine is set free in a gaseous state. This gas is of a greenish yellow colour, and has a pungent, acrid, suffocating odour. It is really absorbed by water; but the solution, unless kept in a blackened bottle or a dark place, is changed in its character by slow decomposition of the water and the formation of chloric and muriatic acids. Its goodness is known by testing it with litmus paper: if good, it will destroy the colour of the paper; if it contain the above-mentioned acids, the paper will be reddened. house : and of late, people labouring under phthi- sis and asthma have taken lodgings in the neigh- bourhood of his works, for the sake of the atmo- sphere of chlorine emanating from them. [Farther experience has not, however, confirmed these favourable reports, and some writers of dis- tinction have regarded it to be prejudicial in phthisis. (See the writer's New Remedies, 4th edit. p. 151, Philad. 1843.) In all cases it has to be employed carefully and experimentally; but no marked benefit can be expected from it in phthisis. It can only be adapted for cases of dis- ease in which the pathological condition of the bronchial mucous membrane, or neighbouring parts, requires the exhibition of an excitant. In this way, it may be occasionally serviceable in chronic bronchitis.] The best method of inhaling chlorine is to put f.ji or f.jii of the saturated aqueous solution into a glass inhaler, and add to it f.^ii of hot water, which gradually drives off the chlorine. This quantity may be inhaled every five or six hours, so as to maintain the effect produced on the mu- cous membrane. [A convenient apparatus for the inhalation of chlorine, iodine, &c. has been prepared by Dr, Corriagn of Dublin. It is figured in the writer's New Remedies, loc. cit., and in his General The- rapeutics Sf Mat. Med. i. 253, Philad. 1843.] When it is thus cautiously inhaled, the evident effects are a slight sensation of constriction in the thorax, with some increase of cough ; in a few in- stances a trifling degree of vertigo has been expe- rienced, but these feelings rapidly subside; expec- toration is produced almost without an effort, and the patient gradually becomes more comfortable than bpfore inhaling the gas. In cases of asthma the relief is peculiarly striking; and in phthisis we have observed that the symptoms of hectic have much abated during its employment: but we have seen no instance of the latter disease cured by it. The beneficial operation of chlorine may depend on its stimulus producing a new action on the diseased surface, which, if it could be maintained for a sufficient length of time, might overcome the morbid action ; and by supporting the tone of the system by other means, without exciting fever, the disease might be cured. In cases where large vo- mica? exist, it is in vain to expect a cure from any means ; but if we reflect on the influence of chlo- rine in improving the discharge from diseased mucous surfaces, such as that of the nostrils in coryza, and in promoting the cure of external ul- ceration, it is not a vain speculation to expect much advantage from its inhalation in phthisis. When chlorine is inhaled without being suffi- ciently diluted, the irritating effects are only tem- porary : very few instances have occurred in which inflammation has supervened. Indeed to no other irritant gas does the pulmonary system so rapidly accommodate itself; the workmen in the manu- factories of bleaching liquor breathe it daily in large quantities with impunity. The best method of overcoming its deleterious effects is to inhale ammonia largely diluted with aqueous vapour or ether; or, if neither of these be at hand, to inhale simple warm vapour. [The inhalation of iodine has been recommended EXPECTORANTS. 115 as an excitant topical expectorant in the same diseases as that of chlorine. It has been strongly advised in phthisical affections. Sir C. Scuda- mere (Lond. Med. Gaz. Feb. 17, 1838, and Feb. 7, 1840) found the addition of a little tincture of conium beneficial in subduing the irritating quali- ties of the gas. The writer—as elsewhere re- marked—has often used the iodine inhalations in phthisis, but his experience has not been favourable to it, and the same view has been entertained by others. (Pereira, Elements Materia Medico, 2d edit. i. 295, Lond. 1842.) It would seem to be better adapted for chronic bronchitis.] The substances which operate topically, either by stimulating the pulmonary exhalents, or as se- datives relieving the constriction on these vessels, and thereby facilitating expectoration, are also few. In those unaccustomed to the use of the former, they undoubtedly excite coughing; but in such cases the spasmodic action is produced by their first impression on the glottis, for when they are admitted into the trachea, no coughing is pro- duced. The first of these, the fumes of boiling tar, was recommended as a remedy in phthisis by Sir Alexander Crichton, who had seen it em- ployed in Russia. It produces in general much increase of cough; but this soon abates, and the expectorated matter is, in most instances, much improved. These effects seemed to promise the most salutary results; but like some other reme- dies which have been occasionally introduced to the notice of the profession, the vapour of tar suf- fered from being overpraised, and from too san- guine expectations being formed relative to its powers, and it fell into neglect. [Creosote, like tar vapour, has been occasion- ally inhaled in the same pulmonary affections; five, ten, or fifteen drops, according to the degree of tolerance of the lungs, being dropped into hot water in an appropriate vessel, and the vapour be- ing inhaled through the tube of an inverted funnel, or by means of any of the inhalers in use.] Another vapour which operates nearly in the same manner as that of tar has been much em- ployed in America, the fumes arising from burn- ing undressed wool. The use of these vapours was first recommended by Dr. Physick, who had found them extremely serviceable for stimulating and healing external sores, and concluded that they might prove equally beneficial if inhaled into the lungs. He conceived that he had established the fact of their utility in phthisis; but the experi- ence of a few instances in which they were tried by the writer of this article does not authorize him to pronounce very favourably respecting their employment. They excited great coughing when they were first used; but this rapidly subsided, and some degree of comfort was certainly experi- enced after each time of inhaling them; but nothing more resulted from their employment. The sedative topical expectorants are better known. Tobacco, when smoked, has been long employed for allaying the violence of the paroxysm in spasmodic asthma; but it is uncertain whether the benefit should be ascribed to the nicotina or the volatile oil. The use of stramonium, in the form of smoke also, has been found highly useful, and was at one time a favourite remedy in asthma. It appears to produce its beneficial effect in two ways. In the first place, it is directly applied to the mucous membrane when this is in a state of great irritability, and by acting as a sedative and allaying this condition, it favours the slower and more perfect secretion of the mucus, which being thus brought into a more natural state, is conse- quently more easily excreted: in the second place, by influencing generally the nervous system, the spasmodic symptoms attendant on the paroxysm of asthma are allayed, and respiration proceeds in a calm and undisturbed manner. The powers of stramonium were, at one time, greatly overrated; but experience has sufficiently demonstrated that it is capable of mitigating the violence of the pa- roxysms, although it may not be able to establish permanent relief from their attacks. Dr. Bree has objected to the employment of stramonium on the supposition that it induces a tendency to apo- plexy ; but this is, at best, problematical. b. The second set of topical expectorants, those which operate by mechanically compressing the thoracic viscera, and thus induce a sudden and forcible expiratory effort, so as to affect the expul- sion of matters from the lungs, are emetic sub- stances. In the operation of vomiting, by the sudden and violent contraction of the abdominal muscles, in order to force the contents of the sto- mach upwards, an impulse is communicated to the whole bronchial system, and by this means the expiratory effort being rendered more forcible, the expulsion of the mucus is effected. The bene- ficial effect of emetics in clearing away mucus accumulations from the lungs is indeed well known; and frequent recourse is had to them in many of the pulmonary diseases of children with uniform advantage. It might be supposed that the best emetics to select for expectorant pur- poses, would be those which operate by directly stimulating the nerves of the stomach, and which call the muscles necessary in the mechanism of vomiting into immediate action; but experience has demonstrated that the antimonial preparations are better suited for this purpose than any other emetics. Besides aiding the expulsion of mucus from the bronchial tubes, they possess the power also of controlling inflammatory action. The employment of emetics for procuring expectoration was formerly in much vogue as a remedy in phthisis. The emetics for this purpose, however, were seldom selected upon any principle: at one time we find sulphate of zinc and sulphate of copper employed ; at another, antimonials, ipeca- cuanha, and other nauseating emetics, if the lungs be loaded with mucus, and little or no febrile action be present, the direct emetics are to be preferred ; for in this case the mechanical im- pulse only is required ; but if, in promoting expec- toration, we are desirous of maintaining nausea afterwards, then the best emetic is the vinous solu tion of the tartrate of antimony and potassa, given to the extent of f.^vi for a dose, in a solution of the extract of liquorice. Squill and sulphuret of potassa have also been employed to excite vomit- ing to aid their expectorant properties. 2. General Expectorants* — These operate either by being received into the circulation, or through sympathy with the stomach : the fire< 116 stimulate the pulmonary exhalents through the medium of the circulation; the second affect the excretories by the nausea which they induce. a. The first of the organic substances which operate by stimulating the pulmonary exhalents is emetina, the active principle of ipecacuanha. In its uncombined state it has not been much em- ployed in Britain; but in France it has been successfully administered in doses of one-eighth of a grain, three or four times a day, in hooping- cough ; and in doses of a quarter of a grain it proves useful in catarrhal affections. It produces expectoration without exciting nausea; and we can readily comprehend how this is effected, if we admit that it is received into the circulation and determined to the lung as its emunctory: but if this be not admitted, it is difficult to explain its mode of acting : — its beneficial influence is un- doubted. When ipecacuanha itself is administered, it is usefully combined with opium, in the form of Dover's powder, of which from three to five grains produce expectorant effects, when neither nausea nor diaphoresis result. The French physicians assert that ipecacuanha is less useful in pulmonary diseases than uncombined emetina, owing to a peculiar fatty matter which it contains interfering with the influence of the emetina. This opinion is merely hypothetical; but nevertheless the evi- dence which experience has afforded in favour of the expectorant power of emetina is sufficient to recommend it to the favourable notice of British practitioners. The value of squill as an expectorant has been long known : it is supposed to depend on a pecu- liar principle which has been named scillitina. If this opinion be correct, it is probable that the squill undergoes decomposition in the stomach, and that the scillitina only is conveyed to the lungs. This opinion, however, is as yet unsupported by proof; and much obscurity still involves the mode in which squill produces its expectorant effect. Squill is contra-indicated in all diseases of an inflamma- tory type. It is usually administered in combina- tion with honey and vinegar in the form of an oxymel, or in tincture, or as a pill in combination with soap and ammoniacum. In these forms it is prescribed with advantage in asthma and chronic catarrh. The dose should not exceed one grain of the dried bulb, as in larger doses it is apt to prove emetic, purgative, or diuretic : one drachm of the oxymel, seven grains of the pill, and thirty minims of the tincture, are equivalent to this quantity of the dried bulb. When over-dosed, squill excites the most violent vomiting, purging, and convulsions, symptoms which induced Orfila to refer its operation to the nervous system; an opinion partly confirmed by the fact that dissec- tions of persons poisoned by squill present no appearances of inflammatory action in the pulmo- nary system. The best antidotes are ammonia and the alkalies, on which account these sub- stances are incompatible in prescriptions with »quill. Several of the gum resins are generally regarded »s useful expectorants, but the expectorant pro- perty of some of them is doubtful. Myrrh is one of these, and assuredly we have never seen it pro- duce expectoration when given alone : conjoined •vith ipeca-uanha or squill, it proves useful in the EXPECTORANTS. chronic coughs and catarrhal affections of debili- tated habits; but in these cases more is due to its tonic than its expectorant influence. It is fre- quently prescribed with the view of supportmg the system in the advanced stages of phthisis; and, probably, no medicine is better adapted for this purpose during a course of the inhalation of chlorine. At best, however, it can only be regarded as an auxiliary. In prescribing myrrh, it should be recollected that its aqueous infusion precipitates salts of lead, which are, consequently, incompati- ble in mixtures with it. In phthisis it is advan- tageously combined with sulphate of zinc or salts of iron; and when there is much acidity of sto- mach, it may be dissolved in liquor potassa? or ammonia?, and administered in any bland fluid or aqueous solution, such, for instance, as the bitter almond emulsion. Its efficacy as an auxiliary is well established in chronic catarrh and humoral asthma, in both of which diseases its tonic influ- ence is beneficial in relieving the exhaustion which follows the profuse expectoration. The dose of myrrh, in such cases, is from four to ten grains, repeated every third or fourth hour. As an expectorant, ammoniacum has been found useful in asthma, peripneumonia notha, and the chronic catarrh of old age; it has also been prescribed in tubercular phthisis. It is seldom given alone, but usually in combination with squill or antimonials. In America it has lately been conjoined with nitric acid : two drachms of it are triturated with f.gii of nitric acid, and then formed into an emulsion with f.^viii of water. A table- spoonful of this solution in a cupful of any bland fluid is administered every second or third hour, in cases of old catarrhs, when there is an infarc- tion of the lungs with viscid mucus, which the patient has not strength to expectorate. It may in this state certainly rouse the energy of the respiratory muscles; but we doubt whether it is equal to ammonia or its carbonate in such cases. It may, however, be administered in conjunction with ammonia; and, when thus combined, no other expectorant produces so much benefit in those irritable coughs which accompany hysterical affections, and are attendant on dyspeptic and hypochondriacal conditions : the expectoration becomes freer and more abundant, the oppression diminishes, and the patient is rendered altogether more comfortable. Ammoniacum, Galen informs us, was employed by Crito as an expectorant in phthisis; it formed the chief ingredient of the pilula? balsamica? of Morton, which held at one time a high reputation; and many other writers have recommended it in this merciless disease. It may prove useful in promoting expectoration where it is deficient, and may have a tendency to allay irritation; but the experience of modern practitioners has not confirmed the encomiums of their predecessors with respect to its value as a remedy in phthisis. The dose of ammoniacum, in these cases, is from eight to ten grains, admi- nistered three or four times a day. In large doses it causes nausea, thirst, and a sensation of heat at the stomach. The emulsion is the best form of administering ammoniacum as an expectorant; but as the gummy matter is not sufficient to sus- pend the resin for any length of time, it should be combined with mucilage. The dose of the mix- EXPECTORANTS. 11? turc is from f.gss to f.gi: it is coagulated by the oxymels, and cannot be combined with spirit of nitrous ether. Assafcetida was regarded by Cullen as superior to ammoniacum in spasmodic asthma; and in phthisical cases, when there is much flatulency, Dr. Parr considers it valuable as combining cardiac and expectorant properties. It possesses, however, no advantages over ammoniacum, and is more heating: indeed, what has been said of ammonia- cum applies equally to it, galbanum, and sagape- num: they are all stimulant expectorants, and may be administered, under similar circumstances, in the same doses and in the same manner. The balsams employed as expectorants are those of tolu and peru, styrax, and benzoin. All of them were formerly much used in affections of the chest, whether recent or chronic; but there can be only one opinion respecting the impropriety of administering balsams in inflammatory states of the lungs. Independently of the benzoic acid which they all contain, and which is powerfully stimulant, the volatile oil, which is another of their components, contra-indicates their adminis- tration in cases of excitement. Dr. Fothergill denounces the employment of balsams in pulmo- nary diseases at any period of the attacks, but he carried his objections too far; and there is suffi- cient evidence to prove, that after the excitement is subdued, there are circumstances which not only admit of the administration of balsams, but in which they have been found highly beneficial. They are best administered in the form of emul- sion, made by triturating the tincture of the bal- sam with mucilage of acacia gum, which renders it miscible with water; and in this form they may be usefully combined with ipecacuanha and pre- parations of opium. Copaiba, which is impro- perly regarded as a balsam, may be exhibited under similar circumstances. It is probable that it acts on the mucous membrane of the bronchial tubes, in nearly the same manner as on that of the urethra in gonorrhoea, by entering the circula- tion, and exciting a new action on the irritated surface. It is only by admitting that it operates in this manner, that we can account for the benefit which frequently results from its administration in the advanced stages of phthisis. Among the plants yielding bitter extractive in combination with mucus and fecula, employed as expectorants, we find marrubium vulgare, tussi- lago farfara, and certraria Islandica. If the first of these, the horehound, was too much vaunted by the ancients, its expectorant properties have been unaccountably neglected by modern British practitioners. It possesses stimulant powers, al- ters the state of the bronchial secretion, and seems to impress a new action on the diseased surface; besides promoting expectoration, it diminishes the oppression of the chest, relieves dyspnoea, and im- proves the digestive function. We have seen much advantage result from its employment in hu- moral asthma, accompanied with great oppression, and when the sputa was tough, ropy, difficult to be expelled, and causing pain in the expectora- tion. Many authors, as well as Tralles, have re- commended marrubium in phthisis. Although we have had no reason to place any reliance on its powers in tubercular consumption, yet we have witnessed much benefit produced by it in that va- riety of the disease which has been named catar- rhal, in which there is much cough, with copious excretion of mucus; a diurnal fever recurring twice a day, nocturnal sweats, and great pr :>stra- tion of strength. In this state the combination of the expectorant and tonic powers found in marra- bium have proved highly beneficial. The dried plant may be administered in the form of powder, mixed with syrup of white poppies, or in the form of an aqueous or a vinous infusion. The aqueous infusion may be made with 2;i of the dried plant and a pint of boiling water; the dose is f.^ii, given three or four times a day. Tussilago farfara, coltsfoot, has been as much neglected as horehound by the moderns, although it held the first rank as a pectoral among the an- cients : indeed its name (tussilago is a com- pound of tussis and ago) speaks the estimation in which it was formerly held. Although it has not deserved the praise bestowed upon it by the an- cients, yet tussilago possesses expectorant proper- ties by no means contemptible. As a gentle tonic expectorant, the writer of this article can bear ample testimony to its influence in the sequel of hooping-cough, when the habit is greatly weakened and the cough continues; and he has seen it equal- ly beneficial in many cases of chronic catarrh. It is best administered in the form of decoction, in making which, care should be taken to strain care- fully, as the hairs of the pappus of the flowers sometimes irritate the gullet and excite much un- easiness there. It cannot be prescribed in combina- tion with acetate of lead. Cetraria Islandica, or lichen Islandicus, or Iceland liverwort, or Iceland moss. Notwithstand- ing the encomiums which have been passed upon it by Scopoli, Hertz, Schneider, Stoll, Wansdorff, Sir Alexander Crichton, and other justly distin- guished physicians, it is doubtful whether this plant possesses any expectorant influence. " In phthi- sis, " says Sir Alexander Crichton, " its good ef- fects consist in improving the matter to be expec- torated; in diminishing the frequency of the cough, and rendering it more easy ; in calming the irritability of the patient, and in preventing or much moderating hectic fever. " ( London Medi- cal Journal, vol. x., page 229.) He, however, admits that it did not fulfil his hopes, in the cases which he saw treated with it at Vienna ; and we have never seen any benefit derived from its use as an article of diet. In preparing it, the bitter should not be entirely extracted; as, in that case, it is merely a nutritive substance, well calculated for phthisical patients, but possessing no medici- nal influence. Among the inorganic substances of this divi- sion of expectorants, ammonia and its carbonate are admirably adapted to free the bronchial system from the load of mucus which oppresses it, after attacks of acute pneumonic inflammation in de- bilitated habits, especially when the expectoration suddenly stops and suffocation is threatened. They operate by the influence which they exert on the nervous system, without augmenting, in an equal ratio, the action of the heart and arteries. The dose of both preparations must be regulated by circumstances: that of the carbonate may be car- ried to gr. x. or even gr. xv., and repeated every LIS EXPECTORANTS. second bour until the effect is produced; after which the dose should be diminished and the inter- vals extended. Owing to the heat of fauces which it causes in the act of swallowing, it should be involved in some mucilaginous substance, such, for instance, as a combination of the compound powder of tragacanth in almond emulsion. b. The general expectorants which affect the pulmonary excretories by the nausea which they induce, are few in number. In attempting to ex- plain their mode of operating, we must take into consideration the similarity between the function of the skin and that of the mucous membrane of the bronchial tubes. Both are exhalent organs ; and both, in febrile and inflammatory states of the system, are liable to suffer constriction capable of impeding their exhalent function, and giving origin to a train of symptoms depending on a deficiency of the natural lubricating mucous secretion. In this condition of the mucous membrane, antimo- nials and nauseating remedies relax this constric- tion, and enable the secretion to proceed; but still it may be demanded—in what manner do such nauseants promote expectoration 1 It is pro- bable that, during the state of constriction of the bronchial exhalents, any mucus then existing in the air-tubes is of a very acrid character; but as it remains adherent, it excites no effort for its ex- pulsion : when, however, the constriction is relaxed, and it becomes diluted and moveable, it still re- mains sufficiently acrid to stimulate the glottis and larynx, and thus to call into sympathetic action the whole set of respiratory muscles requisite for the effort of coughing, to expel the now loosened mucus. This explanation is not completely satis- factory ; it explains the mode in which the viscid mucus is diluted, but not well that by which it is expelled. Among the antimonials, the precipitated sul- phuret was formerly much employed in asthma and chronic catarrh, but the uncertainty of its operation has greatly narrowed the chances of its influence proving beneficial; and as tartar-emetic answers every indication, it is now generally pre- ferred. For expectorant purposes, tartar-emetic is given in minute doses ; for instance, from one- tenth to one-fourth of a grain, repeated at short intervals. In order to secure its expectorant effect, the surface of the body should be kept moderately warm. It is sometimes combined with squill and other vegetable expectorants; but these combina- tions improve neither the powers of the tartar- emetic, nor those of the other matters with which it may be combined. Its influence, however, is augmented by the addition of opium, which has been erroneously supposed to diminish the bron- chial exhalation; on the contrary, it not only aids other expectorants, but promotes it when given alone : an effect which is to be attributed partly to its increasing the natural secretion of the mu- cous membrane, partly to its sedative property di- minishing the irritability of that membrane. Before closing this article, it is necessary to offer a few remarks on the circumstances which should regulate us in our selection of expectorants. The first object is to ascertain the nature of the ough whether it be connected with a state of inflammatory action in the pulmonary organs, or with one of debility ; and in that case, whether it be kept up by nervous irritation. In every pul monary disease attended with cough, there is rea son for thinking that the early symptoms are those of inflammation; at that period, therefore, expec- torants are of little value, except as auxiliaries in bringing on a crisis; but after the inflammation is partly subdued, then the most salutary effects are obtained from expectoration. In this stage of the disease, the nauseating expectorants are to be preferred ; but when the inflammatory action is wholly subdued, those stimulating substances which we have described as calculated to produce the expiratory effort necessary to throw off the load of mucus with which the lungs are oppressed, are then required. It is easy to conceive that thickened, or, as they are termed, well concocted sputa, which are generally sufficiently glutinous to adhere together in masses, will be more easily detached and ejected by coughing than a thin mucus, whether accumulated in the tubes, or spread out upon their sides. The necessity, there- fore, of ascertaining whether the disease be one of excitement or debility is essential : it is neces- sary, also, to take into consideration the period of the attack, whether it be the commencement, middle, or termination, when we are called upon to prescribe ; for although each of these periods may be benefited by expectoration, yet the sub- stances employed to effect this require to be very different in their characters, according to the period in which they are given. In illustration of this point, we have only to take as an example a case of pneumonia. In the commencement of the at- tack the bronchial tubes are comparatively dry but if this state be overcome, either by the use of the lancet, or by a tendency to a spontaneous crisis, the quantity of mucus is then preternatu- rally increased, and is often tinged with blood. The most favourable symptom in this state is a free expectoration; the most unfavourable, the sudden cessation of it. Our object, therefore, should be to aid this effort of nature, or to produce an artificial state resembling it; not with the view of throwing off morbific matter, but upon princi- ples of a sounder pathology. In the commence- ment of the attack, if there be any reason for en- deavouring to promote expectoration, it must be effected by the gentlest means ; such, for instance as the inhalation of warm aqueous vapour, or by nauseating doses of ipecacuanha, tartar-emetic, and opium. Full vomiting, in this state of the chest, is also, occasionally, highly beneficial; and although, on a prima-facie consideration of its mode of action, it may seem at variance with the means just recommended, yet, by favouring a transfer of action, it often induces an increased secretion of mucus from the pulmonary exhalents, productive of the most marked relief. To effect this benefit, however, the vomiting must be full and maintained for a specific time, certainly not less than an hour. If, notwithstanding the em- ployment of these means, the expectoration be- come too abundant, so as to obstruct the free entrance of the air into the lungs, then the stimu- latmg expectorants are indicated, squill, ammonia- cum, the balsams, ammonia, and the topical appli- cation of the expectorant gases. The nauseating expectorants are equally indi- cated in the commencement of catarrhs, especially EXPECTORANTS— in the epidemic variety termed influenza. After bleeding moderately, and the administration of an emetic, the best results have followed the employ- ment of small doses of ipecacuanha, in combina- tion with squills and opium; but when the febrile symptoms have disappeared, and cough attended with a thin frothy excretion only remains, the balsams, gum-resins, and opium, administered in the evening and at bed-time, .prove generally highly beneficial. The same precautions are re- quisite in the administration of expectorants, in the commencement and in the advanced stages of phthisis. In the greatest number of cases of asthma of a recent date, some degree of inflam- mation is present; but from the progress of the paroxysm, and its termination in expectoration, an erroneous notion was entertained that the solu- tion of the paroxysm must necessarily follow its appearance; and, consequently, squill, ammonia- cum, and other stimulants, instead of the nau- seating expectorants, were inconsiderately pre- scribed, and often produced injurious consequences. In that variety of asthma, however, which appears to depend on a state approaching to that of para- lysis of the system of the par vagum, in which the bronchial cells, being deprived of their nervous energy, do not contract sufficiently to aid the ex- pulsion of the air in expiration, and, instead of aiding, prevent the necessary change of the blood in the pulmonary circulation, the nauseating ex- pectorants prove hurtful, by keeping up that state of diminished excitability which is the result of the morbid condition of the bronchial nerves. It is in such cases, and in the low stage of pneumo- nic inflammation, when the febrile symptoms as- sume a typhoid character and the lungs are loaded with mucus, that the inhalation of the expectorant gases, the internal administration of the balsams, and more especially of ammonia, prove undoubt- edly beneficial. [Almost every class of medicinal agents may become expectorant according to the precise con- dition of the system generally, or the pulmonary organs particularly ; and hence we find an expec- torant effect equally from depletives, and from tonics and excitants; from narcotics and counter- irritants ; and from nauseants and emetics.] Under all circumstances there are three general rules to be kept in view in administering expecto- rants : 1. The surface of the body should be kept mo- derately warm, and even in a gentle or breathing perspiration. 2. Whatever determines to the kidneys must be avoided. 3. Purging is not only not to be promoted, but to be most carefully guarded against; for as the action of the secreting vessels of the lungs and those of the intestines are opposed to one another, expectoration is checked when purging occurs. A. T. Thomson. EXPECTORATION.—This word (from ex and pectus, strictly signifies the act of discharg- ing any matter from the chest, but by a figure of speech it is also commonly applied to the matters discharged from the lungs and air-tubes. The act of expectoration is one of the instances ot combined movement in the respiratory machine, EXPECTORATION. 119 which, by an admirable and harmonious consent between its numerous muscles, unerringly pro- duces such a variety of actions. The function of respiration is of such vital importance that accu- mulations or effusions which obstruct it endanger life itself. The structure of the bronchial tree contributes greatly to the easy removal of any superfluous matter in it that might cause such obstruction, for the sum of the area of its branches being considerably greater than that of the trunk, or of the trachea, the air commonly finds easy en- trance into the air-cells, and, on its more rapid return in expiration, carries with it the super- fluous matter. Thus ordinary respiration tends to prevent, in spite of gravitation, any accumula- tion in the air-tubes; but the excretion is more completely effected by coughing and special efforts of expectoration. These consist of a quick and forcible expiration, preceded by a deep inspiration, and accompanied with a constriction of the larynx and trachea, the effect of which is to bring any superfluous matter into positions from which the air, forcibly expired, drives it through the glottis. It is worthy of remark that expectoration cannot effectually take place without a previous full in- spiration, by which air is carried beyond the accu- mulating matter ; hence, when this is prevented, either by weakness of the respiratory powers, or by the impermeability of the bronchial tubes, the excretion is suppressed. The first of these causes of obstructed expectoration is exemplified in adynamic fevers, which may thus prove fatal : the second occurs in pneumonia in the stage of hepatization, and, if extensive, must lead to a fatal obstruction of the respiratory function. They probably occur together towards the fatal termina- tion of bronchitis, phthisis, and other severe dis- eases of the lungs. Expectoration in its other sense, namely, the matter expectorated, is a subject well worthy of a careful study ; for its characters often furnish signs of the greatest value in the diagnosis, prog- nosis, and treatment of diseases of the chest. It can scarcely be said that the examination of the sputa is entirely neglected in this country; but we have had frequent occasion to observe that opinions are very loosely and vaguely formed from it, and of a nature quite inconsistent with the present state of pathological science. Thus the presence of pus in the expectoration is fre- quently looked upon as a sure proof that the lungs are " diseased ;" whilst the far more pathognomic sputa of peripneumony and the well-marked se- cretion of acute bronchitis are hardly recognized. The natural secretion of the bronchial mucous membrane is a colourless liquid of somewhat glu- tinous quality, like a thin solution of gum arabic. It does not greatly differ in chemical composition from the serum of the blood, and it owes its vis- cidity to an animal substance, which Dr. Pearson, (Phil. Trans. 1809,) Dr. Bostock, (Elementary System of Physiology, vol. ii.) and Berzeliu." (Annals of Philosophy, vol. ii. p. 382) concur in considering an imperfectly coagulated albumen. This secretion is the basis of most of the varieties of expectoration; but, unhappily, our knowledge of animal chemistry does not enable us to disco ver the precise nature of the changes in composi- tion which produce these varieties. All that we 120 EXPECTORATION. learn is that albumen, in different forms and pro- portions, is present; for, whether the expectora- tion be mucus, serum, pus, tuberculous matter, or coagulated lymph, the chemist can discover in these but scarcely discernible varieties of this same principle. There seems to be a considerable va- riation in the proportion of saline matter in differ- ent kinds of expectoration ; and on this depends a distinction, formerly much insisted on, by means of the salt or sweet taste. This criterion certainly fails in distinguishing pus from mucus; but we think that an excess of saline matter may be taken as a sign of inflammatory action in the mu- cous membrane. It is by its mechanical and visi- jle conditions, however, that expectorated matter is most distinctly characterized; and to examine these fairly, the entire sputa should be collected in one or more convenient vessels of white ware or glass, in which their quantity, colour, and con- sistence, can be minutely scrutinized. In acute bronchitis there is at first a diminution of the natural quantity of the bronchial mucus, with a sense of roughness and dryness in the larynx and trachea; but soon a saltish liquid is secreted, which increases as the inflammation reaches its height. It is transparent, almost col- ourless, and moderately viscid, resembling raw white of egg diluted with water. It generally re- tains a good many air-bubbles within it, and if expectorated with much coughing, it is usually covered with a froth. When poured from one vessel into another, it falls in a stringy or ropy stream. Andral (Clinique Medicate, torn, ii.) con- siders that its viscidity is in proportion to the inten- sity of the inflammation; an increased viscidity be- ing always accompanied with an aggravation of the fever, dyspnoea, and other symptoms. When the bronchitis is attended with fever, he remarks that the sputa become more viscid during the febrile exacer- bation ; insomuch that one inexperienced might be led to suppose that the inflammation had extended to the parenchyma of the lung: after the paroxysm, however, they return to their former state. At the height of the inflammation, and at other times when the cough is violent, they are sometimes streaked with blood: this is produced by the efforts of coughing, and does not tinge the whole mass. These characters are sufficient to distin- guish the expectoration of bronchitis in its first stages; and as long as it remains in this state, there is no improvement of the symptoms; but when the sputa become pearly or opake, or of a yellow or greenish-white appearance, we may be pretty confident that the inflammation is on the decline. This opacity is first perceived in the morn- ing expectoration, and in a few points only; and it is uniformly accompanied with an amelioration of the symptoms. The evening exacerbation some- times brings back the glairy transparency of the secretion ; but, unless there be relapse, the opacity returns on the succeeding morning, and gradually extends to all the expectoration, which is then nearly opake, and greenish or yellowish white : the smoke and dust in the respired air sometimes communicate a grey or dirty tinge. This change is often remarkably conspicuous after the success- ful operation of a sudorific; and, in fact, free per- spiration will sometimes partially accomplish it early in the disease. After the expectoration has thus become ripened or concocted, it is coughed up readily, and in loose distinct pellets, which, although glutinous in themselves, do not so read- ily unite into one mass as before; they gradually diminish in quantity, and in a corresponding de- gree the cough and other symptoms cease : a re- lapse is equally marked by a return of the expec- toration to its glairy transparent state. Sometimes a cold is prolonged by a series of relapses ; and, notwithstanding the length of its duration, the sputa retaining the same character, the affection preserves its chronic form, and does not terminate until the same change has taken place. These successive transitions, which were noticed by Hip. pocrates and Areta?us, are highly useful to the practitioner in discovering to him the state of the disease, and, taken with the pulse and physical symptoms, will safely guide him in the employ- ment of his remedies. The expectoration in chronic bronchitis is of a very diversified character, and is therefore much less certain in its indications. There is generally in it, opake, yellowish, or greenish-white mucus, like that expectorated at the termination of the acute disease ; but it is usually more diffluent, and often floats in a pituitous or serous liquid. The same mucus is sometimes voided in a more inspis- sated form. Andral describes it as resembling false membranes, and moulded into the shape of the bronchial ramifications ; and Dr. Cheyne (Pa- thology of the Membrane of the Larynx and Bronchia, p. 147,) and Laennec give accounts of a similar expectoration. In the milder cases the mucus thus modified constitutes the whole expectoration; but in a severer form of the dis- ease purulent matter is added, and the appearance, consistence, and odour of the sputa present very great variety. Many tests have been devised to distinguish pus from mucus ; but from what we have before remarked on the close similarity of their chemical composition, it may be judged that they pass by insensible gradations into each other. [Nor docs the microscope exhibit any marked difference in physical character, structure, and apparent com- position between them. (Donne, Coun de Mi- croscopic p. 177: Paris, 1844.)] The utility of minute distinctions of this sort may therefore well be questioned, as they neither enlighten us on the pathology, nor guide us in the practice. Pus is much less viscid than mucus, and not retaining air-bubbles, as mucus does, it commonly sinks in water, whereas mucus generally floats at the sur- face ; and this test gives us as much as is useful in the distinction. When the two are mingled in various proportions, this and all other tests fail in discriminating them. Proceeding from different parts of the bronchial membrane in different de- grees of inflammation or morbid affection, some portions of the expectoration are mucous and vis- cid, whilst others are purulent and diffluent; some greemsh-white like pus , others grey, dirty-look- ing brown, or tinged with blood : generally they are inodorous but sometimes they exhibit a re- markable fetidity. These characters, however varying, are unquestionably diagnostic signs of chronic inflammation of the bronchial membrane; but their value in the prognosis and in practice is greatly diminished by the circumstance of Juch EXPECTO chronic inflammation being frequently complicated I with other lesions. It almost always, for instance, accompanies the last stage of tubercular disease in the lungs, generally furnishing a great part of the matter expectorated ; and its existence is of small importance compared with the phthisical lesion. An inspection of the expectoration alone often fails to distinguish these combined cases from those of simple chronic bronchitis. In gen- eral, it may be said that purulent sputa indicate a severe form of disease ; but they neither necessa- rily imply phthisis, nor any other irremediable malady. The chronic bronchitis excited by ha- bitual inhalation of dust or powder, as among needle-pointers, leather-dressers, porcelain-makers, &c, is commonly attended early with purulent and bloody expectoration ; but if the cases are treated in time, and the patients are removed from the continued application of the exciting cause, they generally recover. So also, severe cases suc- ceeding to measles and scarlatina sometimes pre- sent purulent expectoration, yet they are far from being universally incurable. We repeat, there- fore, that puriform matter in the expectoration, as a prognostic sign, only indicates an aggravated form of disease. The nature of the expectoration gives the dis- tinctive characters to the diseases termed by Laen- nec dry and pituitous catarrh. The former is a kind of asthma, attended with no other expecto- ration than scanty pellets of very tough grey mu- cus, which lodge in the bifurcations of the bron- chi, and sometimes cause severe fits of asthma. It is important to recognize the expectoration of this disease, as it is singularly benefited by the alkaline treatment recommended by Laennec. Pi- tuitous catairh, or humoral asthma, is remarkable for the profuse watery expectoration which accom- panies its paroxysms. This discharge contains albumen, coagulable by heat, and seems to differ but little in nature from the serum of the blood. Its quantity is sometimes enormous, amounting to several pounds in weight. These two forms of secretion sometimes occur at the same time in dif- ferent portions of the bronchial membrane ; and the serous discharge, in smaller quantities, is a common accompaniment of chronic bronchitis. The expectoration of pneumonia is very char- acteristic. For the first two days there is seldom any expectoration ; but, about the third or fourth, a viscid transparent liquid is spit up, uniformly tinged with a rusty or orange hue. At first its viscosity is not so great but that it can be poured from one vessel into another, and it falls in strings or ribands ; but in proportion as the inflammation reaches its height, and passes to the stage of he- patization, it becomes so glutinous that the vessel may be inverted, and even shaken without its falling. The red tinge is generally proportionably increased, but this is a less certain test than the viscidity, of the intensity of the inflammation. If the inflammation declines or is mitigated, the sputa become less vis- cid and rusty, until they present the characters of the expectoration in bronchitis. It is to be regret- ted that this valuable and truly distinctive sign does not show itself early and constantly in the disease. When it is present, it may confidently be depended on, but its absence by no means dis- proves the existence of pneumonia. In some in- Vol. II— 16 i AT I ON. 121 dividuals it never occurs ; and in children it is difficult to obtain a sight of the expectoration. It is also important to know that many adults, like children, invariably swallow the expectoration. The physical signs are, therefore, alone to be de- pended on in the diagnosis of negative cases. As a prognostic guide the sputa are highly instruc- tive. The unfavourable import of a late appear- ance of the sputa was noticed by Areta?us; but M. Andral first pointed out the proportion which their viscidity bears to the intensity of the inflam- mation. As long as this goes on increasing, or remains undiminished, we may be sure that the inflammation is predominant; but if the expecto- ration shows a disposition to return to the colour- less and less viscid state of simple bronchitis, the disease may be known to be on the decline. In a few cases the expectoration increases in viscidity up to the hour of death, but more generally it is either suppressed or changed, particularly if the inflammation have proceeded to the stage of sup- puration. The suppression of the expectoration was considered by the ancients an unfavourable omen ; modern pathology discovers that it is so, either because it proves the inability of the patient to expel it, or because the secretion has ceased, and the inflammation passed to the hepatized and suppurated stages. In the former case suffocation must soon ensue from the accumulation in the bronchi: in the latter the rusty expectoration is often replaced by other kinds. Sometimes it con- sists of brownish dirty-looking opaque mucus; sometimes whitish specks, as of pus, are seen in it, and, rarely, it is entirely purulent. M. Andral describes another kind of expecto- ration, which he considers generally to indicate the stage of suppuration. This is a deep reddish- brown and slightly viscid liquid, like the juice of preserved prunes or liquorice water. In six out of nine cases in which this was observed, the lung was found, on dissection, in the state of purulent infiltration; in two it was hepatized ; the remain- ing case was a slight one, and recovered. Laen- nec does not attach any importance to this kind of expectoration, considering it only as the sign of a cachectic or scorbutic habit. It certainly cannot be considered distinctive, but it may be taken presumptively, and must generally be look- ed upon as an unfavourable sign. The tinge of the characteristic peripneumonic sputa, which is, in different instances, greenish-yellow, orange, rust-coloured, and bright-red, obviously proceeds from the colouring matter of the blood, intimately mixed with it in various proportions. If the in- flammation terminates in resolution, this tinge diminishes and disappears, and the sputa exhihit the characters, and go through the changes of the expectoration in bronchitis. In pure pleurisy there is either no expectora- tion, or one simply of a catarrhal nature. The fluid secreted in chronic pleurisy has been sometimes known to make its way into the bronchi, and to be evacuated by expectoration ; but other signs must rather be depended on for discovering the nature of such a case ; as a similar expectoration is sometimes derived from a pulmonary abscess, and even from sudden and copious secretion from the bronchial lining only. The character of the sputa has been more cor. 3RATI0N. 122 E X P E C T ( suited in the diagnosis of consumptive diseases than in any other; but the advances which have of late been made in developing the true nature of tubercular phthisis, have proved that all the distinctions and tests proposed are more or less fallacious. Thus it was long held that the pre- sence of pus in the expectoration was a pathogno- monic sign of pulmonary consumption ; and all efforts were directed to find out a sure method of detecting it and of distinguishing it from mucus. We have already remarked that purulent expecto- ration is not an uncommon consequence of simple bronchitis, and this disease presents all the phases formerly ascribed to phthisis. Something of the prognosis may, we believe, be learnt by consulting the expectoration, but its distinctive characters are to be depended on only after repeated exami- nations, and in combination with other signs, par- ticularly those of auscultation. In the first stage of phthisis, that of miliary tu- bercles, there is either no expectoration, and the cough is dry, or it is of a simple bronchitic nature. When the lungs are thickly studded with miliary tubercles, there is not unfrequently an abundant serous secretion like that of pituitous catarrh, which is accompanied with a constant and general mucous rhonchus in the lungs. Whenever these present themselves for any length of time in an individual of tuberculous diathesis, and especially if there be any irregularity of resonance on per- cussion about the clavicles, we consider the fate of the patient almost certain, and the disease will probably run a very rapid course. Except in this case, and in that of ha?moptysis, which is treated elsewhere, (see Pulmonary Apoplexv and H.e- mopttsis,) the expectoration does not assist us in the first stage of phthisis. The characters of the sputa in the second stage, or during the softening and evacuation of the tu- bercles, would be much more distinctive were they not always mixed up with the mucous and muco- purulent secretion of a chronic bronchitis, which always more or less prevails at this period. Hence the signs, as relating to the tubercular disease, must be considered in a corresponding degree am- biguous. Attentive examination will often dis- cover in the mucus expectorated fine whitish streaks, which consist of the softened tubercle; more rarely there are little yellowish white masses like grains of boiled rice, which are portions of crude tubercle. As the softening proceeds and the cavities are enlarged, the sputa become less frothy, sink in water, and are principally compos- ed of greenish white masses of irregular shape and outline, sometimes tinged in parts of a dirty red or brownish colour. These flatten at the bottom of the vessel like a piece of money, whence they have sometimes been called nummulary sputa. In some rare instances small portions of the pul- monary tissue itself have been detected with the preceding. When the disease is further advanced, the expectoration assumes a brown, dirty green, or grey colour, and the sputa are frequently sur- rounded with an areola of a bloody tinge. It is exceedingly difficult to say what degree of weight should be attached to these several appearances, even when they are unequivocally seen. It might be supposed that the presence of the whitish sfeaks or of (he little white masses would be con- clusive, as being themselves tubercular matter; but appearances of the same kind may present themselves from other sources. The minute bronchical ramifications, in chronic inflammation, sometimes secrete a purulent liquid, which may produce the same streaky appearance; and ver- micular concretions and filaments of yellowish white lymph formed in the same way may be mistaken for little fragments of tubercle. The little rice-like bodies, which were considered by Baglivi, and Bayle, and even by Hippocrates, as indications of phthisis, are moreover closely simu- lated by certain sebaceous concretions formed in the tonsils, and, according to Andral, by similar productions from follicles in other parts of the pulmonary mucous membrane. The white mat- ter from the tonsils may, however, be always dis- tinguished, as Laennec has pointed out, by their fetid odour and by their greasing paper when heated; and without attention to this test, the sign cannot be depended on. The globular yel- lowish white masses, like irregular balls of flock or wool, which apparently consist of pus held in shape by a little tenacious mucus, have been noticed by several writers as peculiar to phthisis. Dr. Forbes (Transl. of Laennec, 3d edit.) says that this kind of expectoration has appeared to him to be most common in young subjects of a strongly marked strumous habit, and in whom the disease was hereditary. A precisely similar ap- pearance is, however, sometimes presented by the sputa in chronic bronchitis. The dirty brown or green matter, flattening and becoming nummulary when separate, and when together forming a smooth sluggish purilage, which appears later in the disease, and takes its origin from the tubercu- lar excavations, is much more certainly character- istic of phthisis. To sum up, we may say that an occasional examination of the sputa, by far the greatest part of which, as Laennec has remarked, proceeds from an accompanying bronchitis rather than from the tubercular disease itself, can only enable us to distinguish phthisis in the very rare case of tubercular matter, or portions of the tissue of the lung being present: but with Dr. Forbes and M. Andral, we think that by a daily careful inspection of the expectoration, we.shall not fail to find in the successive and progressive changes which it presents, the means of forming a pretty accurate diagnosis, which, if confirmed by the ge- neral and physical signs, will leave no shadow of doubt. As our design in this article has been rather to direct the attention of the practitioner to the importance of expectoration as an aid in diagnosis and prognosis, than to give a complete account of the subject, we refer for further descriptions to the articles in which the diseases of the chest are par- ticularly treated of. In conclusion, we would strongly recommend our readers to consult the second and third volumes of Andral's Clinique Medicate, and Dr. Forbes's translation of Laennec's Auscultation Mediate, where they will find instructive and con- vincing proof of the assistance which the expec- toration gives, especially if taken in conjunction with the physical signs, in the distinction and treatment of diseases of the chest. C. J. B. Williams. FAVUS—FEIGNED DISEASES. 123 [EYE, DISEASES OF THE. (See Amau- rosis, Ophthalmia, &c.) FARCY. (See Glanders.)] FAVUS. The pustules termed favi are so named from the character of the crusts by which they are succeeded ; these being cellular, and fan- cifully compared to an irregular honey-comb. The term favus, however, was differently employed by the ancients : Galen applied it to ulcers which exude, through small orifices, a matter resembling honey in consistence: Celsus regarded it as synonymous with miliary. Favi, in the modern acceptation of the word, are small, yellow, irregu- larly circular pustules, nearly flat — at least, not accuminated; and, according to Biett, always de- pressed in the centre. Their base is slightly in- flamed ; they generally appear in circular patches or clusters; are attended with itching, and fre- quently with glandular swellings from absorption of the matter. These pustules are succeeded, after some days, by a thick yellow, nearly semi- pellucid, somewhat cellular, augmenting crust or scab; at which time they frequently exhale a very offensive, nauseating odour, not unlike that of the urine of a cat. As the crusts dry, they become white, and easily detached. The seat of favi is most commonly the scalp, in the epidermal layer which covers the papilla? of the true skin. As they most commonly occur on parts covered with hairs, Dr. Duncan advanced an opinion that the disease is in the bulb of the hairs, which are indeed easily detached, and display a swelling at the base. Biett accords with this opinion ; but Rayer dissents from it, and sup- ports the view which we have adopted. Favi generally occur during childhood ; they seldom affect the general health, although, when they appear during the period of dentition, they seem to be in a great degree connected with the disordered state of the digestive organs which more or less attends that period, and the increased irritability of the habit. They occasionally, how- ever, appear in adults, on the neck, ears, and occiput: in these cases they are always preceded by some degree of constitutional derangement; headach, an uneasy state of stomach, loss of appe- tite, irregular bowels, and fever: the inflammation surrounding the pustules is more extensive, and the crusts are thicker and harder than in child- hood. Alibert affirms that cooks are very liable to eruptions of favi. They are chiefly known as the distinctive feature of one species of porrigo,— P. favosa; under the head of which we shall have again to direct the attention of our readers to their characters. Biett (Abrege pratique des Maladies de la Peau, par MM. Cazemene et Schedel, p. 231,) supposes that minute pustules of porrigo scutulata, which appear in circular patches, are favi, differing only in their arrange- ment and some little variation in the state of the crusts; but as far as we are enabled to form an opinion by the appearances which they present, when viewed with a powerful magnifier, the opinion of Bateman, (Synopsis, edit. 7th, p. 138,) who regards them as achores, is correct. Rayer (Traite theorique et pratique des Maladies de la Peau, par P. Rayer, vol. i. p. 520,) considers both the pustules and crusts intrinsically different from those of porrigo favosa. As we shall have again to detail c. — Soldiers sometimes feign this affection with the view of ob- taining their discharge, and unwilling recruits to prevent their serving in the army. A fit of ne- phralgia, or passing of gravel, is even pretended, and an alleged calculus exhibited. A similar im- position is practised by females, and occasionally under such circumstances as render it very diffi- cult to account for their conduct. A most re- markable case is recorded in the Edinburgh Me- dical Journal (vol. vii.) of " a young lady, of rather high rank," who feigned this disease, and was believed to have excreted, with great pain, a vast quantity of calculi, " not less than several pint measures in two or three years." The rudest chemical experiments proved the pretended calculi not to be of animal origin ; they were in fact, " common sand and pebble stones." No motive could be assigned for this extraordinary conduct. A similar case in a boy, ten years of age, is men- tioned in the Annals of Philosophy, vol. iv. p. 76 ; and Dr. Thomson of Edinburgh discovered a simi- lar imposition in a woman, by detecting micaceous particles in the alleged gravel. (Beck's Jurispru- dence, by Dunlop, p. 7.) A still more common deception perhaps, and one much more extravagant, is the pretended ex- cretion of calculi from the vagina. Many instan- ces of this fact are mentioned by authors, and many others might be added. In a case mentioned in the Medical Comm., vol. iv. calcined bricks were pretended to be passed from the vagina, and some were extracted from it. A case was men- tioned to us not long since, of a young woman from whom many fragments of coal were extracted by a surgeon. But the most remarkable instance of imposition that has come to our knowledge is that of a young woman, the daughter of a farmer near Edinburgh, who, after feigning, forming, or sustaining an immense variety of affections, in uninterrupted series, from 1817 to 1830, at length fixed upon the excretion of bone from the vagina as the great and abiding malady. Among the diseases, real, feigned, or factitious, which this girl exhibited, were hepatitis, epilepsy, amaurosis, aphonia, deafness, paralysis of the arm, gravel, anasarca, ha?matemesis, irregular convulsions, gas- traigia, dyspncea, vomiting of substances resem- bling liver and bone, and retention of urine. Bone was first detected in the vagina in 1824, while the surgeon was introducing the catheter, and from this period an immense quantity was either extracted or excreted; some pieces were even extracted from the bladder. She was admit- ted into an hospital in 1825, where she still con- tinued to pass bones, believed for some time to be ttw«c of an extra-uterine foetus; but a complete stop was put to the complaint by secluding the patient from all access to such materials. After her discharge the alleged excretion returned. She had an illegitimate child in 1828, and was finally married to a respectable farmer in 1830. Another young woman, in a respectable rank in life, pre- tended to pass vesicular bodies from the vagina, and many were extracted by surgical aid. At first the disease was considered natural, but eventu- ally it was discovered by Professor Thomson of Edinburgh, that the alleged hydatids were artifi- cial vesicles prepared from the intestines of a pig. These were so constructed as to resemble a string of beads. It is hardly necessary to say anything respecting the means of detecting such impositions ; it is, however, important that the young practitioner should be made aware of their occasional existence, 16. Fever.—This disease is frequently feigned, and also in some degree produced artificially. Soldiers and sailors pretend to have an accession of ague during the night, and present themselves as if in the interval to the surgeon. Sometimes they simulate the fit at a time when they can be more readily discovered. Dr. Cheyne men- tions the case of a soldier who pretended to be in a chill, and who was seen to be shaking violently: upon throwing down the bedclothes, however, he was found not in the cold, but it in a sweating stage produced by his own exertion. This expo- sure put an immediate termination to the parox- ysm. (Op. cit. p. 175.) Such persons, Fodere says, often imitate admirably the chattering of the teeth of the cold fit. They likewise use means to produce a greater semblance of fever. Great heat and perspiration, and a quick pulse, are produced by strong exercise immediately before the hour of the visit. In the section on disordered circula- tion, we have noticed various means adopted foi the purpose of disordering the action of the heart and arteries, most of which are equally applicable to the production of the disease now under con- sideration. The skin is sometimes scrubbed with a hard brush to produce redness ; and the tongue is very frequently coloured artificially white, brown, or dark, with chalk, pipe-clay, tobacco, brick-dust, and brown soap, &c. according to the convenience or knowledge of the impostor. The sanguinary pirate Loto, who was lately executed at Gibraltar, very nearly succeeded in deceiving his medical attendants by simulating fever, colour- ing his tongue brown, &c. In all these cases close observation will almost always detect the impos- ture ; and most certainly a few days' confinement will do so. It is only an ephemeral fever that can be feigned with any prospect of success. 17. Practiire.—We have seen several soldiers who simulated lameness, and alleged that a thigh bone had been fractured, by which means the limb had become shortened. This imposture is easily detected by placing the man upon his back and examining both the thighs : the muscles of the limb falsely alleged to be shortened will be found hard and in full action, while the muscles of the other limb are inactive and soft. We hap- pened to know one instance of a soldier who ob- tained his discharge by alleging that he had a plate of metal in his skull, which he said had been introduced there in consequence of the bone hav- FEIGNED DISEASES. 133 ing been fractured ; and we are also aware of an instance where a medical officer was found fault with for having approved of recruits " with plates introduced into their heads." The simulators of this disability must have met with very credulous auditors, for it is to be presumed they did not ex- amine the heads said to be thus mended. 18. Heematemesis.—This affection is readily simulated, and frequently has been so by soldiers, sailors, slaves, and other persons. It is effected by procuring blood, and after swallowing it, pro- ducing artificial vomiting, whereby it is disgorged. The hlood is generally that of some animal; but slaves in the West Indies have been known to swallow their own blood to effect their object. A remarkable case is mentioned by Sauvages, of a girl who feigned ha?matemesis to escape from a convent, and who brought up in the presence of the physician several pounds of blood on several successive days. It was at last discovered that she secretly drank bullock's blood before the visit. (Nosol. Method, ii. p. 299.) This imposition will in general be discovered at least in situations where the medical attendant may reasonably ex- pect to meet with feigned diseases, by narrowly examining the symptoms—when a discrepancy and want of harmony will be found among them which nature never presents. When any suspi- cion is excited, the detection may be made at once by watching the patient, and cutting off the possibility of his obtaining the materials necessary to the simulation. 19. Hematuria.—This disease has been sometimes simulated by taking substances into the stomach which have the quality of reddening the urine, such as beet-root, the fruit of the prick- ly pear, madder, &c.; it has, however, been much more frequently attempted to impose by mixing foreign substances with the urine, particularly blood, after it was excreted. The authors of the article Feigned Diseases in the Dictionnaire des Sciences Medicates inform us that blood has even been injected into the bladder with this view. A little attention suffices to discover factitious hema- turia, however produced. 20. Haemoptysis.—This is a disease very commonly feigned by soldiers and sailors, and also by mendicants. The cough is easily assum- ed, and the sanguineous expectoration is produced by pricking or cutting the gums, throat, or some part of the mouth, or by cutting the fingers or arm and sucking the blood, or by procuring the blood of animals, or by artificially tinging the sputa of a red colour by some foreign substance. Sylvaticus mentions the Armenian bole as being used for this purpose, (Institutio medica de iis qui morbum simulant deprehendendis.—Madrit. 1594) ; Dr. Beck, brickdust; and Mr. Hutchison, vermilion paint. ,Dr. Cheyne justly observes, that the absence of the symptoms which generally attend real ha?moptysis, such as cough, dyspnoea, fever, &c. will naturally excite suspicion, and the appearance of the sputa will confirm this in such cases. The factitious will be very unlike the real sputa of ha?moptysis. The use of the stethoscope will greatly aid in the diagnosis in doubtful cases. It ought to be a rule in the army, that simple spitting of blood, unaccompanied by signs of organic disease of the lungs, is not a sufficient cause for the discharge of a soldier. 21. Hemorrhoids.—The discharge of blood from the anus is easily feigned or imitated. It appears also that ha?morrhoidal tumours have been very artfully constructed by means of small blad- ders, inflated and tinged with blood, and attached to a substance introduced into the rectum. (Percy and Laurent, op. cit.) 22. Hepatitis.—This affection is often simu- lated by soldiers who have been some time in India, when they wish to be discharged. They are commonly well acquainted with the symptoms of the disease, and frequently tell a tolerably con- sistent story. The countenance and general ap- pearance of an impostor of this kind, are, however, often at great variance with his oral testimony. In doubtful cases of alleged organic disease of the chest or abdomen, the person to be examined should be undressed, as he is then unable to con- ceal whatever evidence of health may be supplied by a plump frame and muscular limbs. An op- portunity is also thus afforded of properly explor- ing the cavity in which the disease is alleged to have its site. It is not an uncommon practice with officers in the navy on foreign stations, who are desirous of returning to England, to feign some disease in order to be invalided to a more temperate climate. In the West Indies in particular, this practice was formerly of frequent occurrence ; and it is a curious fact that the disease most frequently as- sumed, and successfully, was that now under consideration, and which is by no means very common among sailors in that country. The causes of this preference in favour of hepatitis are, no doubt, the supposed facility of imposing the belief of its existence on a superficial observer, and the generally received opinion of the tendency of all tropical climates to generate it. The facts just stated might lead to some curious statistical mistakes. Suppose, for instance, infor- mation were sought respecting the relative preva- lence of different diseases in different climates among persons in the navy. If the official records of the medical department were inspected for this purpose, it would be found that a large portion of the invalids from the West Indies were affected with hepatitis; and it is probable that the propor- tion might be greater than among the invalids from the East Indies. Now there cannot be a doubt that liver-disease is, in truth, much more prevalent in the latter climate than in the former. Owing to particular circumstances those invalided for complaints of this kind from the West Indies are chiefly officers; and the much greater propor- tion of this class than of common seamen, in the invalid lists, might be considered as indicating some peculiar causes of hepatitis among officers in that country. Dr. Cheyne has some very sensible remarks on the feigned hepatitis of soldiers. He says that " when men who have not ueen in warm climates obstinately coirrlain of pain in the right hypo- chondrium, and when we cannot discover any en- largement or fulness of the liver, when the puise and breathing are undisturbed, the secretions and excretions natural, and when the alleged pain rp 134 FEIGNED^ sists topical bleeding and blistering, and mercurial purgatives, the sooner we send them to duty the better." Persons in this class often eventually succeed in their object of dismissal from the ser- vice, chiefly from the mistakes of the surgeon. " Such subjects," says Dr. Cheyne, " have often come under my care with their flesh and strength reduced by repeated courses of mercury, their gums absorbed, and teeth shaking in their sockets, whose livers were sound (probably they never were otherwise), but whose broken health required that they should be invalided without delay." (Loc. cit. p. 172.) 23. Hernia and Hydrocele.—Both these diseases have been frequently simulated. The means most frequently used to effect the object, is inflating the cellular substance of the scrotum. But more artful and more severe means have been adopted. Cases are related in the Act. Nat. Cur. of inflated bladders being applied to the scrotum to impose on the ignorant; and it is to the great discredit of the medical profession that some of its members have aided in the production of decep- tions of a more scientific description. In the year 1828, two medical men were tried in France for having respectively, produced in four conscripts swellings of the testicles. It was sworn by one of the conscripts that the operator injected into a wound made by him in the scrotum, a red-coloured liquid which gave him excessive pain. The ope- ration was followed by violent inflammation of the testis. The other operator applied caustic to the scrotum with the same result. This last indivi- dual, a surgeon of the name of Desplats, was sen- tenced to the pillory and five years' imprisonment. The practice of inflating the scrotum is much more common, because more easy. Sir Astley Cooper mentions the case of a man at Norwich who imposed on the surgeon by this means, and thus escaped serving in the army; and we have more than once seen the same plan adopted, but without success, by impressed seamen. A small blow-pipe, or the stalk of a tobacco-pipe, is the instrument commonly used. It is hardly neces- sary to say that no surgeon ought to be deceived by a case of this kind. Some men have the power of retaining the testes in the groin by the voluntary action of the cremaster muscles; and the swellings resulting from such a position of the parts have been mis- taken for hernia. (Hutchinson, loc. cit.) 24. Hydrocephalus.—Chronic hydrocepha- lus has been simulated, at least in one case which we shall quote from Sauvages, who terms the case, after Mangetus, physocepkalus artificialis. In the year 1593, a mendicant exhibited his child for gain as a monster, on account of the immense size of his head. This preternatural appearance was produced by the daily insufflation of air under the scalp, by means of a pipe introduced into a small perforation on the vertex. By this opera- tion, repeated for several months, the scalp at length became extended to an enormous degree. Being detected, this wicked father was condemned to death. (Nosol. Method, t. ii. p. 497.) 25. Hydrophobia.—One would hardly ex- pect that this disease should ever have been feigned. MM. Percy and Laurent, however, mention a case af the kind in a conscript, which, although terri- HSEASES. fying the examiners at first, was eventually cured by the threat of suffocation between two beds. 26. Incontinence of Faeces.---We have known this disease feigned. A boy on board the Desiree frigate pretended that he could not retain his fa?ces, and was frequently found voiding them on all occasions and in all places. Being deemed an impostor, he was severely punished, and at last confessed that he had been advised to do so by his aunt, that he might be discharged the service : this result he was very near obtaining. The following remark of Dr. Cheyne, relative to this pretended malady, is very judicious. " When a patient al- leges that he cannot retain the contents of the bowels, the sphincter ani ought to be examined, and if it contracts upon the finger, opium, with solid food must be prescribed, and a watch set over the individual: if he passes solid fa?ces in bed, he will be a fit subject for a court martial." 27. Incontinence of Urine.—It is somewhat singular that a disease so very rare as this is among persons not advanced in life, should be one very commonly feigned, more particularly by soldiers. This arises, probably, from the circumstance that the infirmity is easily simulated, and is one particu- larly inconsistent with the habits of neatness and cleanliness required in a modern soldier. This disease was extremely common among the French conscripts during Napoleon's wars. Its very fre- quency of occurrence among soldiers is in itself a strong presumption of imposition ; and if it makes its appearance at all in an epidemic form, we may be almost certain that it is feigned. MM. Percy and Laurent say they have had no fewer than fifteen pretended cases of this kind at one time in a recruit- ing depot; and Fodere witnessed its occurrence, almost in an epidemic form, in consequence of two soldiers having obtained their discharge on this ac- count. Dr. Cheyne notices a somewhat similar circumstance in an English regiment, in conse- quence of the facility the soldiers found in impos- ing upon a practitioner unacquainted with mili- tary practice. Independently of evidence derived from collate- ral circumstances, there are many means of de- tecting simulated incontinence. When the dis- ease is real, the clothes of the individual usually exhale a strong amnioniacal odour, which is not often the case when the disorder is feigned. The simulator commonly chooses the time and place which appear to him the best for wetting his clothes: if he sleeps with another person, he is more apt to wet his bed than when he sleeps alone ; and if he is furnished with clean straw to lie upon, he does not commonly wet it before the morning. In real incontinence, more especially if it has existed some time, the glans penis is stated by MM. Percy and Laurent to be pale and shrivelled, from being kept constantly wet with the urine which comes away guttatim; and Fo- dere says, if a ligature be passed round the penis in such cases, the urethra will soon be found dis- tended above it. It is evident, however, that this test cannot be depended upon. In the Austrian army, a man who alleges that he has incontinence of urine is furnished with a urinal, and obliged to do his duty. In the French army it was custom- ary to compress the penis between two pieces of wood ; and Fodere informs us that he succeeded FEIGNED DISEASES. 135 in putting a stop to a fictitious epidemic of this kind by applying a sealed ligature to the penis, which was only allowed to be undone by a person appointed for the purpose. MM. Percy and Lau- rent prescribed with perfect success in a case of this kind, twenty lashes on the loins, with the avowed object of strengthening the debilitated part; and the surgeon of a regiment mentioned by Dr. Cheyne, speedily put an end to a pretended epidemic of the same kind by prescribing a cold bath twice a day in Lough Neagh. Such means as these, with blisters to the perineum, and other appropriate but disagreeable remedies, will almost always put an end to this alleged disability, even when we have not been able to demonstrate to the simulator himself that we have detected him. When this is once effected, there is never any dif- ficulty in curing any feigned disease. The most effectual mode of detecting simulated incontinence is that prescribed by Mr. Comyns, an army sur- geon, and afterwards by Dr. Hennen and Mr. Hutchinson, viz. to administer a strong opiate at bed-time, and to watch the length of time the urine is retained during sleep ; or to introduce the catheter unexpectedly, to ascertain the quantity of urine found in the bladder. In real inconti- nence, the bladder will not retain its contents after a certain time during sleep, or under any other circumstances. The following ingenious method was successfully used by an army surgeon to de- tect and cure a fictitious infirmity of this kind. The surgeon having ascertained from the patient how long he could retain his urine, (of course a very short period,) caused him to undress and stand before him with the abdomen exposed. Upon observing the abdominal muscles called into action to aid in the expulsion of the urine, he suddenly and forcibly thrust his fingers against the belly so as to prevent the voluntary muscular effort. This he repeated as often as he saw the action renewed, until the alleged period of expul- sion was long passed. He then dismissed the pa- tient with the remark that he had retained his urine long enough to enable him to do his duty. The opposite state of retention of urine has been sometimes feigned, more particularly by fe- male convicts. A strict watch will always detect such an imposition. 28. Jaundice.—The yellow colour of the skin in this disease has been simulated by painting it with an infusion of curcuma or tincture of rhu- barb, &c.; and it is said clay-coloured stools have been imitated to perfection by taking daily a small quantity of muriatic acid. What it is impossible to feign or to form, however, is the yellow colour of the conjunctiva, and the want of this will al- ways detect the imposition. It will rarely happen that a simulator will be so ingenious as to produce, at the sanfe time, the yellow skin, the pale stools, and the dark-coloured urine. An ingenious de- vice for altering, at least, if not rendering yellow, the conjunctiva, was that of a French conscript, who always put snuff in his eyes before the sur- geon's visit. (Diet, des Sci. Med. loc. cit.) 29. Madness.—Mental derangement, in some of its forms of idiocy, melancholia, or mania, has been in all ages assumed as a means of attaining certain objects of desire. The names of many persons famous in ancient and modern tim^s are associated with this imposture. Madness is mosst commonly feigned in civil life by prisoners to escape punishment. In the army and navy, and among slaves, it is feigned with the same object, as well as to escape from disagreeable labour; but in the army and navy it is still more commonly feigned with the view of obtaining a discharge from the service. In the latter department of the public service, during the late war, in which so many hearts were broken by the hope too long deferred of returning home, every surgeon of ex- perience met with instances of simulated insanity; and it was equally common among the numerous prisoners of war detained for so many years in this country. All the forms of disordered intellect were feigned ; but the most common was that of furious madness, assumed with the view of effect- ing a temporary purpose, such as the evasion of punishment, the removal to an hospital, &c. When the design was to obtain a discharge from the service, melancholia or idiocy was the form adopted. In several instances the simulators suc- ceeded in gaining their ends; in many others they were detected; and we fear that in not a few instances real insanity was mistaken for feigned, and the patients were treated as impostors. This fact ought to lead the medical officers in the pub- lic service to study with great care the indications of insanity, and ought moreover to induce them, whenever there is a shadow of doubt, to lean to the side of mercy. It is infinitely better that they should be deceived, than that a poor wretch, al- ready suffering under the most grievous of natural calamities, should undergo additional misery from their ignorance. The discrimination of the fictitious from the real disease is not always so easy as those who have never witnessed both are apt to imagine. It is true that when we consider the very peculiar and complex phenomena which characterize true madness, and reflect on the general ignorance of those who attempt to imitate them, we have no right to expect such a finished picture as could impose on persons well acquainted with the real disease. And yet when, on the other hand, we consider how imperfectly the operations of the in- tellect, both in a state of health and disease, are known to medical men in general, and how few opportunities the medical officers in the public service have of observing the phenomena of in- sanity, and reflect how natural it is for the feelings of honourable men to take the part of ostensible distress, it need not surprise us that the pictures drawn even by such rude hands have imposed on educated minds. But it is less because fictitious madness has been treated as real, than because real madness has been treated as fictitious, that we are so anxious to direct the attention of iunior medical officers in the army and navy to the study of the characteristic features of the disease. These can be only thoroughly studied in the receptacles for the insane, but much knowledge "f import ance may be derived from books. Referring tht reader to these sources, we must content our selves in this place with a few general observa tions. The form of madness that can be assumed with most facility is that of furious mania ; and yet the cases of this which we have witnessed have been 136 FEIGNED all lamentably defective as imitations of nature. The actors always overdid their part. They sought to personify the notion of madness usually enter- tained by the vulgar, viz. the total abolition of the rational faculty, instead ot its partial perversion. It is still more difficult to simulate the quiet half- rational insanity of the melancholic or monoma- niac ; as nothing but careful observation of persons so affected can qualify an individual for such a difficult task. This statement might be illustrated in a curious and interesting manner by a reference to the writings of poets and novelists. Such per- sons are obviously much better qualified to paint the disease now under consideration, than the ignorant soldier or sailor; and yet it would not be difficult to point out, in the numerous delineations of insanity presented by authors, such glaring de- viations from nature as could not fail to strike any one versed in the history of the disease. Shakspeare, Goethe, and a few others perhaps, might stand the application of the severest test; but the common class of writers who have attempt- ed such delineations have failed completely. Idiocy has been more successfully imitated; and, perhaps, this may be accounted for by the opportunities which most men have enjoyed of studying the character in the instance of the poor idiot, still to be met with at large in almost every village. Conscripts have pretended that they were incapable of being taught the commonest duties of a soldier; and we knew an instance of a young player, drafted into the army, who acted the part of an idiot so effectually that he soon obtained his discharge. Almost immediately after this he en- listed into another regiment, and then deserted. Independently of the mental phenomena of in- sanity, there are many physical conditions of the system often present in this disease, which it is hardly possible to feign, such as the expression of the countenance, the state of the eye, of the tongue, &c. One very common symptom, and one indeed invariably present in the earlier stages of furious mania, and in most of the forms of monomania, is sleeplessness; and this it is hardly possible for any man to feign. A real madman will be many days, even weeks, without sleep. This circum- stance, alone, if properly taken advantage of, will suffice to detect most impostors; and in order to derive from it all the advantages which it is capa- ble of yielding, a strict and uninterrupted watch should be kept on all patients who are suspected of imposition. In the case of a seaman who en- acted under our own eye the part of a furious maniac, in hopes of escaping punishment, sound steep overpowered him on the second night of his attempt. Abstinence from food is another circum- stance respecting which there will often be ob- served a marked discrepancy between the real and the pretended madman. A strict watch will also generally detect in the simulated disease, great variations of violence, incoherence, or other symptoms, having reference to the visits of the medical officer, the being over- looked, &c. A pretended maniac will often be tranquil when he believes himself alone, or only in the presence of those of whose opinion he is regardless. A bold and clever dissembler will, however, not leave himself thus exposed to detec- tion. We are informed by a gentleman, once in DISEASES. charge of French prisoners of war in this country, that he has known men (afterwards detected and admitted on their own confession to be impostors) carry their simulation to so exquisite a height as to eat their own excrements, even when shut up in their cells, suspecting they might be over- looked. Real madness is seldom sudden in its attack; feigned madness very generally is so. The real disease usually exhibits itself at first in slight and almost imperceptible deviations from the habitual modes of thinking and acting, not reaching its height in many cases until after a progressive in- crease of months, or even years; although, per- haps, the change at last from a comparatively slight degree of hallucination to extreme violence has been sudden. The feigned disease, on the contrary, is rarely preceded by such indications, but bursts out in full violence at once, upon the application of some exciting cause. And yet this rule is not without exception in both cases. We have seen instances of sudden and furious insanity in civil life, without any premonitory sign. The circumstances under which the alleged in- sanity has supervened, the man's previous charac- ter, the probability or improbability of the disease being assumed, and many other obvious consider- ations, will all materially assist the diagnosis. For instance, if we find a man not previously liable to be so affected, nor hereditarily disposed to insa- nity, suddenly exhibit the appearance of this dis- ease, under an impending trial or punishment, or other threatened evil, which might be averted by such a state, there is certainly a presumption in favour of the disability being feigned. It is, how- ever, to be borne in mind, that the very same ap- prehension of exposure, disgrace, or punishment, which affords motives for simulating insanity with the view of escaping them, may give rise to the real disease. Instances of this kind have been mentioned to us as occurring in the public ser- vice, and it would be easy to supply others from history and the records of jurisprudence. For this reason, and because we believe, with Dr. Cheyne, on other grounds, that " we are in more danger of supposing insanity simulated when it is real, than of considering that disease to be real when it is only pretended," we must strongly protest against the decision in any case, that the disease is feigned, solely because there appears a strong reason for its being so. Taken in conjunction with the actual phenomena and other collateral circumstances, the consideration of the probable motives will, however, no doubt, in many cases- greatly aid the diagnosis. The existence or non-existence of causes known to predispose to insanity will be considered in every particular case, and they will have, their due weight. Of this kind are previous attacks of the same malady, under circumstances where there existed no apparent motive for deceit; the exist- ence in the patient's family of a similar disease; eccentric habits, or what may be termed the ma- niacal temperament; a decidedly strumous habit; the application of strong exciting causes of a mo- ral nature; physical disorders, especially such as are known to affect the brain, as prolonged intoxi- cation, previous injury of the head, the repression of cutaneous eruptions, &c. &c. FEIGNED DISEASES. 137 It is well remarked by Dr. Cheyne, that in real insanity there is often the greatest insensibility to decency, propriety, and comfort, evidenced by the grossest language in persons previously of very pure minds, by exposure of trie person, spitting heedlessly in all directions, passing the excrements in bed, or plastering them on the walls of the cell, &c. circumstances not likely to exist, at least in the same degree, in simulated cases. Yet this only affords us collateral aid in the diagnosis. Fo- dere has related the case of a young woman, un- doubtedly a pretender, who committed every kind of indecency in her cell; and the miserable trait formerly noticed, of a prisoner of war devouring his own excrements, is a convincing proof that nothing is too disgusting to appal a determined will. In addition to the means of diagnosis supplied by the actual phenomena of the malady, by its previous history, and by other collateral circum- stances, we have, in suspicious cases, a very im- portant means in the institution of plans calcu- lated to outwit an impostor or to overcome his ob- stinacy. Many harsh measures have been had re- course to in the army and navy, with this view, which are altogether unjustifiable, except in cases of the clearest imposture. In no case, however suspicious, is the medical practitioner authorized to go beyond the employment of means of a strictly professional kind. He may, indeed, use all the artillery of annoyance supplied by medi- cine, and he may even threaten extra-professional infliction, but he must never go beyond this line. When convinced of the imposition in the case of a soldier or sailor, it is the duty of the medical officer to state his opinion to his military supe- riors ; the punishment of such a crime is altoge- ther foreign to his station and profession. Still, both the threat and the actual infliction of punish- ment have often put an end to simulated madness. In a case which occurred in the navy, a sailor who evinced a great desire to throw himself over- board, but was for a time prevented, at length succeeded in doing so ; immediately on reaching the water, however, he began to swim vigorously, and called loudly for a boat. Upon being taken on board, his madness had disappeared, and it did not return. The practice of former times would sanction a conjecture that this might be a case of real insanity cured. In the case of the girl men- tioned by Fodere, his informing the keeper in her presence that on the morrow a hot iron would be applied between the shoulders if she was not bet- ter, was immediately followed by great amend- ment. Actual punishment has often been advised, and even employed, where there existed merely suspicion of imposture; and, although condemn- ing the practice, we must admit that it has fre- quently been successful in detecting deceit. Zac- chias relates a case in which a physician recom- mended corporal punishment, on the principle that, if the madness were simulated, the cheat would not stand the test, and if it were real, the flagellation would do good as a derivative; and the event proved the accuracy of the first opinion. (Fodere, p. 460.) The same means, however, and others equally severe, have often been em- ployed without such a fortunate result, in equally suspicious cases. Examples of this sort, we have Vol. II___18 m* reason to know, were by no means extremely rare in the army and navy, during the late war. A melancholy instance of real insanity treated as feigned is related in Mr. Marshall's Hints to young medical Officers (p. 140); and we could enume- rate others of a similar kind which occurred in the navy. Some cases have come to our knowledge where deception was believed and punishment inflicted, yet, in which evidence of the reality of the dis- ease was most conspicuous. In one of these, which occurred on board H. M. ship-------, two circumstances ought at once to have opened the eyes of the surgeon, viz., the periodical recur- rence of the affection, and the total sleeplessness that prevailed during the paroxysm. They were also, we suspect, much less uncommon in civil life formerly, when the execution of the laws against vagrants was more summary than at pre- sent. In this, as in all other feigned diseases, im- pressing the impostor with the hopelessness of his attempt to succeed in gaining his object, will be found the most effectual means of putting an end to the simulation. A few words inten- tionally dropped in the patient's hearing, but as if incidentally, expressive of the expectation en- tertained by the medical attendant that the case would be cured, and of intended perseverance in the treatment then pursued, have often proved prophetic. We have known instances of a stop being almost immediately put to simulated mad- ness, by sending the soldier to the depot for the insane. It is fortunate that the very treatment most suit- able to the recovery of persons really deranged is that which is most intolerable to the impostor. None but the most determined characters will be long able to resist the horrors of solitary confine- ment, bread and water, and the constant pain of blisters and other counter-irritants. Seclusion is particularly necessary in all such cases, as nothing tends so much to keep alive the hopes and the courage of the impostor as the consciousness that his raving is heard by his fellows, and the belief that an impression favourable to his views may be made on the minds of his officers, by the contin- ued exhibition of his miserable state. 30. Malformation.—Deformity, such as cur- vature of the spine, elevation of one shoulder, shortness or distortion of a limb, inversion of the feet, &c, are occasionally simulated by soldiers, and sometimes with so much success that they obtain their discharge on that account. It may be said that a man who feigned deformity would readily be exposed by a medical practitioner who is intimately acquainted with the healthy configu- ration of the human body. This opinion seems to be well founded, yet cases occasionally occui from which it would appear that a simulator of deformity is not easily detected. We are ac quainted with more than one instance where a board of medical officers have recommended re- cruits to be discharged from the army on account of alleged great deformity, but who were, in fac, remarkably handsome well-made men, and aftei- wards enlisted and were approved for service. 31. Needles in the Body.—Among the \« rious factitious disabilities, induced or voluntarily 138 FEIGNED DISEASES. submitted to by patients, the singular one of the introduction of needles into some part of the body deserves particular notice. The two fol- lowing cases will point out the character of this affection. In July, 1818, a young woman was admitted into Richmond Hospital, Dublin, on account of a painful swelling of the left hand and arm, some- what resembling that which occurs in phlegmasia dolens. The inflammation continued to increase, diarrhcea supervened, and her general health be- came greatly impaired from the constant pain and irritation of the disease. Amputation was per- formed close to the shoulder-joint, on the 21st of September. On examining the arm, eight or nine needles were found in the palm of the hand and forearm. The cause of the inflammation was now evident. This woman eventually confessed that she herself introduced the needles into her hand and arm, and she would assign no other rea- son for so doing but that she was tempted by the devil. An unwillingness to labour so as to pro- cure a livelihood seems to have been the efficient cause of her exciting inflammation for the pur- pose of being admitted into an hospital. For several years after her arm was amputated she was employed in Richmond Hospital as a servant. (Phrenological Journal, vol. ii.) The case of Rachel Hertz is perhaps still more remarkable. At about the age of fourteen, on the 16th of August, 1807, this woman became a patient of Professor Herholdt of Copenhagen. From this date until February, 1819, she suffered under a variety of anomalous complaints, and especially an affection resembling hysteria, or epi- lepsy, or both. About this time a tumour appear- ed near the umbilicus ; and being opened, a nee- dle was extracted from it. From the 12th of Feb- ruary, 1819, till the 10th of August, 1820, a pe- riod of eighteen months, this woman had a num- ber of abscesses formed in different parts of the body, from which two hundred and ninety-five needles were at different times extracted. Her superior and inferior extremities became paralytic, and continued so for a long period ; but she event- ually recovered. Swellings, or abscesses, contain- ing needles, continued to appear from time to time ; so that from the 28th of May to the 10th of July, 1822, one hundred were extracted, alto- gether amounting to three hundred and ninety-five. It was supposed by Professor Herholdt and Dr. Otto, that she had swallowed the needles during her paroxysms of hysteria or epilepsy ; but the truth was ascertained in a very simple manner. A young girl was observed in the act of introduc- ing needles under the skin of her arm ; and being asked who had taught her that trick, her answer was, that she had seen Rachel Hertz introduce needles under her skin. 32. Ophthalmia.—Factitious ophthalmia is, we believe, rare in civil life. It was very frequent among the French conscripts during the late war ; no fewer than twelve per cent, of the inefficient conscripts belonging to the department of the Seine, during a period of ten years, were rejected on account of " impaired vision—diseases of the eyes." During the first ten or fifteen years of the present century, inflammation of the eyes prevail- ul to a great extent in some regiments of the British army, and there is much reason for sup- posing that factitious ophthalmia was then fre- quent. The following is one of the most exten- sive instances of factitious ophthalmia that has come to our knowledge. In the year 1809, three hundred of the men of two regiments which were on duty at Chelmsford, became affected with oph- thalmia. The healthy men of the corps were re- moved to another station, and the sick remained in hospital, but under military command. Infor- mation having reached their commanding officer that one of the nurses of the hospital was in the habit of going to a druggist's shop for the purpose of purchasing medicines, suspicions were excited; and in conjunction with the medical officer in charge of the hospital, he made a successful at- tempt to discover whether the men had any drugs in their possession which might be employed to excite inflammation of the eyes. Accommodation having been provided for about twenty-four men, the number contained in one ward, at midnight the officer made his appearance in the hospital; the men were roused from their beds and forth- with marched in a state of nudity to the new ward. The old ward was secured for the night; and next day when the beds were examined, a number of small parcels of corrosive sublimate were found concealed. Means were taken to pre- vent a supply of this article, and in a very short time two hundred and fifty of the men had re- covered, and were then marched to their respec- tive corps. The means that have been known to be used by soldiers to produce ophthalmia, besides the above, are powdered alum, snuff, salt, lime, tobacco-juice, &c.; also, mechanical irritation of the eye by hard bodies, extraction of the eye-lashes, &c. Presumptive evidence is, in general, all that can be obtained respecting the production of this dis- ease ; but many circumstances are calculated to excite suspicion in the situations where it is likely to exist. Among soldiers it has been found that the right eye has suffered chiefly, because this is the important organ to a modern man of war. The extreme rapidity of the progress of the in- flammation in the factitious ophthalmia is often a guide to the real nature of the disease : it some- times reaches its acme in a few hours, a circum- stance never observed in the natural disease. It is much more difficult to detect the disease in a chronic state. It is not improbable that the de- struction of the eye among soldiers has been pro- moted by the large pension which government has allowed to those who are discharged on ac- count of impaired vision. Formerly every man who became blind of one eye was discharged and received a pension for life of ninepence per day. This usage is, however, amended in the new pen- sioning warrant; for it is there ordered that " no soldier shall be discharged for the loss of one eye, whether it be the right or left." This regulation, if put effectually in execution, will in all proba- bility lead to a great diminution of the prevalence of ophthalmia in the army. When the disease is once detected, the cure of it is obvious; but much difficulty is often experi- enced in putting an end to it where it is merely suspected. When perfect seclusion cannot be ob- tained, as in the navy, a strait-waistcoat has FEIGNED DISEASES. 139 been used to prevent the patient tampering with his eyes. (Hutchinson, loc. cit.) 33. Pain.—There is perhaps no morbid affec- tion more frequently feigned than this; among the disabilities assumed for the purpose of obtain- ing a mere temporary object, there is certainly no one so often met with. It is the usual resource of the worthless and mean-spirited among soldiers, sailors, and slaves, to obtain a few days' respite from labour. The vulgar see little in real disease but pain, or they at least look upon pain as the common symbol of disease, which they regard as something superadded to and existing separately in the body. They constantly describe any chronic ailment as an entity ; " it goes here, it flies there, it works in the bowels," &c. These flying or mi- gratory pains are very common among soldiers and sailors, and are known by the cant name of " the all-overs,-" they are readily detected by a little art. If the surgeon listens attentively to the narrative, and begins to catechise his patient with apparent simplicity and good faith, he may bring him to admit the existence of any symptom however absurd, and thus to betray himself. By the more cunning and more resolute the ex- istence of severe pain, fixed in some particular spot, is feigned with more success, and often in- deed with astonishing constancy. Many instances are recorded, and several have come to our own knowledge, where individuals have supported their assumed character for a long period, under every privation and much real suffering. A re- markable case of alleged pain in the mamma, in a female mendicant, is related by Lentin, (Beytraege zur ausubenden Arzney wissenschaft, Leipz. 1797,) which could only be admitted as feigned on the clearest evidence. This woman went so far as to solicit, and at length to obtain, the amputation of first one mamma and then the other; and, not content with this, she afterwards wished one of her hands to be amputated on account of a similar pain, of which she alleged it to be the site. This woman was proved to be an impostor in respect of part at least of her alleged maladies ; and she was considered by Dr. Lentin and other compe- tent judges as equally so in regard to the pain. The following cases related by MM. Percy, Lau- rent, and Fodere, are remarkable examples of the same kind. A young man having been deceived by a re- cruiting officer, who promised that he should be made an ensign on his joining the regiment, formed the resolution of attempting to obtain his discharge by simulating disease. He complained of having a deep-seated pain in the left knee-joint, on ac- count of which a great variety of remedies were applied, including blisters and moxa. The leg became by degrees extenuated, and he was sent to the baths. At last, after being four years under medical treatment, he obtained his discharge. Upon leaving the hospital, some of his comrades accompanied him a little way on the road, whom he treated with wine; and before they parted he took off the wooden leg he had worn for three years, and threw it into the fire, saying, at the same time, " they deceived me, and I in my turn have deceived them." A soldier came under Fodere's care in the hos- pital of Martigues, complaining of a violent pain in the left teg, which he represented as arising from his having slept on the damp ground. During a period of eight months the most severe and painful external applications were made, and medicines given internally without effect. He still continued in bed, being unable, as he said, to stand. The leg having become wasted from the repeated use of blisters and issues, and apparently shorter than the other, arid he being moreover pallid and emaciated in consequence of the severe regimen to which he had been subjected, Fodere at length obtained his discharge. While waiting for this, however, he was one day detected march- ing without any assistance, and, being taken up, at last acknowledged the imposition. (Op. cit. p. 473.) Pains are also frequently feigned in the internal cavities of the body; and probably these may often be more easily detected than such as are alleged to have their site in the external parts, inasmuch as pains of a simply nervous character are perhaps of less frequent occurrence in the former situation, and pain depending on other causes will be accom- panied by other appropriate symptoms. Still it must be admitted that detection in cases of this kind is more likely to be obtained through means of collateral evidence than by the absence of posi- tive and sensible indications of disease. Every experienced practitioner has witnessed cases of most severe pa.n in almost every part of the body in persons who could not be suspected to feign ; and the whole history of that great and increasing class of diseases termed Neuralgias is but a melan- choly testimony in favour of the possibility of real pain being unmarked by any certain external signs. Too often, we fear, has the absence of symptoms in such diseases been the cause of great additional suffering to the victims of neuralgia in the public service ; and we cannot more emphatically im- press on the mind of the young medical officers in the army and navy the necessity of caution in such circumstances than by relating the following cases. A young soldier, under the care of Fodere, com- plained of violent pains in various parts of his body, now in one limb, now in another, in the chest, head, &c, unaccompanied by any other symptom. Considering these pains as fictitious, Fodere refused to give the man his discharge; but he nevertheless died in the hospital without any new symptom. " After his death," says Fodere, " I anxiously explored, by means of the scalpel, all the old seats of the pains, but could discover no- thing, in the membranes, the muscles, the nerves, or the viscera ; and I was forced to believe that life had been destroyed by the long continuance of the pains. Since then," the author adds, " I have often preferred rather to be too lenient than to run the hazard of being again unjust." (Med Legale, t. ii. p. 471.) A seaman on board one of His Majesty's ships applied to the surgeon, complaining piteously ot a pain in his shoulder preventing the motions oi the arm. He could assign no cause for it, alleg ing that it came of itself and gradually increased to its present violence. No external mark could be discovered, and it being suspected to have arisen from some slight strain, it was ordered that the part should be rubbed with a common liw 140 FEIGNED DISEASES. ment. This was continued for a fortnight with- out relief; blisters were then applied and kept up for another fortnight. There still appearing no external sign of disease, the surgeon, suspecting imposition, ordered the man to move his arm before him. The poor fellow hesitated, and, beg- ging to be spared, was allowed to rest for a few days, when the arm was forcibly moved by an- other person. It was in vain that the man en- treated them to spare him ; the surgeon, confident in his fancied knowledge, and resolved to punish what his nosology told him was imposture, ordered a rope and a weight of eighteen pounds to be brought; he was commanded to swing the one, or to bear from the other the punishment which his alleged crime deserved. He implored, he hesitated ; when the rope, laid on with no slight hand on his shoulders, made him seize the weight; but scarcely had he freed it from the deck when he was forced by pain to throw it down. This scene was exhibited for some time, and sullen resentment at length getting the better of patience, gave additional force to the surgeon's opinion. The man was about to be returned to his duty, and to be punished as an impostor, when a fatal evidence appeared to testify against the sentence of his cruel and ignorant judges : a slight swelling showed itself on the part with signs of fluctuation; it was laid open, and puru- lent matter, to the extent of nearly two pounds, was discharged ! In this case, which we know to be authentic, ignorance was as conspicuous as barbarity. Such a scene could hardly occur in these days, and we heartily trust it never may in those which are to come. (See Med. and Phys. Journ. for January, 1808, vol. xix. p. 1.) 34. Paralysis.—Palsy is frequently pretended among mendicants, and it is also occasionally feigned in the army and navy. The pathogno- monic symptoms of palsy commonly involve some organic alteration, which it is scarcely possible for a man to simulate with success if his case be care- fully investigated by well qualified persons. The fact, however, that impostors have been successful, is a sufficient warning to medical practitioners to devote much attention to the examination of doubtful cases. Coche, a French surgeon, who has given much of his attention to feigned dis- eases, says, «la simulation de cette maladie (palsy) n'est que ridicule;" but experience has proved that, however ridiculous, it has often been successfully practised. Dr. Cheyne mentions sev- eral cases of this kind, in two of which the pre- tended paralytics evinced ludicrous proofs of their still possessing the use of their limbs immediately after they had succeeded in gaining their dis- charge. It ought always to be considered a very suspicious circumstance in a soldier or sailor if the loss of power is confined to a single limb, as the arm, as such a form of paralysis coming on in adults is extremely rare. In a case detected by Dr. Cheyne, his opinion of the disease being feigned was chiefly founded on the following considera- tions • because there coexisted no other signs of disease ; because the countenance indicated health and intelligence; because the function of the brain was undisturbed, and all the senses were entire; be- cause paralysis of the arm is a complaint frequently feigned bv soldiers but verv rare in reality. Feigned paralysis has been frequently detected by subjecting the patient to a powerful electric shock. A case occurred in the New York state prison which resisted all medicines until this re- medy was tried. Upon receiving the shock the patient jumped up, ran into the hall, and asked for his discharge from the hospital. (Dunlop's Beck, p. 12.) Mr. Hutchinson detected animpo- sition of this kind in a sailor, by administering a dose of opium to the patient, and then tickling his ear during steep ; to relieve the irritation " the paralysed hand was instantly raised to the ear, which he rubbed with no small degTee of force, and then turned round upon his left side, dragging the bed-clothes over him with his heretofore use- less arm." Of course the discovery was complete. The editor of the journal in which Mr. Hutchin- son's essay first appeared mentions a similar case in a soldier detected by the same means : in this case the sound arm was previously bound down to the side, under pretence of thereby benefiting the disabled limb. (Med. and Phys. Journ. liv. p. 93.) Shaking palsy is simulated chiefly by mendi- cants. When the general health appears to be good, little attention need be paid to the shaking. For the diagnosis of this disease see the article Pakalysis. 35. Phthisis.—It could scarcely have been imagined a priori, that a disease like phthisis, at- tended with such a complexity of symptoms, and marked by such conspicuous alteration of the ex- ternal parts, would have ever been chosen as a subject of the malingerer. The following extract from Dr. Cheyne, however, will show that this has really been the case; and as this form of simula- tion has never come under our view, we shall con- tent ourselves with the remarks of this excellent observer :—" The soldier, not content with repre- senting one feature of consumption, will often undertake a perfect portrait of that disease, and this he will sometimes execute with great clever- ness. The thought would seem to strike him while in the hospital under treatment for catarrh, or recovering from fever accompanied with pulmo- nary irritation. His cure all at once seems sus- pended ; his food, he says, stuffs him, and he begs to be replaced on spoon or milk diet ; he coughs much at the period of the daily visit; he sup- presses his cough for some time previously, so that if there is any defluxion, it may be expectorated at that period. He expresses a wish to be let blood or blistered for a pain of the chest; begs for some medicine to relieve his cough; applies for a furlough; in short, so well does he act his part, that unless the surgeon is very circumspect, he will discover, when too late, that he has been made a dupe of. (Loc. cit. p. 160.) It is needless to observe that a thorough ac- quaintance with all the phenomena of the real dis- ease will enable any one, who is on his guard, to detect an imposition of this kind. Auscultation will be, in such cases, a most powerful, and fre- quently an infallible means of ascertaining the truth. s 36. Polypus of the Nose---This has been imitated by the matchless ingenuity of the French conscripts, by introducing the testes of cocks and hares kidneys into the nostrils. (Percy and Lau- rent, op. cit.) FEIGNED E 37. Pompholyx.—This affection of the skin is sometimes simulated by the application of blis- tering plaster. The imposture may often be de- tected by carefully examining the vesicles, as parts of the flies are apt to adhere to them. In a young woman who lately produced this affection in order to retain her comfortable position in an infirma- ry, this was the case; and, upon examining her box, small fragments of blistering plaster were found secreted. 38. Pregnancy.—An impregnated state of the uterus is sometimes pretended, to gratify the wishes of relations ; to deprive a legal successor of his claim ; to extort money ; to obtain a re- mission of labour; or to delay the execution of punishment. A medical practioner, who has to give an opinion on a doubtful case of pregnancy, would require to make himself intimately acquaint- ed with the signs of real pregnancy, and he ought especially to consult the best works on legal me- dicine. Auscultation promises to be the most suc- cessful means of discovering whether an alleged case of pregnancy be real or merely pretended. (See Atjscultatiox.) Pregnancy is very frequently feigned by negro slaves in the West Indies with the view of ob- taining ease ; as masters are accustomed to indulge them, when pregnant, with repose from the se- verer kinds of labour. Besides the assumption of the sickness and other common symptoms of preg- nancy, they place pads on the abdomen to deceive the sight. When they apprehend a discovery, they pretend that they have had an abortion, and often speedily re-commence the same course of decep- tion. They know by experience that it is an easy matter to feign the early symptoms of pregnancy. A case of simulation of this kind, which was car- ried to a very refined pitch, was mentioned to one of the writers of this article by the gentleman on whose estate it occurred. A female, whose re- peated alleged abortions had excited the suspicion of the overseer, and who was assured that nothing short of ocular demonstration would obtain belief, had the ingenuity to mutilate and prepare a lizard so as to deceive her cunning inquisitor. This im- position, however, was afterwards completely de- tected. These pretended gravidae ate occasionally locked up some months before the expected period of delivery; and instances have been known where they have remained confined for many months after this period has passed. 39. Prolapsus Ani.—This disease has been simulated by partially introducing into the anus a sheep's bladder or gut containing blood, leaving a portion externally to represent the prolapsed rec- tum. Ambrose Pare mentions a case of this kind ; and the authors of the article in the Dictionnaire des Sciences Medicates another. 40. Rheumatism, Lumbago, &c. — This class of disabilities is frequently feigned by the members of benefit societies, and by soldiers and sailors when they wish to evade a particular duty or to procure their discharge. Rheumatism, when severe, is commonly marked by some functional derangement or organic alteration, which it is difficult to simulate successfully. With respect to soldiers and sailors they ought very rarely to be discharged on account of alleged rheumatism, &c. &c. unless in cases where there is an obvious HSEASES. 141 organic change, such as great extenuation of a limb or nodosity of the joint. As in the case of simple pain, it is often difficult to discriminate these fictitious cases of rheumatism from the real disease. Still an attentive observer will in most cases be able to detect the feigned disease. The following remarks by Dr. Cheyne on this subject are very judicious, and well deserving the attention of military and naval practitioners: — " Chronic rheumatism is distinguished by some disorder of the digestive organs, impaired appetite, a look of delicacy, a degree of pyrexia in the even- ing, yielding in the latter part of the night or early in the morning to perspiration. Some emaciation, wasting of the muscles of the affected limb, fulness of the veins, and puffy enlargement of the affected joint, take place. There is in general an increase of the temperature of the affected part. These symptoms are much influenced by the state of the weather, and they in some degree yield at length to proper treatment; whereas those who feign this disease usually retain their appetite and looks; have no diurnal return of fever, and.no inflamma- tory symptoms. They give a glowing account of their sufferings, alleging that they have entirely lost the use of the part affected, which seldom happens in genuine rheumatism. There is for the most part no adequate cause assigned for the com- plaint ; no relief from remedial treatment is ac- knowledged ; and while real rheumatic affections are aggravated by damp, the impostor complains equally at all times." (Op. cit. p. 175.) 41. Short Sight. — This being a state of vision easily feigned, and, when real, incapaci- tating the subject of it for the duties of a soldier, is one of the most common disabilities pretended by unwilling recruits. It is also assumed by sol- diers in order to obtain their discharge. During the operation of the French conscription, and particularly in the early part of it, before effective means of prevention were taken, short-sightedness was feigned to a singular extent by the young conscripts. In the department of the Seine, of every thousand conscripts who were exempted from service in consequence of disabilities, from the year 1800 to 1810 inclusive, fifty-eight were excused in consequence of being near-sighted. At last the alleged disability became so common that a law was passed forbidding men to be exempted on this ground ; and all such persons were ordered to be employed as pioneers, hospital-servants, &c. Besides being assumed where it does not exist, this defect can be produced by the habitual use of concave glasses ; and this practice was exten- sively adopted by the young men in France liable to serve. In short-sighted persons, the crow-feet wrinkles at the corner of the eyes are strongly marked, and there is an habitual frowning or knitting of the brows ; but these signs are by no means unequivocal. The surest tests are enforcing the employment of concave glasses suited to the exact degree of imperfection assumed by the simu- lator, and putting him to read a book quite close to the eye. If able to read a book in this position without the glasses, and unable to read with the proper glasses at a corresponding distance, we may be almost certain that the disability is feigned And yet even in this we may be mistaken. MM. Percy and Laurent mention a young sdiooieiaster. 142 FEIGNED DISEASES who, in expectation of being some day drawn for the army, practised reading with all kinds of glasses beforehand, and when he was drawn he obtained his exemption without difficulty. When any doubt is entertained regarding the existence of this defect, the most advisable measure is to follow the example of the French government, and place the individuals in situations where long vision is less necessary. This disability is rarely feigned by sailors, because, if real, it would not incapacitate them for the duties required of them. 42. Somnolency. — Occasionally persons al- lege that they are unable to undergo any fatigue, and sometimes that they are incapable of muscular motion on account of a constant and irresistible sleepiness. Dr. Hennen has recorded a most ob- stinate case of this kind. (Military Surgery.) Another case is detailed in the Edin. Ann. Reg. vol. iv. The subject of this case was a soldier in the Somerset militia, and only eighteen years of age. He had been confined for desertion. From the 26th April to the 8th July, 1811, he lay in a state of apparent insensibility, and resisted every means which it was deemed advisable to attempt for the purpose of rousing him. These means consisted of thrusting snuff up the mostrils, elec- tric shocks, &c. &c. It was at last conjectured that the torpidity might be owing to a fall, where- by his head might have been injured, and the operation of dividing the scalp was performed for the purpose of ascertaining whether there was not a depression of the cranium. The requisite inci- sions were made, the scalp was drawn up, and the skull examined without a word of complaint. When the instrument destined to scrape the bone was applied, he once, and only once, uttered a groan. As this case seemed to be hopeless, the man was discharged and conveyed to his parents. Two days afterwards, he was seen two miles from home, cutting spars, and carrying reeds up a ladder. The following case of feigned somnolency, or loss of sense, is a good example of the obstinacy with which the symptoms of disease may be simu- lated for the purpose of avenging an injury, or to obtain unjust compensation. A clergyman hear- ing his wife and servant-maid disputing in the kitchen, went below, and interfered so far as to repel some rudeness offered by the girl to her mis- tress, which he did by pushing her to one side. The girl fell against the dresser, either by accident or design, whereby she received a slight contusion over her eye. She then ran to the street-door, and told the people that she had been almost murdered by her master; and to corroborate this assertion, she fell apparently into an epileptic fit. Shortly afterward she was conveyed, as one ex- piring, to an hospital, and the clergyman and his wife were dragged to jail. The windows of his house were broken, his furniture was thrown into the street, and an account of the dreadful murder cried over the whole town. The girl lay for ten or twelve days without showing the least sign of sense or recollection. Mr. Dease having been called into consultation, soon detected the impos- 'ure, and the woman almost immediately disap- peared The terror and shame of being so pub- licly exposed made such an impression on the wind of the clergyman that his life was brought into the most imminent danger, and the expenses attending his confinement greatly injured his for- tune. (Dease's Remarks on Medical Junspru- Somnolency is, however, a real disease, and may originate without any obvious cause as a symptom of other diseases, or from external injury. Persons whose minds are alienated will frequently remain in bed for several weeks together in a semi-comatose state, resisting every argument and entreaty. This fact, and the following histories of real somnolency, will teach the medical officer to be extremely cautious in pronouncing any such apparent affection to be simulated. Rudolphi, when in Milan, in 1817, witnessed the case of a journeyman book-binder, nineteen years of age, who was affected with a curious sort of sleepiness, in some degree resembling intoxi- cation. In Rudolphi's presence he fell asleep, although he still continued to fold sheets along with the other workmen. His eyes were shut, and when it was wished to excite his attention, a loud knock was given on the table, by which he was awakened, and then he answered questions. The voice of one of the workmen, who was his friend, excited his attention, even when the tone was low. Upon being partially roused, he looked about with his eyes half open, and seemed to be aware of what was going on around him ; for ex- ample, when a sheet was purposely folded wrong and given to him, he appeared to be displeased. He wrote a note in Rudolphi's presence. His comrades used sometimes to lead him about when he was asleep, and to make him play at billiards, &c.; but he did not recollect that he had been so employed after he awoke. WThen allowed to remain asleep for a few hours, he began to snore, nodding his head as many persons do when asleep. A strong and active hussar, after many an in- effective effort during eight months to rouse him from a state of somnolent listlessness and inatten- tion to his person and duties, was discharged from his regiment, being generally considered as a skulker. Being forwarded to Chatham, he came under the care of Dr. Burrell, of the 72d regi- ment, who, from an absence of every other symp- tom of disease, was at first led to adopt the same opinion. In the course of a week, however, some difficulty of articulation was discoverable, greater heaviness in his look and sluggishness in motion appeared, which in a few days ended in coma, convulsions, and death. On dissection, two tu- mours of a firm medullary structure were discover- ed, in contact with each other, one of the size of a pullet's, the other of a pigeon's egg, situated in the right hemisphere of the brain, and projecting considerably beyond its surface. (Dub. Hosp. Rep. vol. iv. p. 138.) A seaman belonging to one of His Majesty's ships fell from a considerable height, and pitched upon his head: on examination, no fracture or depression could be discovered, the only mark of injury being a tumour of the integuments, which soon disappeared. From the moment of the acci- dent, however, the patient exhibited symptoms of coma, inattention to surrounding objects, &c; and he was therefore bled largely, purged, &c. The soporose state continuing without any other marked symptom, and there being discoverable FEIGNED DISEASES 143 not the slightest inequality of the bone, or other local indication of any injury beneath, the surgeon began to suspect imposition, and had recourse to the most vigorous counter-irritation, by blisters to the head, &c, partly on account of the painful impression produced by these means. This man at length was invalided, and on his way to England was seen by the gentleman to whom we are indebted for this interesting history, in the Naval Hospital at Gibraltar. At this time he lay in a listless semi-comatose state ; rousing up when spoken to, opening his eyes and answering ques- tions very rationally. A very marked symptom in this case was the incessant action of the left hand in alternate flexion and expansion, a symp- tom which had come on immediately after the accident, and had never since left him by day or by night. When the hand was restrained he seemed more uneasy, and as soon as it was disen- gaged the motions were resumed. He was sent to some of the naval hospitals in England, and his subsequent history is not known until he came under the care of Mr. Cline in May 1800, in St. Thomas's Hospital. At this time, says Sir A. Cooper, he was in a great degree destitute of sen- sation and of voluntary motion ; his pulse was regular, his fingers were in constant flexion and extension. He had a depression near the supe- rior edge of the left parietal bone. Mr. Cline trephined him, removing the depressed portion of bone, and the man gradually and completely re- covered. (A. Cooper's Lectures, by Tyrrell, vol. i. p. 312.) 43. Syncope.—A most disagreeable part of the duty of the medical officer is to attend at the corporal punishment of soldiers and sailors. On these occasions it is not rare for the culprit to feign fainting, in the hope of having his punish- ment remitted; and the medical officer is some- times called on to decide. In other circumstan- ces, also, syncope is simulated by soldiers and sailors with the view of obtaining particular ends; and it is occasionally the resource of the mendi- cant to impose on the charitable. Except in the extremely rare case of persons having a voluntary power over the action of the heart, there can seldom be any difficulty in dis- criminating the fictitious syncope from the real. The total suppression of the pulse, or its great diminution in point of strength and volume, the coldness of the surface and of the perspiration, the paleness of the countenance, cannot be assumed at will ; and without these, the seeming exhaus- tion or alleged loss of muscular power will not im- pose on any person of experience. The state of the countenance alone suffices to indicate the real disease in almost every case. It is hardly necessary again to inculcate on the mind of the young military or naval surgeon, that he must in all cases where the slightest doubt ex- ists, take the side of mercy. It is better that he should be a thousand times imposed upon, than that a fellow-creature should be punished white labouring under a severe disease, to say nothing of the risk of death occurring if the syncope is real. 44. Swelled leg. (Barbadoes leg.)—Tume- faction of the leg is sometimes excited by soldiers putting a concealed ligature round the leg and letting the limb hang over the side of the bed du- ring the night. There was a case not long since in Fort Pitt General Hospital, which was supposed by some of the medical officers nearly to resemble Barbadoes leg. This man had been sent home from India to be discharged. On admission into the hospital his thigh measured in circumference twenty-two inches and three-quarters, the calf of the leg seventeen inches and a half, and the ankle fifteen inches. Six days after the ligature had been discovered and removed, the thigh measured twenty inches, calf of the leg fifteen inches, and the ankle fourteen inches. Close examination will almost always detect the impression of the ligature in such cases, and the practice may be prevented by inclosing the limb in a box, or wrap- ping it in a marked bandage. 45. Ulcers.—The formation or irritation of ul- cers by artificial means has been in all ages a fer- tile source of successful imposition to that class of persons who live by exciting the compassion and charity of the benevolent. In former times the more cunning and less daring vagrants imitated ulcers by fixing certain foreign substances on the skin, such as dry, shrivelled leaves, part of the skin of a frog, and even pieces of flesh. A curious case is quoted by Fodere from an old French sur- geon, Pigray, of a young woman who presented herself to the king of France to be touched for a large open cancer of the breast, but which, al- though " le mieux simule et contrefait qui se puisse voir," Pigray discovered to be a slice of spleen fixed on the mamma! (Fodere, torn. ii.p. 486.) The actual formation of ulcers has been much more practised, and in the compulsory military service of all countries has been often carried to a very great extent. This was particularly the case during the late war among the French conscripts, and in the army and navy of this country. The most common site of these artificial ulcers, indeed almost the exclusive site in the army and navy, is the leg, a place, no doubt, selected partly because their existence in that position effectually incapa- citates the patient from military duty. These fac- titious ulcers are either formed entirely by art, or, which is the more common case perhaps, artificially aggravated into great and severe affections from slight sores occurring naturally, or from slight accidents. The means used to effect these objects are very various : vesicants, irritants, caustics, compression, friction, puncture, excision, &>c. &c. Sometimes a portion of skin is cut out, and then some irritating substance, such as lime, arsenic, corrosive sublimate, tobacco, the skin of salted herrings, acids, &c. applied to establish the ulcer, after which it is kept up by milder kinds of irrita- tion. Mr. Hutchinson says, that the use of mine- ral acids is most difficult to detect. There was an old woman, who lived contiguous to the re cruiting depot at Dublin, who had the credit of carrying on a great deal of business in this way among the recruits. Her applications appeared to be a mixture of quick-lime and soft soap. But one of the most approved methods of operating i<* the firm compression of a copper coin against the tibia ; and we have reason to know that this was the most common practice in the navy. Copper has always enjoyed a great reputation as acting injuriously on the animal body, and it is probable that this reputation has been the chief caubo of iti H4 FEIGNED DISEASES. being employed to produce or aggravate ulcers, although its main effect depends on the mecha- nical impression produced by it. Mr. Hutchinson once found, in dissecting the teg of a sailor, which he had amputated for extensive caries of the tibia, a half-penny imbedded between the muscles, » nearly three inches from the margin of the ul- cer," and which the man confessed to have thrust into the ulcer nine months before. (Loc. cit. p. 88.) Friction with sand seems also to have been extensively employed to produce ulcers; a process termed in the flash language "fox-hunting." (Dunlop, in Beck, p. 8.) An experienced eye will readily distinguish between an ulcer of recent formation asserted to be old, and one really old ; but it is not so easy to discriminate one of long standing, kept up by repeated slight irritation, from a natural ulcer. In some cases after the es- tablishment of the ulcer, so refined has been the imposition that a blister has been applied round it, with the view of producing the red glossy appear- ance possessed by the cicatrix of ulcerated parts. But the most distinguishing difference is the ready curability of the factitious ulcers, when secured from the tampering of the patient. When once a soldier or sailor is suspected of keeping an ulcer open, the obvious means of treat- ment are, seclusion if practicable, and defending the ulcer from injurious applications. The most common methods adopted by medical officers to effect this last object have been to seal the band- ages, or to inscribe on them, after they are applied, coloured lines drawn along the limb in such man- ner that it would be impossible to re-produce them if the bandage were removed and re-applied. Even these precautions have not always been found sufficient. Some of Mr. Hutchinson's pa- tients kept up mechanical irritation by means of pins thrust through the bandages. He was there- fore under the necessity of locking up the whole limb in a wooden box contrived for the purpose, and this he found an effectual remedy. 46. Vomiting. — Some persons possess the power of expelling the contents of the stomach at pleasure, and thereby simulate disease of that organ. In 1828, a soldier was for about six months in the General Military Hospital, at Dub- lin, on account of supposed disease of the stomach, chiefly indicated by a frequent disgorging of his food. About the end of that period it was ascer- tained that, instead of losing flesh, he increased in weight, a circumstance which was considered conclusive evidence that he did not suffer under any material disease. He was forthwith dis- charged from the hospital, and we have ascer- tained that he afterwards performed his duty effi- ciently. Vomiting became epidemic in the hospi- tal during tne time this man was a patient, but it ceased as soon as he was returned to his duty. Percy, in his article on simulated diseases, in the Dictionnaire des Sciences Medicates, mentions the case of a drummer who for a long time de- ceived the medical officer of an hospital by eject- ing the contents of his stomach. He could at pleasure regurgitate his food. In a quarter of an hour after he had swallowed soup, he used to re- turn the whole, apparently with great pain and general distress. It was eventually discovered mat he orivately purchased solid food, particularly hard-boiled eggs, which he did not vomit, and the imposture was thus detected. Mr. Hutchinson mentions a case of feigned, or rather of factitious vomiting in a sailor, which was produced by voluntary compression of the epigas- trium. The vomiting returned periodically, and upon the cause being discovered, was at once pre- vented by securing the patient's hands. Mr. Hutchinson adds, that he is thoroughly convinced of the existence of this power in certain persons to excite vomiting by pressure on the region of the stomach whenever they please. (Loc. cit.) Dr. Cheyne says that vomiting is voluntarily pro. duced by some persons by swallowing air and then eructating, in which process part of the contents of the stomach is brought up along with the re- turned air. (Dub. Hosp. Rep. p. 165.) We are, however, cautioned by this distinguished physician not to be too hasty in deciding on the nature of vomiting in suspicious cases, as he himself con- fesses to have been in one case deceived by a p*e. tended vomiting, and in another to have consi- dered a case of vomiting as feigned which eventu- ally proved fatal. 47. Wounds.—These have often been feigned when they had no existence ; have been greatly exaggerated when slight; and have been artifici- ally produced by the patient or with his concur- rence, in a very aggravated form. a. Fictitious wounds.—The pretence of being wounded when uninjured, or of being severely wounded when only slightly hurt, has ever been the resource and refuge of the coward in the day of battle. This practice has even been carried to such an extent as seriously to affect military ope- rations. Ca?sar, in his account of the blockade of Utica, speaking of the wounded in a skirmish wherein the enemy were driven with great terror into their intrenchments before the city, says, " qui omnes, discessu Curionis, multique praterea, per simulationem vulnerum, ex castris in oppi- dum propter timorem se recipiunt. QuS re ani- madversa, Varus, et terrore exercitus cognito, buccinatore in castris et paucis ad speciem taber- naculis relictis, de tertia vigiliS silentio exercitum in oppidum reducit." (De Bell. Civ. lib. ii. 35.) In the official report of the capture of Tarragona by the French, in 1811, Count Contreras, the governor, complains of having lost a great many officers in the last defence by their having feigned wounds, in order to avoid military duty. (Courier, July 30th, 1811.) "I have many times known," says Northcote, " cowardly lubbers during action, come tumbling down the ladder with the most violent groans and complaints, though, at the same time, they have received little or no hurt, and all I could do or say could not prevail on them to make a second trial of their courage, nor go up again till the action was»all over. Nay, I have been told by those quartered at the same gun, that some dastardly fellows have actually put their feet or stood in the way of the carriage, on purpose to be hurt, that they might have a plausible pretence for going down to the doctor, which I must own I have great reason to believe, having sometimes met with such contusions in the legs and feet, occasioned (according to their own confession) by the carriage, but at the same time so slight as was scarce worth mentioning; FEIGNED DISEASES. 145 though sometimes very violent, at other times there was scarce any injury or contusion to be perceived, notwithstanding the most grievous com- plaints of pain and uneasiness." (Northcote's Marine Practice of Physic.) Very distinguished men have had the meanness to simulate wounds. In one of his expeditions, Gustavus Adolphus is said to have pretended that he had received a con- tusion in the leg from a musket-ball, and, as a proof of the fact, exhibited a red spot on his leg and a corresponding blemish on his boot, which refused to receive the usual polish. (Hist. Sketch of the last Year of the Reign of Gustavus IV. of Sweden, p. 57.) One of the writers of this article was requested to visit an officer for the purpose of examining a gun-shot wound, which he alleged he had receiv- ed from the enemy in his left arm. Upon exam- ining the site of the wound, no injury could be discovered, except an abrasion of the cuticle, about the size of a large pea. The injury seemed to have been occasioned by a pen-knife rather than by a bullet. Care had been taken to destroy the sleeve of the jacket, so that it was impossible to learn any thing positive regarding the alleged cause of the wound by examining the clothes. Officers have been frequently accused of feigning wounds or contusions after a battle with the view of having their names recorded in the Gazette, or for the more sordid purpose of claiming a pen- sion. In a case of feigned wound without loss of continuity, which came under our own notice, the man had stained the part to represent the purplish yellow hue of ecchymosis on the decrease, alleg- ing that the contusion had been received some days previously. b. Factitious wounds. Mutilation.—The in- fliction of wounds by the individual, chiefly for the purpose of mutilation, is a practice which has prevailed in all ages and countries where military service has been forcibly imposed upon men. Mu- tilation was a frequent practice among the con- scripts of ancient Rome, more especially during the decline of the empire; and it would appear that it is from the most common species of muti- lation among them, viz., by cutting off the thumb (pollicem truncando) that our modern word pol- troon is derived. At first this sort of mutilation exempted the individuals from service; but after- wards the law was altered, and in the prescribed levy from any district, two maimed recruits were only reckoned as one. Soldiers who voluntarily disabled themselves were branded and still retain- ed in the service. Mutilation was very frequent among the French conscripts during the wars of the Revolution and the Empire; and the same regulation was eventually adopted in France as among the Romans, viz., the retention in the ser- vice of all men whose mutilation could be proved to have been intentional. A species of mutila- tion very common among them was the extrac- tion of the incisor teeth, or the filing them down below the gum, a condition of parts which pre- vented the soldier from biting off the end of his cartridge in loading his musket. Mutilation has been very prevalent in the army and navy of this country; and the modes in which it has been effected have often been more Vot. II.—19 w than usually bold and severe. The wounds havo frequently been inflicted during battle, or in a crowded barrack-room, with the view of giving greater plausibility to their alleged accidental oc- currence. Frequently, however, more especially in the navy, the act of self-mutilation has been openly practised. During the late war a naval officer went on board a merchant vessel at Yarmouth for the pur- pose of impressing seamen, and while on board said, jestingly, to a boy about ten years of age, that he would take him with some others; upon which the lad ran below, and immediately return- ed with one of the fingers of his left-hand cut off, exclaiming—" You can't take me now ! My father cut off three fingers that he might not be pressed, and I have done the same !" A seaman in the Ambuscade cut off his thumb in the pre- sence of his officers, in a sudden fit of anger and despair at being kept in the service at a time when some others were discharged .■ and several in- stances have come to our knowledge where sea- men cut off the whole or greater part of their hands, with the avowed purpose of obtaining their discharge. Others, again, who have committed similar mutilation of their persons, have pretended that they were done by accident. In many cases of mutilation the object of the men is two-fold,—to procure their discharge from the service, and to obtain a pension. The self- inflicted wounds of soldiers are most commonly produced by the musket, and they almost always pretend that they have been accidental. During the period of four years from 1824 to 1828, there were twenty-one soldiers pensioned in Ireland on account of injuries they had received in one of their hands by the explosion of their own mus- kets. Recent regulations in the army deprive soldiers of pensions who are disabled by such ac- cidents, except they occur in the performance of military duty ; and if the mutilation is proved to be intentional, the individuals are still retained in the service, although unfit for the ordinary duties of a soldier. Mutilation occurs in the army more frequently in the hands and fingers than in any other part of the body. In one regiment, how- ever, where the practice became so far epidemic that nine cases of mutilation by the explosion of muskets happened in the course of six weeks, the lower extremities chiefly suffered. We have known a number of cases of mutilation occur among sol- diers when they were on a visit to their friends ; and little doubt could be entertained that the maim- ing was voluntary. The injury commonly oc- curred about one or two days before the expira- tion of the furlough. Mutilation has been practised, but much more rarely, by parish paupers, with the view of obtain- ing immunity from labour. It has also occasion- ally occurred among slaves in the West Indies: but we have been told that their animal courage is seldom sufficient to prompt such bold mea- sures. There will rarely, if ever, occur any difficulty on the part of the surgeon in detecting the impo- sition in the case of wounds being alleged to exist when no wound has been received. In the case of self-inflicted wounds or mutilation, however, it will not always be easy to prove that they have 146 FEIGNED 1 been intentionally produced. The proof will rest sometimes on the nature of the wound, sometimes on the circumstances under which it is stated to have occurred, and sometimes on other collateral circumstances. In the case of a soldier or sailor it will often be a matter of great importance to the individual, that the decision come to is the true one; as it will frequently have the effect of ob- taining for him his discharge from the service, and perhaps a pension, or of depriving him of both advantages, and perhaps entailing punishment also. In forming his opinion of the probability of the wound being self-inflicted, the surgeon will be guided by the consideration of the nature and extent of the wound, its situation, the nature of the alleged cause, &c. For instance, if the wound be of such a kind as renders it improbable that the patient either could or would have in- flicted it; if it be of great extent and more than sufficient to effect the object the perpetrator may be supposed to have had in view,—if it be in a part of the body to which the patient's hands, or an instrument wielded by him, could not have reached, —the probability certainly is that it is accidental. On the other hand, if these circumstances are re- versed, and if the mode in which it is stated to have occurred is improbable or impossible,—if the alleged cause or instrument is ill calculated or not at all calculated to produce the effect,—the sur- geon will be more disposed to regard it as volun- tarily inflicted. The examination of collateral circumstances will often afford more positive evi- dence than grounds of a merely medical kind. The following case affords an example of both kinds of evidence. A seaman on board one of His Majesty's ships lopped off two of his fingers with an axe upon a post, in the fore part of the ship termed the manger, and in the confusion of the moment left them there. He then ran down into the hold, and uttering a piercing cry rushed on deck, exhibiting his mutilated hand, and assert- ing that he lost his fingers by the accidental col- lision of two water-casks. Here the character of the wound sufficed to disprove the truth of the al- leged cause;—no collision of casks could produce so clear a wound, or so complete an amputation ; still more certain evidence, however, the man's own stupidity afforded ; for shortly after his two fingers were found on the manger, and lying near them the axe which had divided them. The improbability or even impossibility of a wound being inflicted by the patient himself, is, however, no certain proo!' that it has not been in- flicted intentionally ; since the unhappy men have been known, like the ancient Romans, to assist each other in the perpetration of this partial sui- cide. Instances of this kind have been mentioned to us both in the army and navy ; the wounds be- ing produced both by fire-arms and cutting instru- ments. During the late war we remember an in- stance of a father cutting off one of his son's fingers to prevent him serving in the militia. There was a young convict on board the hulk for boys at Chatham, not long since, who placed his right arm over a space between two beds, and got a companion to strike the forearm with a long piece of wood. Both the bones were thus frac- 'ured; and ever, after the arm had been put up in USE ASES. splints, he found means to displace the bones, and thereby prevented a perfect union. [See a table of feigned, pretended, simulated or excited diseases or disqualifications in the writer's Dictionary of Medical Science, 4th edit. p. 303, Philad. 1844.] In concluding this article, we cannot dismiss from our minds the possible impression it may leave on the minds of junior medical officers in the public service; whom we would guard, on the one hand, if possible, from suffering a spurious humanity to be detrimental to the interests of the army or navy, and, on the other, with even more anxiety, from the vain desire of acquiring tempo- rary consideration by a stubborn and cruel incre- dulity, or by an affected shrewdness in detecting imposture where no imposture may exist. There are cases mentioned in the preceding part of this article, which show, indubitably, that the simulation of disease has frequently been prac- tised without the existence of any interested mo- tive, indeed without motive of any kind; that there is, in short, a species of monomania of which this simulation is the characteristic. Such cases may occasionally be remembered with ad- vantage. But there is another consideration equally wor- thy of being entertained by all who do not wish the common feelings of a man to be lost in those of a mere disciplinarian. For notorious malin- gerers we are in no degree disposed to plead; but when instances of deception become frequent, in any country, in any garrison or station, in any regiment, or in any ship of war, the question may very reasonably present itself—is there not some- thing wrong in the arrangement of the place, in the government or administration of the particular portion of the community in which such frequent deceptions are resorted to ; — something which, acting injuriously on the bodies or the minds of the men, is therefore not beneath the Considera- tion of the medical officers of the establishment, who alone can appreciate the mischief, and by whose mediation alone it is likely to be remedied ' The privilege conferred by their profession, of be- ing the friends of mankind, is one which ought not to be willingly resigned. The negro-slave, and the conscript of an impe- rial conqueror, may be equally placed beyond the pale of such considerations; but the British sol- dier or sailor ought never to be so ; even the con- vict is not shut out from mercy. The condition of both soldiers and sailors has, during late years, been much ameliorated ; and deceptions are less frequent both in the army and navy than of old. These amendments in their condition have often arisen out of the representations of enlightened and humane medical superintendents. Wherever, therefore, we repeat, the instances of imposture are numerous,—wherever these manifestations of discontent are frequent among men whose gene- ral characters afford an assurance that in ordinary circumstances they would not prefer pain and pri- vation to duty ; the circumstances in which such opposite and desperate resolutions are taken, should undergo the most scrupulous and fearlesri investigation. Such a duty is enjoined by ar, FEVER. 147 authority higher than any temporary authority to whom its performance may happen to be disa- greeable' J. Scott. J. Forbes. H. Marshall. FEVER.—The word fever, derived from the Latin term febris (a derivative of the verb ferveo or ferbeo, signifying to be hot,) is applied to a class of diseases characterized by morbid heat of skin, frequency of pulse, and disturbance in the various functions. In the Greek language, the word xvpcZia (from irvp, fire,) expresses fever; hence the origin of the term pyrexiae, under which the ancient wri- ters comprehended fevers and inflammations, a classification which has been retained by modern nosologists. It therefore appears that upon one symptom alone, increased heat, the nosological distinction of a very numerous and important class of diseases has been founded. Though this characteristic feature is very generally observed, nevertheless in some cases of fever, strictly so called, the heat of skin is not above the natural standard, sometimes even below it; from this circumstance, therefore, it is evident that other phe- nomena are necessary to constitute a febrile disease. We know so little about the cause of the gene- ration of animal heat, that no satisfactory expla- nation of its increase or diminution in fever has been given : it seems probable, however, from some experiments, that its evolution is intimately dependent on the condition of the brain and ner- vous system, and until physiological investigations shall unfold with greater certainty the mode in which animal heat is generated, the pathologist must be satisfied with the ultimate fact, that in febrile diseases there is generally, among other phenomena, increased heat. There are some diseases, the symptoms of which are so characteristic, and so invariably present, that there is little difficulty in determining their precise nature and seat. The various organic inflammations — of the brain, lungs, intestines, &c.—are examples of this class: there are others of which the precise locality is either so varied or obscure, either as regards the symptoms during life, or, in many instances, on dissection after death, that we are unable to discover their nature. To this latter class fever properly belongs. It is true that in most cases of fever we can discover the existence of certain lesions, but these are too vague or indefinite to enable us uniformly to de- cide on the primary seat of the malady. It is more than probable that in what is usually called idiopathic fever there is alteration either of the solids or fluids, although its precise locality can- not in every case be detected; but without disease in either the one system or the other, we maintain that fever cannot exist. It is too generally imagined that the primary disease which induces fever is essentially local in- flammation. The application of this doctrine to the early stage of fever, we hold to be not only at variance with facts, but dangerous as to the prac- tical deductions to which it leads. We know that irritation, far short of inflammation, is sufficient to excite feverish indisposition, more particularly at those periods of life at which the vascular sys- tem is easily excited by apparently trivial local or sympathetic disturbance, (for example, in infancy or childhood by dentition or intestinal irritation,) and that this feverishness disappears when the cause is removed. The paroxysm of an intermit- tent is induced by the peculiar effect of a mala- rian poison ; in this disease, the whole phenome- na of fever are well marked, but certainly few will maintain that the febrile disturbance is the conse- quence of local inflammation. There can be lit- tle doubt that the error alluded to may in a great measure be imputed to the attempts to discover the cause or nature of fever in the various local lesions which are observed in fatal cases. On the other hand, the important fact should ever be kepi in view, that the primary disorder, whatever it may be, passes readily into inflamma- tion, and that the lesions which arise in the pro- gress of fever constitute the principal source of danger, and are in many instances the more im- mediate cause of death. If we trace the early records of medicine, we find that the nature of fever has afforded ample field for discussion from the time of Hippocrates to the present day. Both the solids and fluids have been investigated, and arguments adduced in support of the opinion, that a morbid condition of either the one system or the other was the cause of fever. The ancients possessing a very scanty know- ledge of anatomy, either in its healthy or morbid state, and the secretions being evidently vitiated in the progress of fever, it was natural that a mor- bid condition of the fluids should, in the early ages of medicine, be considered as its primary cause. The humoral pathology was accordingly received as the only explanation or theory of fever, for many centuries. We find the early medical writers entertaining the idea, that the system waged war against something noxious within itself, and that in the attempt to expel the offend- ing agent, a violent commotion was excited. By this plausible theory, the duties of the physician were restricted to assisting nature in her efforts to get rid of what was deemed injurious to the wel- fare of the body : in fact, fever was imagined to be a natural and salutary process, indispensably necessary to throw off whatever was noxious, whether generated within the body, or introduced by external causes. Some theorists, in their anx- ious desire to support this doctrine, endeavoured to deduce the term fever from the Latin verb feb- ruare, signifying to purge or purify, and by those who implicitly believed in this theory, the deriva- tion was no doubt considered apt and appropriate. The application of the doctrines of the humoral pathology in explanation of the phenomena of fever, received much apparent confirmation from the circumstance, that in eruptive fevers, after more or less febrile disturbance, various eruptions appear on the skin. It was rendered still mor«> imposing, when the chemical doctrines of Para- celsus and Van Helmont were first promulgated. These chemical philosophers imagining that in fevers the fluids possessed at one time an alkaline at another an acid quality, conceived that an effei vescence took place, which gave rise to a febrilo paroxysm—an assumption which led to not a few fatal practical errors. 148 FEVER. The idea that particular forms of fever depend on a morbid state of the fluids has been main- tained bj many pathologists in more recent times. The vital fluid has been subjected to chemical analysis with the object of ascertaining the com- parative difference in its component ingredients during fever: these researches tend to show, that previous to the attack, the blood is materially altered in its properties, and that its constituent principles undergo progressive changes, as the disease proceeds. This department of chemical pathology has been lately much elucidated by the experiments of Dr. Cluny, detailed in his published lecture on typhus fever, and also by the observations of Dr. Stevens, who states that on opening the heart in fatal cases of yellow fever, he found, instead of blood, a dissolved fluid nearly as thin as water and black as ink. In both sides of the heart the fluid was equally black, and throughout the vas- cular system all distinction between venous and arterial blood was completely lost. Dr. Stevens supposes that when the blood is found in this state, it is entirely deprived of its stimulating properties, and therefore unable to excite the heart or to support life. It is affirmed, also, that the changes in the blood take place in a certain deter- minate order. It first loses its solid parts and be- comes thin ; it is then deprived of its saline prin- ciples, and becomes black and vapid ; and lastly, from its preservative elements being destroyed, it loses its vitality so as to be incapable of support- ing life. Dr. Stevens considers this diseased state of the blood as the first link in the chain of the morbid phenomena which constitute fever. He believes that the aerial poisons from which all pestilential diseases arise are attracted with the atmospheric air into the circulation, mix directly with the blood in the pulmonary system, and that this poisoned or diseased state of the whole circulating current is the cause of the subsequent morbid action in the solids. Similar views with respect to the pathology of fever are gaining ground in France, in which country the doctrines of solidism have almost exclusively prevailed. The study of the structure and functions of the human body, in its healthy as well as in its mor- bid state, being the most satisfactory method of investigating the nature of disease, and lesions having been discovered in various organs of those who have died of fever, the attention of patholo- gists has in later times been directed to the state of the solids, in hope that the origin of fever might be discovered. The locality of the disease, however, has been most warmly disputed; indeed there are few organs of the body which have not been fixed on as the seat of fever; from which it may be in- ferred, that the doctrines of solidism are as little likely as those of the humoral pathology, to ex- plain every variety of this inscrutable disease. The functions of the brain being almost inva- riably affected in fever, it was to be expected that the solidists would endeavour to trace its origin to ttv nervous system. We accordingly find, that towards the close of the seventeenth century, Stahl maintained that the phenomena were the result of a general commotion in the system, in its en- deavour to throw off a spasm induced by torpor of the brain and nervous system. This explana- tion, which, after some modifications, was adopted by Hoffman, was the first attempt to assign to the brain an important share in the pathology of this disease. It formed the basis of the theory in- vented by Cullen, who believed that in fever cer- tain causes produced collapse or diminution of the energy of the brain. The effect of this on the voluntary muscles and the extreme vessels was universal debility, and spasm or constriction of the capillaries: the subsequent re-action of the sanguiferous system, however, had the effect of resolving this supposed spasm, and consequently removing the fever. The prominent importance the Edinburgh Professor assigned to the fictitious debility which was imagined to result from this unknown condition of the brain, notwithstanding his theory that there was an inherent protective power in the system by which this fancied weak- ness was to be overcome, has been followed by serious practical errors, by abstracting the young and inexperienced mind from the more acute forms of fever, and from those important local complications which very frequently take place in its progress. Besides, as Dr. Parr has remarked, in this system the production of spasm by debility is an isolated fact without a support, and the in- troduction of the vis medicatrix naturae is the interposition of a divinity in an epic, when nc probable resource is at hand. It is evident that in the definition of fever giver by Cullen in his nosology, he expressly discoun- tenances the idea of primary local disease; con- sequently he only partially adopted the doctrine of solidism, his theory merely implying that the various exciting causes act primarily on the brain. This doctrine prevailed not only in British but in many continental schools, till Dr. Brown, evi- dently to gratify a feeling of resentment, opposed it with great bitterness. He invented and pub- licly propounded with much plausibility an oppo- site theory, which had the merit of great simpli- city. According to Brown, the living system is an organized machine endowed with an inherent principle of excitability, arising from a variety of internal and external stimuli, and from which the excitement which constitutes the life of the ma- chine is maintained. Upon these principles he founded the character and mode of treatment of all diseases, which were supposed to consist but of two families, the sthenic and the asthenic; the former produced by accumulated, the latter by exhausted excitability, and marked by indirect de- bility. The remedial plan was as simple as the arrangement. Bleeding, low diet, and purging were employed to cure the sthenic, and stimulants, of various kinds and degrees, the asthenic diseases. Fevers, therefore, under this hypothesis, like other diseases, are either sthenic or asthenic, as they are the result of accumulated or of exhausted excitability. This doctrine obtained but few ad- herents in the British schools, though, as we shall presently notice, it prevailed extensively for a time in several parts of the continent, more par- ticularly in the north of Italy. Another class of solidists asserted that inflam- mation of the brain was the cause of fever. Ploucquet, who appears to have first taken this FEVER. 149 view, admitted, however, that from particular cir- cumstances, other organs became occasionally im- plicated. Though this theory evidently implied that fever was dependent on local inflammation, it gave the disease a wider range—it assumed in- flammation of the brain to be the source of fever, but that from the operation of certain causes, other irritations were in some instances superadded. Marcus and Clutterbuck have subsequently adopt- ed this view, and have severally adduced argu- ments, in its favour. Admitting, however, that the various exciting causes of fever do in some instances exert their action on the brain, we have no evidence that they produce, in the first instance, inflammation in this organ : on the contrary, the symptoms denote that the nervous system has only received a peculiar and powerful impression. When, on subsequent re-action taking place, a general impulse is given to the circulation, and the nervous system is roused from its depression, inflammation of the brain does frequently take place, especially in young plethoric subjects, just as it may supervene in any other organ to which, from causes hereditary or acquired, the individual may be predisposed. It should also be impressed on those who are inclined to adopt this doctrine, that although in a considerable proportion of per- sons who die of continued fever, the membranes, and frequently the substance of the brain, bear unequivocal marks of inflammation, yet such morbid appearances are by no means invariably observed. We are next to advert to the doctrine which as- cribes the phenomena of fever to primary affection of the intestinal canal. Lesions of the intestines in fatal cases of fever had been long ago pointed out by those who devoted much attention to the study of morbid anatomy. Bonetus stated that on dissection of persons who died of malignant fever, he found the stomach and intestines inflam- ed. Bartholinus made a similar observation; and in the works of Sydenham, allusion is made to ulceration of the intestines in continued fever. Subsequently Roederer and Wagler (De Morbo Mucoso, Goettinga?, 1762) published a description of an epidemic mucous fever which prevailed at Gottingen, in which the appearances which were found after death in the alimentary canal are mi- nutely detailed. From these statements, it appears that the morbid appearances in the alimentary canal had attracted the attention of pathologists long before the promulgation of the theory in France, that fever was the result of inflammation of the mucous membrane of the intestines. This view, which was first maintained by Broussais more than twenty-five years ago, has become the prevailing opinion in France, though it has gained compara- tively few proselytes in other countries. (Examen des Doctrines Medicates et des Systemes de No- sologic, &c. Par F. J. V. Broussais. Prop de Med. cxxxviii. cxxxix. Those who maintain the physiological doctrine of Broussais, contend that fever is entirely symp- tomatic of irritation or inflammation of the mucous membrane of the intestines. The leading principle of this theory is, that every irritation which is capable of producing an impression on the brain is reflected by this organ on the mucous mem- brane of the bowels. Broussais applies it to other acute diseases; for instance, in small-pox or measles, the inflammatory excitement by which they are accompanied is supposed to be first con- veyed to the brain, and afterwards reflected on the mucous membrane of the intestinen, and that thus inflammation (gastro-enterite), the supposed cause of these eruptive fevers, is produced. It is affirmed that inflammation and its conse- quences are invariably found in the mucous lining of the intestines, on examination of persons who have perished from fever, and that the treatment which is founded on this view is the most success- ful. Broussais, indeed, asserts with unparalleled boldness, that the tables of mortality declare in favour of the new doctrine, and that its influence on the population would be more favourable than vaccination itself. Though Roederer and Wagler, Prost, (La Me- decine eclairee par l'ouverture des Corps), Baillie, (Morbid Anatomy), and others, had previously detected morbid appearances in the bowels, in their dissections of persons who had died of fever, the theory of Broussais, that inflammation of the mucous membrane of the intestines is the cause of fever, had the effect of directing the attention of pathologists still more particularly to the condi- tion of the intestines in this class of diseases. In 1813, M. Petit and M. Serres* published the ac- count of a disease, very frequent in Paris in 1811, 1812, and 1813, which they called entero-mesen- teric fever, and which was characterized by all the symptoms of continued fever, but originated appa- rently in certain changes in the inferior portion of the small intestines and ileo-ca?cal valve, ac- companied with enlargement and suppuration of the corresponding glands of the mesentery. The precise anatomical lesion of the intestines, how- ever, was not ascertained by these laborious patho- logists, but subsequently by M. Bretonneau of Tours,-(- who, after investigating the subject with great minuteness, came to the conclusion that the primary source of fever was in the conglomerated mucous follicles, or glands, situated in the lower portion of the ileum and solitary glands of the ca?cum. A most full and elaborate work has been lately published by M..Louis,$ in which the pathological views of Petit, Serres, and Bretonneau, as to the primary seat of fever, are confirmed. This author, moreover, has given a most minute account of the various secondary lesions which supervene on this supposed primary intestinal disease. These views of the nature of fever now prevail almost exclusively among the French pathologists. Mild fever is supposed to arise from gastro-enteritis alone, the various forms which it occasionally assumes being regarded as gastro-enteritis, with particular complications. For instance, inflamma- tory or ardent fever (a form rarely observed) im * Traite de la Fievre Entfero-Mesenterique observee, recontme, et signage publiquement a I'Hotel Dieu de Paris dans les annees 1811, 1812, et 1813, par M. A. Petit, Pun des Medecins du dit Hopital, compose en partie par E. R. A. Serres, &c. f Trousseau, de la Maladie a laquelle M. Bretonneau a donne le nom de dothin-ent6rite. Arch. Gen. de Med. x. 67. 1826. I Recherches Anatomiques, Pathotogiques, et Thera peutiques sur la Maladie connue sui les norns de Qastro Entente, &c. par P. Ch. A. Louis, M. D. 150 FE V ER. ports an intense degree of this lesion; fne adynamic (typhus mitior) is regarded as gastro-enteritis which has assumed such a degree of intensity that the general powers decline, while the intellectual functions are more or less disturbed. The more malignant forms of fever (typhus gravior) are supposed to be gastro-enteritis complicated with irritation of the brain, from sympathy with the state of the alimentary canal; and when fetor of the breath, perspiration, and stools are observed, the disease becomes what has been termed putrid fever,—that is, putrid symptoms are superadded to the primary gastric inflammation. It cannot, however, be conceded that in every form of fever this local disease does exist, as it has not been universally, nor even in the majority of instances, discovered on the most minute exami- nation of the intestines in fatal cases. The more probable inference is, that this gastro-enterite, or follicular disease, occurs only occasionally, and that it is much more common in some places than in others. We know that it is observed more frequently in the fevers of France than in those of Britain ; very rarely, if ever, in the epidemic fever of Ireland ; and that it is only occasionally met with in the epidemic visitations in the northern districts of England and Scotland. From its being observed in a greater proportion of cases in London and Manchester, it is probable that there are some local causes or circumstances in particular places, which produce this intestinal affection. Whether in those cases in which it has been found after death, (for we maintain that the pathognomonic or diagnostic symptoms by which it has been supposed to be indicated are by no means uniform or satisfactory,) it be the cause or effect of the febrile symptoms by which it is ac- companied, is still a question about which there is great difference of opinion, though the majority of British physicians regard these intestinal lesions as only the sequela? or consequences of fever. [Of late years, many of the French, and some of the American, pathologists have maintained, that the intestinal follicular lesion, referred to above, is characteristic of one form of continued fever—the typhoid. To this view reference will be had hereafter. It is not uncommon in the United States. Dr. Bartlett (History, Diagnosis, and Treatment of Typhoid and of Typhus Fever, &c. p. 86, Philad. 1842) considers the red-tongue fever of Kentucky to belong to it.] The assertion that the treatment founded on the gastro-enteritic pathology is the most success- ful, is only an assumption; indeed, it may be fairly inquired how many hundreds annually sur- vive the treatment calculated to increase gastric inflammation — how many are daily stimulated with bark, wine, and ammonia, and yet recover 1 Besides, how can this doctrine be applied in ex- planation of the phenomena of intermittent fever ? In France as well as in this country, periodic fevers are successfully treated by stimulants — bark, and even arsenic ; not to allude to the com- plete suspension of the febrile paroxysm for twen- ty-four, forty-eight, seventy-two hours, or even longer. These circumstances, when duly weighed, must .*n our opinion disprove the general conclusion, !h«* every form of fever is the result of gastric inflammation. On the other hand, we are bound to admit the occasional existence (more frequent in some localities than in others) of the various intestinal lesions, which have been so minutely and elaborately described by the French patholo- gists, to whom, if this discovery be not entirely due, the merit must be conceded of having, with indefatigable labour, followed up the few hints which previous writers had thrown out, and thus brought to perfection one of the most important pathological facts connected with the morbid ana- tomy of fever. The celebrated Pinel took a more extended view of the nature of fever than any preceding writer of the continental school. He distinguished symptomatic from primary or essential fevers, and comprehended under this latter class, acute dis- eases in which there is a quick pulse, hot skin, and disorder in the various functions, the symp- toms being independent (as he supposed) of local disease. While he admitted, however, in his classification, the existence of fevers without pri- mary disease in any organ, he evidently localised the varieties when he stated that the seat of in- flammatory fever (angeio-tenic) was in the organs of circulation ; that the origin of bilious fevers (meningo-gastric) was in the mucous membrane of the intestines ; that a particular form of gastric fever (adeno-meningeal) depended on disease of the mucous follicles alone; that in another variety (ataxic) the brain and nervous system were chiefly affected ; another type (adynamic) being charac- terized by great prostration or depression of the vital powers, and often complicated with symp- toms which have been usually referred to pu- tridity. These views have been since partially adopted, and have evidently given origin to the doctrine entertained by a large proportion of physicians of the present day, that fever is an essential disease, that is, the symptoms are independent of primary organic lesion ; though it is admitted that in the majority of cases, local inflammations become de- veloped in its progress, and constitute the principal source of the severity or danger of the disease. The doctrines of Brown, which had obtained, as we have stated, comparatively few converts in his own country, made a strong impression in the north of Italy. Rasori, who had visited the medi- cal school of Edinburgh, was so enamoured with the Brunonian system, that, on his return to Italy, he published a compendium of this system, (to which the learning and ingenuity of Darwin had given a new impulse,) as well as a translation of the celebrated Zoonomia of Darwin. A few years afterwards, however, a petechial fever appeared at Genoa, in which the stimulating treatment recommended by Brown was evidently so injurious, and positively fatal, as to induce Rasori to reconsider the theory. He then became convinced of its inconsistency and error, and ulti- mately acknowledged this conviction in an account which he published of the epidemic of Genoa. (Storia della Febre Petech. di Genoa. Del Prof. Giovanni Rasori.) This epidemic, from whatever causes it arose, had many of the characters of what Brown termed an asthenic disease, and was consequently treated by stimulants. From thr numbers who perished under this plan, and from FEVER. 151 observation of its symptoms and progress, during which local inflammations not unfrequently oc- curred, Rasori was induced to substitute a modi- fied antiphlogistic, or, according to the language of the Italians, a contro-stimulant treatment. Bloodletting in the commencement of the dis- ease, when the patient was young and vigorous, and when the symptoms demanded it, was found decidedly beneficial; and in less severe cases, saline purgatives, antimonials, (more especially the tartar emetic in liberal doses) and acidulated drinks were employed. These remedies, with blisters in the advanced stage, stimulating friction to the abdomen, with the view of allaying the gastric irritation, light bed-clothing, and rigorous diet, constituted the treatment employed in the epidemic. This change of Rasori's opinions produced a considerable sensation, and had the effect of over- turning the leading principles of Brown's system in Italy. The professors in the north of Italy, who were formerly attached to Brown's views, taught the doctrines of Rasori with some unim- portant modifications, and ultimately several works emanated from the different universities, explain- ing the leading principles of the " Doctrine of Contro-stimulus," or, as it was afterwards termed, the " New Medical Italian Doctrine." As it would lead to digression, we must refer those who wish to obtain information on the Italian doctrines to the several works alluded to.* Tommasini, whose learning and reputation rank him as a leading authority of the Italian school, considers fever to be the immediate result of a morbid condition of some internal organ ; and in this he is followed by a large majority of the Italian physicians. Others, however, adopt the views of Rubini, and ascribe the phenomena of fever to the effect of a contagious principle absorbed into the circu- lation, which, after producing inflammatory action, gives rise to symptoms indicating failure of the powers of the system. The antiphlogistic treat- ment is consequently pursued in the commence- ment of the fever, and afterwards a stimulant plan, when the powers of the system appear to give way. The doctrines of Broussais have obtained an inconsiderable number of adherents in Italy, so that we find the views of this celebrated patholo- gist much more generally received in France than in any other country. In our opinion, both essentialists and localists have taken a much too limited view of the etiology of fever. It appears to us that fever, whatever be its form, depends on some modification of one or other of the elements which enter into the compo- sition of the human body, or in other words, that it follows as a consequence of a morbid condition of either the solids or fluids. We know that, when the function of any organ ♦Prima Lines Materia; Medics, Auctore Syrus Borda. —Delia Nuova Medica Italiana, Proluzione alle lezione di Clinica Medica nella P. Uiiiversita di Bologna per Panno Scholastico, 1816-1817. Del Professore Giaconio Tommasini —Dell' Inflammazione et della Febre Con- tinua ; considerazioni Patologico-Pratiche. D. G. Tom- masini, Pisa, 18i0.—Del Metodo di curare, &c. Del Pro- fess. Giaconio Tommasini. Bologna, 1821. — Lezioni di Terapea Speciale sulle Inflammazione, e Rendiconto Clinico, di V. Mantovani, Pavia, 1820. — Institutiones Pathologies. Auctore F. A. Fanzago. becomes seriously disturbed, more particularly if inflammation arise, fever is induced. It is proba- ble that the various external causes, terrestrial or atmospheric poisons for example, induce fever by their action on particular parts, in the same way as the different poisons are known to affect par- ticular structures. On this principle the symp- toms peculiar to some epidemics may be explained; for instance, catarrhal fever, in which the mucous membrane of the air-passages is affected ; or gas- tric fever, in which a peculiar impression seems to be made on the mucous lining of the intestines. We shall endeavour to show, in treating of the pathology of the fluids, that the blood is not only materially changed in fever, but that the diseased state precedes the attack, and that the changes take place in a determinate order. This view is corroborated by Andral, who states " that the fever termed inflammatory seems often to arise from no other source than the blood being too rich in fibrine; in like manner, an impoverished state of the blood, whether accidental or natural, is often connected with mucous fevers, and with those characterized by a sudden sinking of the vital powers; and that the source and primary seat of typhous fevers, properly so called, is proved to be in the blood, inasmuch as they are caused by the introduction of deleterious substances, such as ani- mal or vegetable effluvia, into that fluid." It is in this way only, by the blood becoming contaminated, and in this state circulating through the system, that fever can be supposed to be, ac- cording to the language of Dr. Fordyce, " a gene- ral disease which affects the whole system, the head, the trunk of the body, and the extremities ; the circulating, absorbing, and nervous symptoms; the skin, the muscular fibres, and the membranes; the body, and likewise the mind." (Dissertations on Fever.) When putrid substances are injected into the blood of the lower animals, this fluid loses its power of coagulating, and acquires a rapid ten- dency to decomposition: great sensorial disturb- ance, convulsions, delirium, hurried breathing, and bloody exhalations also take place, followed by speedy death ; and if the poison injected be highly concentrated, the animal is almost instantly de- stroyed. The effects which follow from the use of food of an unwholesome quality, or from an insufficient quantity of food, are probably owing to the changes which the blood undergoes from these causes ; hence scarcity may act both as a predisposing and exciting cause of fever. In this way, the origin of the disease in times of general distress among the poor is readily explained ; and the history of epidemic fevers in Britain shows the intimate connection that has always subsisted between scarcity and fevers of a low or malignant type. It is also extremely probable, that in fevers which are produced by living in an impure atmo- sphere, the blood becomes the medium by which the morbific matter is circulated through the sys- tem. To prove the effect of putrid emanations on the animal economy, Magendie confined a healthy dog in a situation which exposed him to putnu miasmata. For the first four days there was no change; he then began to emaciate, and died much extenuated within six. Magendie imputed th« 152 FEJ death of the animal to the effect of the miasmata he respired and took with his food. On opening the body, which was much emaciated, the mucous membrane of the bowels was found inflamed. CLASSIFICATION OF FEVERS. Pyrexia?, or febrile diseases, have been divided into two great classes, — Fevers and Inflamma- tions. In the present article, we shall consider the first class only, referring the reader for the consideration of the second, viz. symptomatic fe- vers (inflammations), to the separate articles in the work. The different forms of fever have received vari- ous distinctive appellations, founded on their sup- posed causes. We accordingly find in systematic works various subdivisions, — camp, hospital,pri- son, or jail fever. Others have preferred, as a ground of distinction, the peculiar phenomena which each type of the disease presents; hence the origin of the nomenclature, inflammatory, bi- lious, nervous, malignant or putrid, petechial, typhoid, yellow fever, &c. The types of fever which are met with in tem- perate countries have been arranged according to certain phenomena observed in each. In one form, the symptoms or series of phenomena con- stituting the febrile paroxysm observe a continued or uninterrupted course ; in a second, they do not follow a continuous course, but become either sus- pended for a definite period, or a considerable re- mission or abatement only takes place ; in a third, the febrile symptoms are accompanied with a pe- culiar eruption, which, with certain symptoms, indicates a particular form of eruptive or exanthe- matous fever. A classification of fevers, founded on these dis- tinctive characteristics, being sufficient for every practical purpose, the following arrangement will be adhered to in the present work:— 1. Continued. a. A simple. b. Complicated. c. Typhus. 2. Periodic. a. Intermittents. b. Remittents. 3. Eruptive, or E xanthomatous. a. Variola. b. Rubeola. c. Scarlatina. Before entering on the consideration of the va- rieties of fever, it will be proper to make a few observations on the phenomena which occur in a febrile paroxysm. The paroxysm consists of three stages,—the cold, the hot, and the sweating, which in general succeed each other in the order enume- rated. These terms have been given from the peculiar symptoms observed in each stage : thus in the cold stage, there is sensation of cold accompanied by shaking ; the hot stage is indicated by increased heat; and the sweating stage, by the diaphoresis i>r perspiration which terminates the fit. The successive stages which constitute a true paroxysm of fever are only observed in intermit- tent fever, in which there is a perfect intermission, ER. or apyrexia between the fits. In continued and in symptomatic fevers (inflammations), though there may be sensible abatement of the febrile symptoms at irregular periods, complete suspen- sion of the disease for a definite time, as is ob- served in periodic fevers, never takes place. Though these diseases are often ushered in by a sensation of chilliness or actual shivering, almost invariably by morbid heat of the skin, still the rigor or cold stage is so frequently unobserved, that it cannot be said to be essential either to the continued or symptomatic forms of fever. The first symptoms of the cold stage [or stage of concentration] denote a primary impression on the nervous system. This is evinced by the disinclina- tion to exertion, and the evident feebleness or actual prostration. To these succeeds more or less restless uneasiness, which induces the patient to endeavour to obtain relief by frequent change of posture. This restless state is generally accompanied with more or less mental inquietude ; hence the inability to fix the mind on any subject requiring continued at- tention. These are the sensations precursory to the rigor or shivering fit, the first indication of which is a feeling of chilliness: this may be general or only partial; for instance, it may be confined to one or more of the limbs, or to the loins, while the other parts of the body feel com- fortably warm. The chilliness, after continuing some time, passes into tremor, which begins first in the lower jaw, and then gradually extending over the body, terminates in general muscular agi- tation. The tremor is often very severe ; in some instances so violent, that according to practitioners who have witnessed the more intense forms of intermittent fever, convulsions have actually super- vened ; this, however, is to be regarded as a rare occurrence, at least in temperate climates. The skin feels cold, not only to the patient himself, but sensibly so to another person; and when the ther- mometer is applied, the temperature is found to be many degrees below the average standard of health: according to Dr. Wilson Philip, it has been ob- served as low as 74° Fahrenheit. As the cold stage passes off, the skin becomes gradually warmer, though the patient is not always sensible of the change ; hence, while he still com- plains of feeling cold, the skin often feels comfort- ably warm, or even warmer than natural, to an- other person. The appearance of the skin in the cold stage indicates a deficiency of animal heat; the lips, nails, fingers, and toes, in fact those parts at a dis- tance from the centre of the circulation, are pale and shrunk, while the skin becomes rough, resem- bling that of a fowl after it has been stripped of its feathers : hence the term cutis anserina has been applied to express this condition of the skin. The shrinking of the integuments is exemplified by the fact of a ring which fits the finger before the approach of the cold stage, becoming so loose as to fall off soon after it commences. It is also not uncommon for ulcers to dry up, or tumours to diminish in size, and even to subside altogether, while the cold stage of fever lasts : but when the hot stage becomes developed, the finger enlarges, so that the ring again fits tight, ulcers again dis- charge pus, and tumours re-appear. From the intimate sympathy between the ner FEVER, (CONTINUED) 153 vous and circulating systems, there is in the cold stage of fever some alteration in the pulse. At the very commencement of the fit, before the rigor has come on, it is more feeble than natural; during the shivering it is small, quick, and occasionally irregular. The breathing is generally at the same time hurried, often suspirous, and the patient com- plains of tensive pain or constriction in the pre- cordial region. When this unnatural state of the muscular, circu- lating, and respiratory systems has continued for some time, the mental functions not unfrequently become disturbed, indicated by the restlessness so common in almost every kind of fever, by some degree of confusion, and sometimes delirium, or even coma. In some instances the nervous influence of parts at a distance from the brain becomes im- paired, as in the instance of some of the senses becoming affected, or of the patient complaining of a sensation of numbness in the extremities. The organs of secretion are at the same time more or less deranged. The patient is indifferent to food, and complains of thirst and of a disagree- able clammy state of the mouth. In some in- stances there is gastric disorder, manifested by fre- quent retching or vomiting, or purging of bilious fluid. This gastric irritation is, however, seldom observed in the periodic fevers of temperate coun- tries, though in the bilious remittents of hot cli- mates it forms a prominent character of the dis- ease, and is not unfrequently attended with jaun- dice. The urine in the cold stage is limpid. The analysis of the symptoms of the cold stage of fever proves the consecutive disturbance of the nervous, circulating, and secreting systems. It is, however, to be remembered that there is great dif- ference in the intensity of the affection in the several organs ; the prominent characteristic—the sense of cold, or even the rigor may be altogether wanting, or only represented by a degree of gene- ral indisposition, such as languor, chilliness, and sense of feebleness. This will be more particu- larly pointed out when irregular periodic fevers are noticed. The duration of the cold stage of fever varies from half an hour to four or five hours, but there is every intermediate variety as to its length. It is often longer in the first than in the subsequent paroxysms, and shorter in remittents than in inter- mittents; so that, although its average duration may be computed between one and two hours, much depends on the type of the fever, its sever- ity, and the climate in which it occurs. It is al- ways longer and more severe in warm than in temperate countries; it may even be mitigated by the adoption of certain measures to be pointed out when we come to notice the treatment; but as a general rule, it has been observed that when the cold stage is short, the subsequent stages of the fever are almost invariably severe. Though there is seldom any danger to be appre- hended in the cold stage, it is proper to state, that under some circumstances, so great has been the shock given to the nervous system, that the vital powers have never recovered such a degree of en- ergy as to produce re-action; indeed individuals have actually died in the cold fit. The approach of the hot stage [or stage of ex- pansion,] of fever is indicated by the chilliness Vol. II___20 or shivering subsiding, or alternating with warm flushings. The natural heat and colour of the skin then return, the shrinking and cutaneous constriction being succeeded by fullness, especially of the features, which in the beginning of the hot stage appear more turgid and animated than in health. This is followed by increased heat, which becomes gradually diffused over the body, the thermometer indicating an increase of several de- grees above the ordinary average temperature of health, (varying from 100° to 105° Fahrenheit,) while the skin feels dry and parched. With these external changes, there are corresponding altera- tions in the functions of the several organs : for ex- ample, the depression, stupor, or coma of the cold stage is succeeded by sensibility to external im- pressions, so that sounds or brilliant light are offensive; there is generally pain in the head, back, and limbs, and not unfrequently transient delirium. The breathing becomes more free; the pulse, from being small, feeble, and rapid, becomes more full and expanded, and the sense of precor- dial constriction, which is so oppressive in the cold stage, subsides. In this accelerated state of the circulation, hemorrhage from various parts, more particularly from the nose, lungs, uterus, or bow- els, is not uncommon. These evacuations of blood have generally been remarked to be salutary, by relieving local congestions, which are apt to take place in the hot stage of fever. There is little change in the natural functions • there is perhaps more thirst; the urine becomes high-coloured, but on standing does not deposit any sediment; and should there have been much gastric disturbance during the cold stage, it gene- rally abates or goes off entirely as the hot fit be- comes developed. The hot stage gradually terminates in copious perspiration. This constitutes the sweating stage, [or stage of termination,'] which is generally fol- lowed by great relief. The upper parts of the body first become bedewed with moisture, the sweating afterwards extending over the trunk and lower extremities. The sensorial disturbance now vanishes, the pulse resumes its natural tranquillity, the breathing becomes easy, and the urine in many instances deposits a sediment some time after it has been voided. The sweating, after continuing some time, disappears, but the patient remains weak and exhausted after the paroxysm has quite disappeared. Though these three stages occur in regular progression in every well-marked paroxysm of periodic fever, there is great diversity in the in- tensity and duration of each paroxysm as well as of its several stages, as will be fully illustrated when the different forms of periodic fevers are treated of. FEVER, CONTINUED. —The division of fever which, according to the proposed arrange- ment, comes first under consideration, is the con- tinued. This class of fevers has been so termed from the paroxysms consisting of remissions and exacerbations, without intervals of abatement or pyrexia, as in the intermittent and remittent types. In systems of nosology every variety of con- tinued fever is comprehended under the term Sy- nochus (from the Greek word awe^u, to continue.} 154 The milder forms have been termed synochus mi- tior; the more intense, synochus gravior; the intensity depending on the various local inflam- mations which arise in the progress of the fever. 1. Simple Fever__There is, perhaps, no dis- ease in which the premonitory symptoms are so diversified as those of fever; this is owing to the o-eneral resemblance observed in the commence- ment of every febrile disturbance, whether idiopa- thic or symptomatic ; and it is not until the symp- toms have continued for some time that the prac- titioner can discriminate the precise nature of the lisease. In idiopathic fever there is generally a period A undefined indisposition, evinced by disinclina- tion to mental exertion : the individual is incapa- citated from any ordinary mental effort; his percep- tions are less clear and distinct than usual. To this condition of the mental powers the term lan- guor is applied, and it is always an indication of he commencement of febrile action. A sensation if lassitude or diminution of muscular vigour is lext felt; the patient feels fatigued and averse to anv kind of exertion ; if he attempt to walk, his mivements are feebly or unsteadily executed. The muscles soon become unable to support the weight of the body ; hence the recumbent posture is not only most easy, but indispensable. Boer- haave first applied the characteristic term debilitas febrilis to this state of the muscular system in fever. The alteration in the expression of the countenance, so marked in fever, is probably inti- mately associated with this condition of the mus- cular system, and forms a diagnostic of great value to the experienced practitioner, not only of the nature of the disease, but of the various changes which take place in its progress. It is difficult to give in words an idea of the febrile countenance: there is a look of anxiety, denoting much inward distress; the features are pale and sharp; and the whole expression is so changed as at once to alter the character of the countenance: hence the fa- vourable impression which is always taken from any improvement in the aspect of the features. Irregular chills and sometimes shivering come on; but more generally there are alternate fits of heat and cold of short duration, which continue to recur at intervals, even when the skin is hotter than natural; and it will be observed that during the time the patient complains of chilliness, the skin does not feel cold to another person, nor does the thermometer indicate any diminution of tem- perature. It appears, therefore, that the coldness is produced by some cause within the system it- self, and is by no means to be attributed to exter- nal temperature, as it is observed in hot as well as in cold climates, and to recur when every pre- caution has been adopted with respect to the tem- perature of the apartment and the clothing of the patient. About this period there is great restlessness, and uneasiness of an undefined and indescribable nature, which, after a short time, is succeeded by pain in the loins and extremities, with feeling of getieral soreness. These symptoms, denoting the first stage of fever, are succeeded by those indicating re-action. The face becomes flushed, and the heat over the surface is steadily and uniformly above the natural FEVER, (CONTINUED) temperature, varying from 100° to 105° Fahren- heit. The heat on some parts of the body is per- ceptibly greater than on others ; hence, in those irregular accessions which take place, the increase is chiefly perceptible in the face, hands, and feet. Sometimes, on the other hand, there is no increase of the animal heat in fever; the skin throughout the course of the disease retaining its natural temperature, or in some cases falling even below it: such deviations are always to be regarded as unfavourable, though, as physiology has not yet discovered the source of animal heat, we are igno- rant of the causes on which they depend. If the circulation be now examined, the pulse, which at the beginning is oppressed, will be found quick, seldom, however, exceeding 100°. Besides increased frequency, it may have acquired other characters; it may be quick and soft, or full and strong, seldom, however, hard or tense. It occa- sionally, though very rarely, happens that the pulse does not, during the progress of fever, vary from its natural condition either as to frequency or power, and even when the other symptdms are well marked. A similar anomaly has just been pointed out as to the heat of the skin, which now and then does not exceed, or even falls below the natural temperature. Though the function of respiration is not neces- sarily involved in fever, still, when the febrile ex- citement is considerable, the breathing become*. hurried. This condition must be distinguished from that which depends on some inflammatory condition of the lungs. The absence of cough in the one instance, and its almost invariable pre- sence in the other, with the sounds elicited by auscultation, will tend materially to aid the practi- tioner in forming a proper judgment of this symp- tom. It should also be kept in view that in those forms of fevpi m which the brain is severely affected, the breathing becomes embarrassed. It is sometimes short and quick, or slow and inter- rupted. In these cases the state of the breathing is the effect of the disturbance in the brain, and not of pulmonary disease. When the fever has thus become developed, the primary disturbance of the brain is succeeded by symptoms which indicate increased action in the cerebral vessels. This is indicated by headach; the pain being in some instances confined to the forehead, sometimes to the occiput. It varies in intensity as well as duration, but is always increased on any movement of the body, or any circumstance which excites the circulation. In many instances of the mild forms of fever, how- ever, the patient never experiences headach; he complains only of giddiness or of a sense of heaviness or weight, particularly in the occiput. It is not easy to explain the cause of these differ- ences in sensation, but it is important to bear in mind, that they all depend on one and the same condition of the brain, and require similar though perhaps modified treatment. As the disease proceeds, the languor and lassi- tude of the first stage give place to sensorial dis- turbance, indicated by great restlessness and irrita- bility, and sometimes slight delirium towards evening, which abates or totally disappears in the morning. The various senses are more or less disturDed; FEVER, (CONTINUED) 155 the hearing is often morbidly acute, so that even slight sounds give uneasiness if not pain; some- times it is dull and obtuse; the sense of smell is vitiated ; the taste is so altered that common articles of d^iet are scarcely recognised, and there is gene- rally great aversion or loathing of food ; the mouth is clammy ; the tongue covered with thin white fur; and there is more or less thirst. The excretions are altered, both as to quantity and quality ; the urine is high-coloured and tur- bid, or deposits a sediment on standing ; and the evacuations from the bowels are generally of an unhealthy character. The fever is now said to be fully formed, or, in popular language, to be at " its height." In the majority of cases, towards the evening, or in some instances at irregular intervals, there is an exacer- bation, or general increase of the febrile excite- ment, which abates towards the morning. The accession is indicated by greater restlessness, by the skin becoming more hot, the face more flushed, and by increased thirst and frequency of pulse. It is probably in consequence of the increased velo- city of the circulation through all the organs, and consequently in the brain, during these exacer- bations, that the patient is so much more restjess and indisposed to sleep; and hence it is that, when there is disposition to congestion or inflam- mation in any organ, it is often developed at these periods. With regard to the duration of simple fever, the symptoms may continue without any particu- lar change for a few days; but its limitation de- pends on a variety of circumstances. It may last only one day, and this constitutes the common ephemeral fever, which terminates in twenty-four hours; a form to which women in childbed, from a variety of causes, are occasionally subject: or it may go on for an uncertain number of days, or even weeks, terminating, however, in the majority of instances, about the end of the second or begin- ning of the third week. It not unfrequently happens that its duration is materially diminished by some spontaneous evacuation ; either by the skin or bowels, or perhaps by some accidental hemorrhage; or without such Spontaneous efforts of the system, by moderate venesection, if the febrile excitement require the loss of blood, or in milder cases, by purging, confinement to bed, and the adoption of a mild farinaceous diet. The ancients, who accurately observed the phe- nomena and progress of fever, remarked that the symptoms showed a tendency to abate at regular periods, which were called critical days. This crisis was observed to occur on the third, seventh, fourteenth and twenty-first days from the com- mencement of the symptoms, or first invasion of the disease. If the symptoms passed over the first period, those who gave credence to this doc- trine predicted, that the fever would go on to the second or beyond it; for example, if the symptoms did not abate on the seventh, that the fever would not terminate till the fourteenth day; if this day were exceeded, that it would run on to the twenty- first, and so on. Modern physicians place very little confidence in this restricted duration of fever. The ancients, being afraid of interfering in any way with the efforts of nature to get rid of what they supposed hurtful to the system, considered every kind of treatment improper, and were, therefore, more likely to observe, in the milder forms of fever, an abatement by crisis on particular days. The mo- dern treatment of the disease, founded on more just views of its pathology or nature, is very likely to interrupt or disturb such regular periods of de- cline ; and therefore, though the doctrine of criti- cal days is not in our day altogether exploded, practitioners are either less inclined to look for them, or to reject the idea as not according with nature. Besides, in fever complicated with local inflammation, such regularity in the crisis cannot be expected to occur; the symptoms depending in some measure on the condition of the organ, which may, in the progress of the disease, have become inflamed. It cannot, however, be doubted that the notion of critical days was originally founded on correct observation, that fevers are disposed to terminate favourably or unfavourably at certain periods; and though such critical termination can- not in every, or even in the majority of instances, be discerned or traced, the fact, that simple or un- complicated cases occasionally do so, should al- ways be kept in view. The convalescence, or period of the decline of fever is observed to be gradual; the feelings of the patient improve, his countenance becomes ani- mated, and its expression so altered, that except by those who are acquainted with the previous aspect of the countenance, the ii dividual would not be recognised—the sleep becomes longer and more refreshing—the pulse comes down gradually till it returns to its natural frequency—the skin becomes cool—the tongue clean, the appetite for food returns—the thirst ceases, and the strength and spirits improve. These favourable changes indicate the stage of convalescence, which is con- firmed in a few days under proper management, especially if great attention be paid to the regula- tion of diet, and avoiding undue bodily or mental fatigue. No consideration should induce the practitioner to relax in firs close attendance during this most important, but too often neglected period of the disease. The description now given applies to the mild epidemic fever of this and other temperate cli- mates. It is almost unnecessary to state, that there is every gradation not only in the intensity, but in the duration of the symptoms. The symp- toms may be so mild as scarcely to require more than an aperient, quietude, and abstinence; or they may assume a severe character,—the fever passing into some of the other forms to be after- wards described. Inflammatory Fever.—A variety of contl nued fever of a hyper-acute form is occasionally observed, and, though not very common in tempe- rate climates, it does now and then occur, and re- quires notice. It has been called >flammatory fever (synocha), and may occur at all ages and in all habits, forming the general character of fever in young and plethoric subjects, who have great muscular power and corresponding vigorous cir- culation. When it occurs in cold and temperate countries, it is distinguished from simple fever (synochus) by its more sudden invasion,—by the more pungent heat of the skin, flushing of the face. suffusion of the eyes and intolerance of light J56 FEVER, (CONTINUED) more intense headach, throbbing of the carotid and temporal arteries, watchfulness, and delirium. The pulse is seldom very rapid at first, but as the dis- ease proceeds, it becomes full, round, and tense, but never remarkably frequent, and the blood after venesection generally exhibits the buffy coat. The breathing is quick, the thirst incessant, and the febrile restlessness distressing. In some in- stances, there are nausea and vomiting, with pain in the epigastrium, stretching to either hypochon- drium, more especially if this form occur in the summer and autumn months in warm climates, where it is generally termed bilious or bilious in- flammatory fever. When inflammatory fever be- comes fully developed, spontaneous hemorrhage not unfrequently occurs; if it proceed from the nose, it generally affords great relief to the symp- toms, on which account it should not be interfered with, unless it produces feelings of exhaustion. From the violence of the general excitement in inflammatory fever, local inflammations are ex- ceedingly apt to intervene. It may also pass into other forms : we accordingly find that in warm climates, more especially in the West Indies and some districts of the United States, it assumes very often the remittent type, or it may lapse into a low kind of typhoid fever. Its duration varies according to circumstances. It now and then assumes an ephemeral character, —disappearing in twenty-four hours : mild cases of longer duration by proper management may pass off in a few days; but if the symptoms be neglected in the commencement, the fever may last two or three weeks or longer, and then gra- dually subside, the symptoms losing their acute character as the disease advances. It is proper, however, to state that in our expe- rience of the epidemic fever of this country, this form, (synocha,) if it really do occur, has been seldom observed. A few sporadic cases, which have many of the essential characters detailed, certainly present themselves occasionally in the spring months ; but these form a comparatively small average proportion of the ordinary fever of Britain. It is, therefore, to the fevers which occur in warm climates that the description given more particularly applies; the character of fever, as will be afterwards explained, being materially in- fluenced by climate and season, It is also neces- sary to bear in mind the local inflammations which almost invariably arise in the course of these acute fevers, and the effect of such compli- cations on the febrile symptoms. Gastric Fever.—When the symptoms of common fever are attended with more than ordi- nary gastric derangement, the term gastric fever has been applied. Hippocrates, with his charac- teristic discernment, evidently alludes to this va- riety of fever, in treating of acute diseases with heat and biliary dejections,- and Galen, the first writer who distinguished fevers into sanguineous and bilious, founded his idea of the latter on the condition of the stools. This form of fever has in later times been called by different names. Baillou first termed it gastric fever; Hoffmann, the cho- leric; Baglivi, the mesenteric,- John Peter Frank, febri* continua gastrica; Pinel, the meningo- (rastrtc. Disorder in the alimentary canal gives rise, not unfrequentlv, to fever of a particular form. In other instances, symptoms of gastric disorder may supervene on common fever; in either case, the train of symptoms, which are very much alike, and require a similar mode of treatment, are in the one case the cause, in the other, an accidental accompaniment of the fever. Gastric fever may occur sporadically ; at other times the gastric symptoms form the prominent type of an epidemic; and from its prevailing in the summer and autumn months after very hot weather, it would seem to be produced by some atmospheric or terrestrial emanations peculiar to this season of the year. There are several ac- counts on record of epidemic gastric fever; indeed, the fevers of Britain towards the end of summer and in the autumn are almost uniformly accom- panied with gastric irritation, and from our indi- vidual experience of the character of fever for the two preceding years (1830 and 1831,) we can affirm that an unusual degree of gastric disorder has accompanied the disease during the whole of that period. The type of the fever has moreover been low and typhoid to a degree which has not been witnessed for many years preceding, so much so as to preclude the employment of evacuations of any kind, and to render stimuli necessary to an extent very unusual in the London Fever Hos- pital. From a communication with which we were lately favoured by our friend Dr. Brown of Sun- derland, it appears that a similar type of fever preceded the late visitation of cholera in the north of England. This fact, with the similarity of the symptoms of epidemic fever in those situations in which cholera has hitherto appeared, renders it probable that some peculiar condition of the at- mosphere has given a tendency to gastric disorder, not only in fever but in other acute diseases. It is a singular circumstance, also, that when cholera appeared in London, epidemic fever sensibly di- minished both in frequency and severity, while the gastric irritation and prostration of strength, which formed the prominent features of fever, have also nearly subsided. In gastric fever there is great variety in the mode of attack and sufferings of the patient. In some cases there is so little evidence of illness that the patient follows his ordinary pursuits, thinking he is only indisposed from derangement of stomach, till the prostration of strength and the gradual accession of febrile symptoms show evi- dently the nature of the disease. In other cases the symptoms from the beginning are so well marked, as to leave little doubt of their nature and tendency. The precursory symptoms are very similar to those of other forms of fever — sense of chilliness, rigors, irregular flushes of heat, languor, las- situde, pain in the head, loins, and extremities. The face is pale and sallow, the conjunctiva vel- low; the mouth clammy and bitter, the breath fe- tid ; the tongue at first is slightly coaled with thin white or grey fur, which increases in thickness, becoming yellow over the body and root, while the point and edges are red : in other cases, it is clean and morbidly red from the beginning. More or less disturbance of the stomach is ob- served early m the disease ; there is pain or s^nse FEVER, (CONTINUED) 157 of weight or distension in the epigastrium; often nausea and retching, which generally ends in vo- miting of bilious fluid : the state of bowels is vari- able ; there is either constipation alternating with diarrhoea, or there is purging from the commence- ment, the stools being watery, of a pale green, or brownish yellow colour, extremely fetid, and occa- sionally mixed with blood. The pulse, which from the commencement may not have been much accelerated, now becomes rapid; the breathing hurried ; the heat of skin pungent; the febrile uneasiness and general pain increased ; and to- wards evening, there is exacerbation of the symp- toms, with watchfulness and delirium. As the morning advances, however, a distinct remission lakes place, accompanied with gentle moisture on the forehead and chest. The coating on the tongue becomes more thick, sometimes dry and brown; and the urine, scanty and passed with pain, de- posits a lateritious sediment. At a still more advanced period of the disease, we observe the morning remissions so slight as to be scarcely noticed, while the whole complexion of the symptoms becomes aggravated; the deli- rium, which was perhaps only noticed towards evening, is constant; the tongue, palate, and throat are more dry, and covered with viscid mu- cus, or a dry, hard, black crust envelopes the tongue, which is sometimes irregularly fissured and covered with aphtha? ; the speech and sense of hearing are impaired ; the eyes suffused ; the pulse is very rapid and compressible; the evacuations are passed unconsciously, with tympanitic disten- sion of the abdomen. This congregation of symp- toms denotes an intense and advanced form of gastric fever, from which the patient not unusually perishes, though if the previous powers have been vigorous, and the treatment judicious, the patient may be recovered. When a favourable termina- tion is about to take place, the delirium abates, the morning remissions become again distinct and of longer duration, the skin cool and soft, the tongue and palate moist, the former throwing off its dark incrustation and exhibiting the subjacent mucous membrane morbidly red and tender; the bowels become pungent, the stools more consistent, and the abdomen feels soft from the subsidence of the tympanitic distension. When a fatal termination is about to ensue, the yellowness of the eyes, headach, delirium, and flushing increase ; the patient, at one time furious, becomes drowsy and comatose; the stools, and occasionally the urine, bloody and passed involun- tarily ; the tongue, tremulous, and, as well as the teeth, covered with dry black fur, cannot be pro- truded. To these symptoms succeed picking of the bed-clothes, starting of the tendons, hiccup, rapid breathing, cadaverous smell of the perspira- tion and breath, cold sweats, imperceptible pulse, and coldness of the extremities. It is necessary to state that in gastric as well as other forms of fever, local inflammations arise in its progress. It is, therefore, important to watch the symptoms in the different organs, more par- ticularly the brain, which from the inflammatory type of the fever at the commencement is often severely affected. In like manner the several or- gan? in the chest and abdomen may become in- flamed, and render the disease formidable. o Frank states, that in some cases quantities of worms are expelled from the stomach and bowels during gastric fever. In such instances the febrile symptoms are accompanied with those peculiar to vermination — wandering pains, itching of the nose and anus, prominence of the abdomen, vo- miting, tenesmus and copious mucous stools. The duration of gastric fever is uncertain. When the disease is mild, it may not last above a week or ten days ; generally, however, it is tedious and protracted, more especially if neglected in the early stage. It is unnecessary to state that its duration will be materially affected by any inflam- matory complication with which it may happen to be associated. The history of epidemic gastric fever, written for this work by Dr. Cheyne, gives an admirable sketch of this variety of fever; and we beg par- ticularly to call attention to the observations of that able physician on this subject. (See Fever, Epidemic Gastric.) 2. Complicated Fever. — In the preceding observations it has been our object to show thai in simple fever the disturbance in the various or- gans, however severe, is only functional, no in- flammation in any organ having as yet taken place. It is necessary, however, that the practitioner should bear in mind, that although fever at its commencement may be mild, in a large proportion of cases it assumes a severe character, in conse- quence of some local inflammation arising in its progress. Hence, whatever be the primary effect of the exciting causes on the various organs, the transition from excitement to inflammation is often rapid, more especially when there is predisposition to disease in any particular organ. From what has been previously advanced, as well as from the facts which will be adduced when the causes of fever are discussed, there are strong grounds for supposing that the febrile poison pro- duces a peculiar or specific effect on certain or- gans of the body in the first instance. The affec- tion thus primarily induced, whatever it may be, is not, however, of an inflammatory character, though it is evident, both from symptoms observed during life, and from morbid appearances after death, that inflammation does arise in certain or- gans in the progress of fever. If the febrile poison be not in a state of great concentration, it may be presumed that a peculiar action only is exerted on one or more organs; if the poison be in a state of greater activity, it would appear to produce se- vere organic lesion — inflammation and its conse- quences. We do not pretend to explain the modus ope- randi, or theory of action of the causes alluded to; or why, in individuals exposed to the same causes, in one case very slight effects, while in another the most severe and often fatal symptoms are produced. There may be greater aptitude foi the reception of the febrile poison in one persor than in another, arising from individual peculiarity or idiosyncrasy, as it has been termed. This tendency of the primary febrile affection to pass into inflammation, which local inflamma- tion is the cause of the severity in the majority of cases of fever, should never be overlooked. Il is equally important to bear in mind that the inflammatory action which supervenes, is of a 158 FEVER, (CONTINUED) less intense kind than in the ordinary phlegm- asia?. There are few organs in the body which are not occasionally affected in fever. Some, how- ever, suffer more uniform and severe lesion than others; as, for instance, the brain and spinal mar- row, the mucous membrane of the lungs, and of the alimentary canal. Inflammation of the paren- chyma of organs is occasionally, though less fre- quently, observed. Cerebral complication. — From the almost in- variable disturbance in the brain and nervous sys- tem in fever, it is particularly necessary to watch any tendency to transition from functional disor- der to inflammation of the brain. Not only the symptoms during life, but the morbid appearances discovered after death prove that inflammation of the membranes of the brain is by far the most frequent and dangerous of the local inflammations that occur in the progress of fever. The cerebral affection assumes various degrees of intensity. In some cases it is mild, in others severe ; and between these extremes there is every intermediate modification. Sometimes the cere- bral affection appears in solitary instances during a mild epidemic, or it may form the prominent character of epidemic fever. If the symptoms be attended to, it is impossible to overlook the first indications of acute affection of the brain in fever. The general symptoms may at first be little urgent, and proceed as has been stated in the history of mild fever. The patient, however, is afterwards observed to com- plain of more constant and severe pain in the head, accompanied with throbbing of the carotid and temporal arteries, flushing of the face, and heat of the scalp. In general the pain is confined to a particular part, very often to the forehead and temples, occasionally shooting to the occiput; at other times it is felt chiefly in the back of the head. In many instances the cerebral inflammation is not indicated by pain, but by giddiness. Even if the head be shaken, or suddenly moved, no pain is induced, though the giddiness and flushing are increased. Moreover, when pain in the head has existed, it is often of short duration ; but, not- withstanding it has ceased, the local affection may be proceeding with equal, if not increased vigour, and, if not arrested, may speedily destroy life. The absence of pain in such cases, therefore, must not be allowed to throw the practitioner off his guard ; he must be guided in his opinion of the condition of the brain by the presence of other equally pathognomonic signs. Thus the eyes are brilliant or suffused, their expression either mor- bidly animated or dull, but generally sensible to fight; hence the contracted eyebrows, half-closed eyelids, and the relief experienced from a dark loom. The sense of hearing is also morbidly acute. Sounds which the patient has been accustomed to hear without even exciting attention, become dis- agreeable, or even painful; every precaution in such cases is therefore taken to lessen the inten- sity of sounds. Though the febrile action usually produces a state of watchfulness, this condition is much in- creased when the brain becomes inflamed ; it is often accompanied with a degree of restlessness or moaning; but after the cerebral vessels have been unloaded, the patient generally becomes tranquil, and enjoys intervals of refreshing sleep. There is also in cerebral inflammation more or less intellectual disorder. In milder cases, the patient is perfectly conscious while awake, but if he drop asleep, it is interrupted by talking; and when he awakes, he is for a time forgetful, utters perhaps a few incoherent sentences, and then be- comes perfectly sensible. As the evening ap- proaches, however, the confusion becomes again perceptible, especially on the termination of the occasional short periods of disturbed sleep which attend this stage of the disease. In more severe cases, delirium is observed at intervals during the day when the patient is awake ; and if the symp- toms in the brain be urgent, it is incessant, loud, and noisy. The symptoms enumerated indicate a degree of inflammation of the brain, not uncommon in the epidemic fever of this country, which, if treated by the early and vigorous employment of suitable measures, is in general readily subdued, and the recovery proceeds satisfactorily. The cerebral affection, however, occasionally assumes a more severe form ; and those destruc- tive changes which often rapidly take place in the delicate organization of the brain, sufficiently show the intensity of the previous inflammatory action. The symptoms which indicate this more severe form of brain affection differ from those which at- tend the sub-acute, chiefly in degree. The pain is more severe and constant; the patient often rolls the head from side to side; the eyes are more suf- fused ; the sensibility to light and sound is great- er ; the breathing is rapid and suspirious; the anxiety of countenance is increased; the restless- ness and delirium assume a more formidable char- acter : while the noisy vociferation or screaming is incessant, the violence of the patient often re- quiring restraint. The pulse is more round and tense, but in some cases it is soft, irregular, or in- termitting. The skin is hot, and often perspires profusely, in consequence of the incessant bodily agitation or struggling. If active treatment be neglected in the beginning, or should the attack in the brain be of such a severe character as to bid defiance to the treatment employed, the pow- ers of the system give way; the delirium does not subside, but it loses by degrees its acute charac- ter; the patient becomes drowsy, and observant only when roused ; the eyelids are half closed; sometimes there is squinting or rolling of the eye- ball, with dilatation of the pupils; muscular tre- mor and starting of the tendons come on ; deglu- tition is performed with difficulty ; and the drow- siness finally passes into profound coma. The patient then becomes insensible to all external ob- jects; the urine and stools are passed involunta- rily ; the tongue becomes dry and brown; the teeth and lips covered with sordes; the pulse rapid and feeble, occasionally irregular; and life is speedily destroyed. It is necessary to bear in mmd that between acute and sub-acute inflammation of the brain in fever, there is every variety cf degree or intensity. In many instances the cerebral inflammation as- sumes a slow insidious character, and is onl\ FEVER, (C detected by vigilant examination. Sometimes when there is considerable excitement in the brain, the pulse and other febrile symptoms do not indicate much febrile action; the pulse may not be above the average frequency of health. In some cases the pain ceases entirely, and is succeeded by par- tial insensibility. The skin may be cool, and the tongue little furred ; yet notwithstanding these favourable circumstances, a low form of chronic cerebral inflammation may be going on. In some instances, again, inflammation of the brain suddenly comes on in the progress of the fever, when there were no previous warnings of its approach. Hence the necessity of watching with incessant vigilance every case of fever during its progress; as no case, however mild or promis- ing, is free from the possibility of sudden attacks of inflammation of the brain. Pulmonary Complication.—The organs of respiration at certain seasons, and in particular epidemics, suffer from inflammation in the course of fever. Laennec states on this subject, that "one of the most interesting results which auscul- tation has furnished is the constant presence of a catarrhal affection, either latent or manifest, during the whole course of continued fever. At the com- mencement, and most commonly through the whole period of the fever, the catarrh is latent, without cough and expectoration, and only to be discovered by the stethoscope. Sometimes it be- comes manifest on the approach of a crisis; and, indeed, the crisis by expectoration noticed by the ancients is neither more nor less than this catarrh. Catarrhal fever is applied to those forms in which the catarrh, just stated to be inseparable from con- tinued fevers, early manifests itself, and gives rise to a copious mucous expectoration. The same appellation has also been given to those violent catarrhs which are accompanied by a symptomatic fever; but in this case the fever, though consider- able at first, and often of long continuance, soon loses the character of acute fevers, terminates long before the catarrhal affection, and never presents that combination of cerebral congestions and ab- dominal disorder, more or less severe, exhibited by true idiopathic fevers, which must be considered as diseases affecting at the same time a great many organs, and perhaps still more particularly the fluids. In eruptive fevers the pulmonary catarrh is equally constant, and most commonly in them it is manifest. In measles it is well known always to be so, and it continues often for a long time after this disorder is cured. The same thing occa- sionally takes place after simple continued fevers; but in these I have also had frequent occasion to observe, that when a crisis takes place, at the very time when the lateritious sediment shows itself in the urine, every sign (even stethoscopic) of perhaps a very intense and extended catarrh dis- appears at once with the coma, tympanitic affec- tion, quick pulse, heat, and earthy character of the skin. During the paroxysms of intermittent fever the stethoscope detects in like manner symptoms of catarrh, for the most part dry and latent, and of which some traces remain in the intervals. Even the fevers which are most decidedly symp- tomatic, for instance those arising from a wound, very commonly present the same phenomena. It would, therefore, seem that the first effect of febrile ) N TIN U E D) 159 action is to produce a congestion in the mucous membrane of the bronchi; and this effect is readily conceived on taking into consideration the energy of the actions of concentration and expansion which constitute fever. The inflammatory fever of nosologists, that is, the fever characterized by a flushed countenance, moist and clean tongue, and a moist and moderately hot skin, is, of all fevers, that in which the marks of dry catarrh are the least perceptible. I have even observed two cases of this fever in which the sound of respiration through their whole course was uniformly strong and pure, that is, unmixed with any kind of rattle over the whole extent of the lungs. It may here be remarked that this species of fever is, of all, the least liable to change into another form; that it is rarely accompanied by symptoms of any consider- able degree of cerebral congestion ; that it is hardly ever attended by signs of irritation, or by eruptions or ulcerations of the mucous membrane of the in- testines, or by a tympanitic state of the same ; and, lastly, that it is almost the only fever in which the blood exhibits the inflammatory crust. In all these respects, then, the inflammatory fever appears to differ either in its nature or cause from other continued fevers; it is unquestionably the most simple of all, and can least of all be consi- dered as a primary affection of the solids. Pulmo- nary catarrh is occasionally a striking symptom of pernicious intermittent fever. This appears to have been the case in the epidemic catarrhal fever of 1778 ; for we find a French Medical Society about that time giving it as a prize question, ' To ascertain the relations of remittent catarrhal and pernicious fevers? " (Laennec, p. 101-2.) Although bronchitis is a very frequent compli- cation of fever, especially in some epidemics, and at particular seasons, it is by no means so univer- sal as the observations of Laennec would lead us to suppose ; neither is it to be considered an essen- tial constituent of either continued or remittent fevers ; but that it does occasionally supervene in both forms is undoubtedly true. It is, perhaps, of all the complications, the most universal in the fever which occurs in the winter and spring months in this country ; and no doubt its fre- quency is in a great measure to be imputed to the sudden variations of temperature peculiar to the climate of Britain. The symptomatic bronchitis of fever is scarcely to be recognized during the first few days. When it becomes more developed, the symptoms are, besides those which are proper to fever, pain or constriction in the chest, slight acceleration in the breathing, with wheezing sound (mucous rattle) of the respiration on applying the ear or stetho- scope to the chest. There is generally at the same time cough, which comes on in fits; it is dry in the early stage, but in the course of a day or two expectoration of viscid mucus, which is expelled with difficulty, and occasionally streaked with blood, takes place. As the bronchitis proceeds, the expectoration becomes more copious and easy, and of a pale yellow or greenish colour. The mucous rattle may be partial or extensive, accord ing as the bronchitis is confined j ? "mail oi large portion of the lung. When it is heard ovei the whole of one lung, the bronchial affection '« severe; if it be distinct in both lungs, the ca^ 160 F.EVER, (CONTINUED) generally terminates fatally. In some cases, how- ever, there is no cough, the existence of the bron- chial affection being indicated by slight acceleration in the breathing, with sense of constriction in the chest. The absence of cough renders the local disease very apt to be overlooked ; but the state of the respiration, with the aid of stethoscopic examination, will generally sufficiently point out its existence. In many instances, especially in persons who have had former attacks of pulmonary catarrh, the bronchial affection assumes a more intense form. The breathing is hurried and oppressed, especially after fits of coughing ; sometimes it is slow, labo- rious, and wheezing; the lips are of a dark blue, or livid colour; the cheeks flushed or of a dusky hue. In still more intense cases, the whole counte- nance becomes suffused with dark-coloured blood, and from the air-cells being clogged with viscid mucus, the blood is not duly arterialized; the functions of the brain are, consequently, more or less embarrassed, according to the severity of the bronchial affection. The patient first becomes occasionally incoherent, and afterwards comatose ; the pulse soft and feeble; the tongue covered with deep brown, or almost black crust, while the tem- perature of the skin, more especially of the parts at a distance from the centre of the circulation, falls below the natural standard. It is unnecessary to add that these symptoms indicate great danger ; for although recovery under such circumstances may take place, the majority die from the destruc- tive effect of unoxygenated blood on the brain and nervous system. It should be kept in mind, that in cases of fever accompanied with severe affection of the brain, the various local complications become so much ob- scured as to be in many instances entirely over- looked. It has been already remarked that symp- tomatic bronchitis is often latent in the early stage. When the affection of the brain has been urgent, the bronchial affection never becomes so fully developed as to be recognised by its usual symptoms ; it may be going on in an intense form, without any suspicion of its existence. The advantages to be derived from auscultation under such circumstances must be evident; and, there- fore, in all the severe forms of fever, the applica- tion of the stethoscope should never be omitted. Though bronchial inflammation is the only form of disease of the chest, which can be said to be peculiar to the severe forms of fever, yet true pneumonia and even pleurisy may arise in the progress of the fever, more especially during the stage of convalescence in cold variable weather, and often under such circumstances prove fatal. In some instances these inflammations, also, assume a slow insidious character, or become en- tirely latent; and so obscure do such complica- tions become, that extensive organic changes have been discovered after death, the signs of which have been either very doubtful or entirely wanting during life. Such cases are more common when the previous affection of the brain has been se- vere ; and hence the necessity of frequent stetho- scopic examinations in the course of fever, espe- cially if protracted. It is here necessary to advert to a particular form of fever, which has at various times appeared i epidemically in different parts of the globe. From the catarrhal symptoms which gave the peculiar character to the disease, it was termed catarrhal fever, epidemic catarrh, or influenza. The dis- ease appears to have been the consequence of an atmospheric poison acting on the mucous mem- brane of the air-passages ; and from the extent to which it prevailed, and other circumstances ob- served in those who were seized with the disorder, to have had strictly and truly an epidemic origin. It spread over large territories, travelling from north to south, though less frequently from east to west. The epidemic of 1781-2 is recorded to have first made its appearance in China, and to have traversed Asia into Europe; from thence it crossed the Atlantic, and extended the following year over the continent of America. The symptoms usually commenced with alter- nate fits of chilliness and heat; sometimes shiver- ing preceded the febrile indisposition. The patient soon after felt great languor and feebleness; the debility and depression of spirits being always to a greater degree than could have been anticipated from the mildness of the other symptoms. The most striking feature of the disease next appeared —a distressing pain and sense of constriction in the forehead and temples, often extending over the whole face, and accompanied with a sense of soreness in the cheek-bones. These symptoms were followed by uneasy sensation about the eyes, sneezing and hoarseness, incessant cough, with soreness and constriction about the precordia, or stitches in the chest, and pain in the back and loins. To these succeeded lachrymation and pro- fuse discharge of thin mucus from the nostrils and lungs, which continued through the course of the disease. The appetite and sense of taste were much im- paired or entirely lost; in many cases there was nausea, and sometimes vomiting ; the tongue be- ing coated with thin mucus. The thirst was in- considerable ; the state of the bowels variable; in some they were regular, and in others confined; sometimes there was spontaneous diarrhoea, gene- rally attended with pain, at various periods of the disease. The pulse, though frequent, was soft and easily compressed ; the heat of skin was relieved by irre- gular sweatings. Daily exacerbations and remis- sions of the cough and fever were in many in- stances observed ; in others, they did not occur, or, if they did, were so slight as to escape observation. The disease was in some cases very mild; some- times there was only slight fever, with soreness of the throat and uneasiness in the chest, but no discharge of mucus; but the languor and lassitude were always well marked. In some the disorder began like smart fever, and in a day or two as- sumed the characters of common cold, and conti- nued to hang about the patient for a period vary- ing from a week to a month. Abdominal Complication.—Of the organs situated in the cavity of the abdomen, the mucous membrane, but more especially the follicles of the small intestines, undergo certain changes, and al- though these intestinal lesions are by no means invariable, yet, as we have before stated, in some FEVER, (CONTINUED) 161 epidemics, and in the fever of particular localities, they are frequently observed, and form severe and often dangerous complications. In milder cases of the common fever of this country there is probably little if any intestinal affection ; but in the more severe forms the intes- tinal disease becomes a prominent characteristic of the fever, and generally induces sympathetic disturbance of the brain, or should the cerebral affection have already existed, never fails to in- crease it. In gastric fever the abdominal symp- toms are often so obscure and insidious as scarcely to attract serious attention till the disease has made some progress. Indeed, in fever, destruc- tive disorganization of the bowels may be going on without the practitioner or patient being at all aware of its extent, from the want of diag- nostic symptoms to indicate the intestinal lesion on which the danger depends. It is often the cause of slow and protracted fever, and a febrile indisposition which is mild at the beginning often becomes serious from the supervention of this se- condary intestinal affection. It may be suspected in such cases, when, in addition to the ordinary febrile symptoms, the skin is dry and parched, the thirst excessive, the lips and prolabium red, the tongue red at the point and margin, the bowels irregular (diarrhoea alternating with constipation), and the abdomen tympanitic, with or without ten- derness. When the brain becomes sympathetically dis- turbed, the face is flushed, delirium supervenes followed by more or less stupor or coma, and in- sensibility to pain and to the evacuations by urine and stool. Dr. Bright, who has given an excellent account of the symptoms and morbid anatomy of this in- testinal affection as it occurs in the course of con- tinued fever, (Report of Medical Cases,) considers diarrhoea to be the first symptom which indicates its existence. This sometimes exists from the beginning, but more commonly does not come on for nearly a week; the stools are frequent, five, six, or eight in the course of twenty-four hours, and, at first, feculent, dark, and fetid; but afterwards thin and watery, and as if ochre had been mixed with them. The ochre diarrhoea Dr. Bright considers to be characteristic of the commencement of intes- tinal ulceration, the increasing or decreasing fre- quency, quantity, and consistence of the evacua- tions indicating the progress of the intestinal dis- ease. There may or may not be abdominal ten- derness or tormina, but when there is pain of the abdomen on pressure, he considers it indicative of inflammation having extended to the perito- neum. Dr. Bright corroborates the opinion al- ready given as to the subsequent sympathetic dis- turbance of the brain arising from the condition of the intestines, but admits that the cerebral affec- tion may precede and be entirely independent of the intestinal disease, though it progressively in- creases or diminishes according to the progress of the ulceration of the bowels. We have already alluded to the opinion enter- tained by many French pathologists that the folli- cular disease which was first described by M. Petit is the primary cause of fever. Cruveilhier states that, after he and his fellow-students had watched at the Hotel Dieu the progress of severe Vol. II___21 o* fevers (les fievres graves), and the seat and cha- racter of the lesions after death, they became tired of the vague denomination of inflammatory, bilious, mucous, adynamic, and ataxic fevers, finding the same anatomical characters were always discovered in the intestines; they therefore proposed to sub- stitute the term intestinal fevers, for the more vague phraseology which had been introduced. He asserts that this follicular disease occurs under three forms: 1. the acute or inflammatory form • 2. that accompanied with prostration and stupor (adynamic form); 3. that attended with cerebral excitement and delirium (ataxic form). Inflam matory complications may arise and give a parti- cular character to the disease, but still the original primitive follicular disease exists, and constitutes the most characteristic feature of the malady, which is seated always in the extremity of the small intestines. The ileo-ca?cal valve is the prin- cipal seat of the lesion; it extends thence as from a centre, gradually diminishing from the last twelve inches to two or three feet in the ileum. The follicles of the ca?cum, appendix ca?ci, and ascending colon, are also occasionally affected The mesenteric glands corresponding to the dis- eased portion of intestine are inflamed and en- larged : hence the name entero-mesenteric fever given to this disease, of the symptoms of which Petit has given the following summary :—Feeling of debility and general indisposition ; loss of appe- tite ; lassitude; and irregular attacks of fever; the countenance expressive of prostration ; the skin, especially about the lips and ala? nasi, often harsh and dry ; disinclination to exertion ; great torpor and intellectual dulness. The febrile symptoms are obscure during the day; but there is an exacer- bation towards night, without shivering or much heat of skin ; the eyes, before languid, become in- jected; there is slight delirium; the thirst is ur- gent ; the teeth are dry; the tongue is coated with grey fur; the stools, which vary in frequency md abundance, are bilious, or serous, and insufficient to account for the prostration; the abdomen is soft, and not distended; there is little if any ten- derness, but pressure applied to the right side, be- tween the umbilicus and crest of the ileum, often causes pain. As the symptoms increase, the cheeks become livid; the eyes sunk and suffused > with constant somnolence and delirium, though the patient when roused gives intelligent answers. Petechia?, subsultus, and tremors supervene ; the pulse becomes rapid and compressible; the teeth covered with sordes, and the tongue with brown or black crust. Abdominal tenderness now suc- ceeds, the pain being in some cases still confined to the ileac region, and without tympanitis; in other cases more diffused, and accompanied with distension. The stools are frequent, serous, and offensive, and the urine is scanty. Excoriations succeeded by sloughing of the nates, and ten- dency to gangrene on those situations to which blisters have been applied, protract the sufferings of the patient, unless, as generally happens, death puts an end to complicated misery. It is asserted by the French pathologists that it is the most com- mon form of fever in France, and that it may occur sporadically, or constitute the principal fea- ture of epidemic fever. The successive changes which take place in ina 162 FEVER, (CONTINUED) mucous follicles during the progress of fever will be explained in the morbid anatomy. It will then be shown that the destructive processes of ulcera- tion go on progressively, until the coats of the in- testines are destroyed in succession, and intestinal perforation at length takes place. The symptoms which denote that this lesion has occurred are, sudden intense pain, with rapid distension of the abdomen, small quick wiry pulse, and peculiar al- teration of tue countenance. Intestinal perfora- tion is always fatal, geneully within thirty-six hours. Though peritonitis cannot strictly be said to form one of the complications of fever, it occasion- ally supervenes, more particularly at the period of convalescence. Peritoneal inflammation is readily distinguished by the acute pain in the ab- domen, increased on pressure ; by the knees being drawn up towards the belly ; by the sickness or vomiting, and the small wiry incompressible pulse. In some cases, however, there is neither sickness, vomiting, nor frequency of pulse; but only tender- ness of the abdomen on pressure. Whether, therefore, this symptom (ahdominal tenderness) be accompanied with other distinguishing signs of the disease or not, it should never be overlooked, but treated with decision, as abdominal inflamma- tion may be going on, and even proceeding to a fatal termination, with a quiet pulse and soft skin. In the preceding account of the complications which occasionally arise in the progress of fever, we have confined the description to cases in which the lesion has arisen either in the brain, in the chest, or in the abdomen. It happens, however, that in some instances complications take place in more than one organ at the same time. Thus there may be cerebral affection from the commencement of the fever, and in its progress pulmonary or abdominal symptoms may arise ; or there may be primary gastric symp- toms, with which the brain sooner or later sym- pathizes. In still more severe cases, inflamma- matory symptoms in the brain, chest, and abdo- men may exist at the same time. It is seldom, however, that in such instances the organs suffer equally, there being generally one on which the inflammatory action has seized with greater in- tensity. It is important to remember what has been al- ready stated, that in those more severe cases in which the cerebral affection predominates, should inflammation in some other organ subsequently arise, the symptoms are more or less masked by the cerebral disease. Hence arises the obscurity of the symptoms in those cases of latent pulmo- nary disease with which fever is frequently com- plicated, the symptoms being in a great measure concealed by the condition of the nervous system. In like manner, should peritonitis supervene, the pain may be so slight as not to be felt even on pressing the abdomen : if, however, this condition of the brain subside, the tenderness of the belly becomes developed, so that the practitioner is very apt, if not aware of the cause of the sudden sen- sation of pain, to ascribe it to an unexpected at- tack of intestinal inflammation.* * That some estimate of the comparative frequency of the several local lesions which arise in the progress WT fever may be formed, the result of 521 cases selected 3. Typhus Fever. — Different explanations have been given of the origin of the application of this term to a peculiar form or type of fever, characterized by the more early and severe affec- tion of the brain and nervous system — by the more constant changes which the mucous mem- branes undergo — by affection of the cutaneous and glandular systems—and in the advanced stage by great prostration and symptoms denoting pu- trescence. According to some it is derived from the Greek word Tv, to smoulder, or to burn and smoke without vent. Various other appellations have been given to this class of fevers. It has been designaied ma- lignant fever from the severity of the symptoms. Willis termed it nervous fever; Huxham, the slow nervous fever. John Peter Frank combined, under the name nervous, every fever accompanied with prostration and unusual affection of the ner- vous system ; other writers have termed it prison, jail, hospital, camp fever, &c. The order first established by Pinel, to which he gave the name adynamic, (want of power,) is more closely allied to typhus than any other type of fever. It is occasionally observed during the prevalence of epidemic fever, and distinguished by great debility, prostration, feeble but not always accelerated pulse, intellectual disorder, impeded or difficult articulation, and involuntary evacuation of the urine and stools. A variety of this form he called ataxic (irregu- lar) : it resembles the adynamic as to its origin, but he conceived there was greater disturbance of the nervous system, generally the effect of sub- acute cerebral inflammation. We have been able, during the prevalence of epidemic fever, to discriminate both the adynamic and ataxic varieties, and we were certainly struck with the accuracy of Pinel's description ; but though these forms bear a strong analogy to typhus, we think they only form an intermediate class between the more acute and typhoid types. Though the majority of French writers have retained typhus fever in their arrangement as a distinct class, others, more especially Louis and Cruveilhier, as we formerly stated, ascribe the whole symptoms to primary affection of the mu- cous follicles of the intestines. To this, however, we by no means assent, as we have traced the progress of typhous fever, both in the London Fever Hospital and in private practice, to its fatal termination, and on the most minute examination have been unable to discover the follicular disease which these authors state to be so invariably its cause ; while on the other from the journals of the London Fever Hospital is an Ca,^SQHn Wh,lC^ the, ?eleT was not aPParp"t'y compli- cated with local inflammation in any organ .... 163 Cases complicated with cerebral affection . ...... 114 thoracic affection.............. 103 abdominal affection............ 71 cerebral and thoracic affection . - 26 cerebral and abdominal affection 30 cerebral, thoracic, and abdomi- nal affection................ jj FEVER, (CO NTINUED) 161 hand we have met with follicular ulceration in individuals the symptoms of whose previous dis- ease had no resemblance to those of typhous fever. [Of late, two distinct forms of continued fever have been admitted by many pathologists, to one of which they have given the epithet of typhoid; the other being true typhus ; and it has been maintained, with what truth will be investigated hereafter, that these differ essentially from each other in their anatomical characters—the typhoid affection being connected with, if not dependent on, an inflamed or ulcerated condition of the in- testinal follicles; whilst in true typhus there is no lesion of follicles. By many, and, at one time, by M. Louis, it was maintained that typhus is contagious whilst typhoid is not; but it is now admitted by that distinguished observer that the latter disease can be propagated from one indi- vidual to another.] The typhoid form of fever is observed in some individuals during an epidemic of a very different type. When such sporadic cases occur, they probably arise from some peculiarity in the indi- vidual, or in the circumstances in which he may be placed. It is not uncommon to find fever, which at first is very mild, assume by degrees the typhoid character. If an individual, seized with fever, reside in an unhealthy district, or be con- fined in a small crowded apartment, where no attention is paid to ventilation and cleanliness, the probability is that a disease, comparatively mild at first, will be converted into one of severity and danger, from the low character which the symptoms assume. This is corroborated by the amelioration in the general aspect of the case within a short time after a patient has been removed to a more open dis- trict, or into a well-ventilated chamber. Physi- cians attached to fever hospitals are often struck with the marked improvement under such circum- stances. The amelioration is not to be imputed to the treatment pursued, so much as to the effect of a more pure atmosphere and the frequent ablu- tion and changes of linen, which are so essential in fever. At other times the type of an entire epidemic is typhoid, and of such epidemics there are many recorded histories; hence the importance of en- deavouring to ascertain, after the example of Sydenham, not only the character of fever in different localities, but the nature of the epidemic at different seasons, that the physician may suc- cessfully apply those principles of treatment which the type of the fever requires. There can be no doubt of the existence of every intermediate gradation between the common forms of fever (synochus) and typhus, so that it often becomes a matter of nicety to discriminate to which class a particular case or number of cases properly belongs. Sometimes we find, indeed, the one form passing into the other, more fre- quently mild fever lapsing into typhus. There is, in general, a perceptible difference in the severity of the symptoms in different cases of typhus. This has led to the distinction, pro- posed by Cullen, of Typhus Mitior and Typhus Gravior. In typhus mitior the febrile symptoms are mild, though it is evident from the intellectual disorder and prostration, that the nervous system is much affected. It is probable that in these cases, espe- cially at the commencement, there is no inflam- matory action in the brain, — the whole pheno- mena, viz. great languor, feeling of debility, mus- cular prostration, soft feeble pulse, giddiness, in- tellectual dulness, and transient delirium, being the result of the peculiar operation of the febrific causes on the nervous system. Sub-acute inflammation of the brain often super- venes on this condition of the nervous sy-stem; and when this takes place, the more prominent symptoms of cerebral inflammation are recognized; and to the difference in the intensity of the cere- bral affection may be traced the infinite variety of nervous symptoms which individual cases present. Of the lesions in other organs which arise in the more severe cases of typhous fever (typhus gravior), congestion or inflammation of the mu- cous membranes, bronchial and intestinal, and in- flammation of the parenchyma of organs, are the most important. The congested state of the ca- pillaries of the mucous membranes, the blood being at the same time in a state which favours its transudation, occasionally gives rise to hemorrhage from different parts, more frequently, however, from the bowels than from either the nose, lungs, or any other cavity; and when the hemorrhage is excessive, the already exhausted powers of the patient are often irrecoverably sunk. A similar hemorrhage action is not unfrequently manifested in the skin, in the form of small red spots (pete- chias). These vary in colour and size; they are sometimes of a bright red, in other cases of a darker red or even purple hue, and generally distinct; in some instances the spots cohere, and form an ec- chymosis of greater or less extent. These patches are termed vibices. In cases of still greater malignity, carbuncles and gangrenous inflammation of the skin, more particularly on those parts which are subjected to pressure, often arise: and the lymphatics, more particularly the submaxillary, cervical, and ingui- nal, and in some cases the parotid glands, become inflamed, the cellular substance in which they are imbedded not unfrequently suppurating, and thus forming what some writers have considered a cri- tical abscess. At particular seasons also, erysipe- las is very apt to supervene, but more particularly in hospitals, — erysipelatous inflammation rarely- supervening on fever among the better classes. From the peculiar changes which take place in the blood in typhous fever, and to which many pathologists of the present day ascribe all the phe- nomena, the secretions are more vitiated than in the other forms. This is exemplified in the re- markable fetor of the breath and perspiration, which is so peculiar as to be readily recognised, and in the evacuations from the bowels, which are always exceedingly offensive. After these general observations, we are pre- pared to enter on the particular symptoms. Symptoms of typhous fever. — It has been al- ready stated that a distinction of typhous fever has been made, founded on the difference of intensity of the symptoms. The invasion of the iniiuei form (typhus mitior) corresponds very much witb that of common fever. The patient complains o 164 FEVER, (C< giddiness, listlessness, and indisposition to exertion, alternate chills, and hot flushes, with uneasiness or pain at the pit of the stomach. These precur- sory symptoms are succeeded by pain in the back and loins, burning heat of the skin, flushing of the face, sense of weight in the head or giddiness, noise in the ears, and disposition to quietude. The expression of the countenance indicates in- tellectual dulness. The pulse is frequent and soft; the digestive organs are deranged ; food is dis- liked ; cold acid drinks are relished; the tongue is coated with thin white fur, which becomes gra- dually thicker and of a brown colour, sometimes it is clean but morbidly red ; the mouth is clammy from superabundant secretion of mucus in the throat and mouth; sometimes there is pain in the epigastrium, nausea, and vomiting. Towards the third or fourth day, the symptoms in the brain be- come aggravated, the head feels more heavy, the mind is more confused; the patient, restless and watchful through the day, becomes delirious at night, while, according to some writers, an erup- tion of miliary or larger vesicles, with intervening redness of the skin, appears on different parts of the body. The disturbance in the intellectual powers gra- dually increasing, the delirium, which was only perceptible at night, is observed to recur at inter- vals during the day ; the hearing becomes dull; the patient more torpid; the answers given to questions evincing hesitation and marked indiffer- ence to surrounding objects. About this period epistaxis occasionally <,akes place ; petechia? appear in different parts of the skin, more especially on the chest, abdomen, arms, back, and thighs. This petechial eruption is not constantly observed in typhous fever, but seems to form an occasional characteristic of some epidemics; and from this circumstance the disease has been termed petechial fever. Dr. Stoker states that, of five hundred and forty patients received into the Cork-street Hospi- tal, three hundred and eighty-six had petechia?. In the London Fever Hospital, the cases now (June, 1832) under treatment have almost inva- riably the petechial eruption. These spots or exudations of blood are not con- fined to the skin, but spread over the serous and mucous membranes ; hence, in fatal cases of pete- chial fevers, the surface of the viscera have been found studded with small bloody effusions. The condition of the alimentary canal in typhous fever is various, not only in different individuals, but in different seasons and epidemics. Some- times the bowels are torpid throughout the whole period of the disease; in other cases there is diar- rhoea from the beginning, which only disappears with the cessation of the fever. The urine is al- ways scanty and high-coloured, and towards the decline usually deposits a sediment. This is the usual progress of typhus fever for the first nine or ten days, about which period another train of symptoms appear—those denoting collapse or failure of the powers. This stage is announced by the decline of the previous more acute symptoms — by the pulse becoming more rapid and soft—the tongue dry and brown, often tremulous, and protruded with difficulty—by the incrustation of the teeth with sordes—by the in- creasing intellectual disorder, indicated by the iNTINUED) more constant low muttering delirium, and the greater insensibility and deafness — and by the condition of the muscular system, evinced by muscular tremor and subsultus tendinum, and in some cases irregularity or intermission of the pulse, by the patient lying sunk on his back, or sliding to the foot of the bed, the muscles being unable to support the body, even in the horizontal posture. From the stage of collapse the patient not un- frequently recovers, the period at which this favour- able change takes place being very uncertain; it occurs in some instances about the fourteenth or fifteenth day, but often not till a much later period, depending on the more or less tedious character of the epidemic, and the complications which may have arisen. It is announced by progressive amendment in the symptoms, by the delirium and other symptoms of sensorial disturbance disap- pearing, the patient enjoying intervals of refresh- ing sleep; by the countenance improving, and the evacuations being passed consciously, the pulse becoming more slow, the skin cool and soft, and the tongue more clean at the edges, and moist over the body. When these favourable appear- ances are observed, the convalescence, though slow, is gradually established, the individual, how- ever, remaining in a very weak state for a long time. The progress of the disease to a fatal termina- tion is indicated by coma, more or less profound, hiccup, retention of urine, or involuntary evacua- tion of the urine and stools, and tympanitic dis- tension of the abdomen. A modification of typhus fever has been de- scribed by Dr. Armstrong under the name of con- gestive typhus, which, in the opinion of this writer, differs from the more common forms of the disease. This theory presumes that the functions or structure of some important organ are deranged by an almost stagnant accumulation of blood in some part of the venous system. There is no re- action ; the system does not recover, or only im- perfectly, from the first shock or stage of oppres- sion, the energies of the system being either nearly extinguished by the venous congestions, or so much oppressed as to be unable to create excite. ment. The local accumulations of blood in the veins are supposed to obstruct, from the beginning, the common series of febrile phenomena; and there is, in consequence, either no morbid heat of skin, or the heat becomes concentrated in some particular parts of the body, while on others it is below the natural temperature. This form, ac- cording to this author, is characterized by the sudden invasion, by the overpowering lassitude, muscular feebleness, deep pain, giddiness, or sense of weight in the encephalon ; pallor of the coun- tenance ; anxious breathing; cool skin; low, struggling, and variable pulse; irritable state of the stomach ; mental dulness, apprehension, and confusion, rather than delirium; heavy, suffused eye, as if from intoxication or want of sleep; rough, foul, and dry brown tongue; the bowels, torpid in the beginning, becoming in the advanced stage generally loose; the stools copious and in- voluntary, and accompanied with inflation of the abdomen. The general torpor causes diminution or suspension of the secretions, and such deficiency FEVER, (CONTINUED) 165 of cutaneous excitement, that if blisters be ap- plied, they either do not act at all, or so defective- ly, as to leave an appearance as if the part had been slightly seared by a heated iron. Petechia? generally appear earlier in this than in any other varieties of typhus, and in the last stage there are sometimes gangrenous spots on the extremities, oozing of blood from the mouth and nostrils, and hemorrhage from the bowels. Dr. Armstrong has described several modifica- tions of congestive typhus, all of them recog- nised by the depressed state of the heart and circu- lation—the uneasiness in the head—the precordial anxiety — the peculiar condition of the tempera- ture and skin — the total want of excitement, or its partial and unequal development—the sus- pended or vitiated secretions—and the local load and general oppression. (Practical Illustrations of Typhous Fever, by John Armstrong, M. D.) When typhus fever becomes complicated with local inflammation, constituting the typhus gravior of Cullen and others, the symptoms from the com- mencement are more severe, and when the cause of this severity is investigated, it will be found to depend on the inflammation which has arisen either in the brain, in the lungs, or intestines. 1. The cerebral complication is known by the more marked and early affection of the brain — the more deep or severe pain, or sense of weight in the head, giddiness, or oppression — suffusion of the eyes — more constant delirium, and dispo- sition to coma — muscular tremor and subsultus tendinum — soft, rapid, and occasionally intermit- ting pulse — and involuntary evacuations. 2. There is invariably bronchitis in the more severe cases of typhus. It is generally very ob- scure, from the absence of the more prominent symptoms, so that if it be not indicated by cough and accelerated breathing, there is nothing to lead to the suspicion of pulmonary disease. The ap- plication of the stethoscope, however, will enable the practitioner to discover the bronchitis, some- times confined to an entire lobe, or in more severe cases extending over both lungs. Not unfre- quently, but especially in the winter, and during some epidemics, pneumonia supervenes, and rapid- ly destroys life. 3. The state of the intestinal canal forms ano- ther important feature in the class of fevers under consideration. The symptoms by which the in- testinal affection in fever is attended, we have seen to be very obscure; but its existence may be inferred, when the tongue is morbidly red at the point and margins, while the body is dry, fissured, and covered with dry, brown, or black incrusta- tion ; when the belly is tympanitic, and there is hemorrhage from the bowels. There may or may not be abdominal tenderness on pressure; more commonly, and particularly when there is much sensorial disturbance, the sensibility is so blunted that the patient does not feel inconve- nience even from firm pressure. [Adynamic fever accompanied by such intes- tinal lesion has of late years been regarded as an essentially different fever from typhus, and has received the name typhoid fever, or typhoid affec- tion. It is the dothinenteritis already referred to; the follicular enteritis, abdominal typhus, &c. of authors. By many pathologists it is be- lieved that all continued fevers are divisible into two distinct forms—the typhoid and the typhus. In the former, along with symptoms of ataxic adynamic fever, the intestinal affection is generally well marked from an early period. Diarrhcea is one of the most constant phenomena, and is usually present from an early period; but is not always in a ratio with the extent of disease of the intestinal follicles. Meteorism, enlargement of the spleen, rose spots, and sudamina, are amongst the most prominent phenomena; espe- cially the first and third of these. Meteorism is certainly found in a large proportion of cases: at times, it occasions painful distension,—the uneasi- ness being augmented on pressure; but at others it is so slight as not to be distinctly recognised, except by more or less increased resonance on per- cussion. It occurs more especially towards the termination of the disease, when, as in other febrile diseases, it is of unfavourable import. In the large majority of cases, the taches rouges, red or rose spots, are seen most frequently on the lower and middle portions of the chest, and upper part of the abdomen. They are generally of a round shape, and although they do not seem to project above the surface of the skin, they can be felt by passing the finger over it. Their number varies ; sometimes there are not more than six or eight, whilst at others they are almost confluent Their size also varies, but it rarely exceeds that of a pin's head. When the spots are pressed upon by the finger, the colour disappears, but re- turns immediately afterwards. To determine whether the meteorism, enlarge- ment of the spleen, taches rouges, and sudamina occur equally in other diseases, Dr. Hale, of Bos- ton, ( Observations on the Typhoid Fevers of New England, &c. Boston, 1839,) constructed the fol- lowing table : TYPHOID FEVER. OTHER ACUTE DISEASES. No. Cases. Per cent. No. Casta. Per cent. Whole number - . 197........159...... Meteorism - - - 130......66 - - 9......6 Spleen fi-lt - - . 19...... 9 - - 0......0 Itose spots - - - 177......90 - - 0......0 Sudamina - - - 75......38 - - 8......5] Morbid Anatomy of Continued Fever.— Though morbid anatomy has not yet unfolded the true nature of fever, more sound views of its pa- thology and treatment have been obtained, by comparing the symptoms during life with the morbid appearances found on dissection. Before examining the morbid appearances in each organ, it is necessary to premise, that in some instances of sudden and early death from fever, no changes of structure sufficient to account for the fatal issue have been discovered. We are to conclude, there- fore, that in these cases the duration of the febrile excitement had been too short to produce any ap- preciable alteration of structure in any organ. 1. Morbid appearances in the Brain.—The dura mater is scarcely ever altered in appearance, though in some cases a small quantity of serous fluid has been found between this membrane and the arachnoid. Louis observed in one case tho inside of the dura mater lined with a thin pseudo membrane. In the majority of cases, the arachnoid mem brane exhibits traces of previous inflammatory action ; it is sometimes simply vascular, in other 166 FEVER, (CONTINUED) cases thickened and opaque, with more or less effusion between it and the pia mater. The fluid varies in colour and consistence. It is generally transparent and colourless ; but in instances in which the previous inflammatory action has been more intense, it is opaque, of a light straw colour, and of greater consistence, approaching to the na- ture of coagulable lymph. In the ventricles there is generally a small quantity of serous fluid, varying from one or two drachms to half an ounce ; it rarely amounts to an ounce. The vessels of the pia mater, which often adheres in points to the arachnoid membrane, are generally more numerous, distended, and tortuous than in the natural state of this membrane, espe- cially in those cases in which the other parts of the brain exhibit traces of vascular turgescence. According to Louis, the injection of the pia mater is greatest in the rapidly fatal cases, and serous effusion in those of which the progress has been more slow. The consistence of the substance of the brain in fever is variable; sometimes it is extremely soft, so that it lacerates easily; in other cases it is unusually firm. It is difficult to determine how far these opposite states indicate of themselves the previous existence of inflammation. Louis does not seem inclined to believe that either condition is to be considered as the result of inflammation, as the change is uniform throughout the whole brain, and the symptoms during life do not bear an invariable relation to the appearances in the brain after death. Injection of the substance of the brain is not unusual, the vascular turgescence being observed in a larger proportion of cases in the medullary than in the cortical portion. The blood-vessels are not only more distended, but more numerous, as may be observed on making a section of the brain so as to expose the centrum ovale, when numerous bloody points, the orifices of divided arteries, are interspersed, giving the section a dotted appearance. The cerebellum seldom exhibits any alteration, if we except that of the membranes at the base of the brain, and the effusion with which it is fre- quently associated. A slight degree of softness of its substance has in some cases been observed. The spinal cord has not undergone that minute investigation which would enable us to speak with certainty as to its general state in fever. When the medulla oblongata is divided, so as to allow the removal of the brain, a quantity of serous fluid escapes from the vertebral canal in those cases in which there has been considerable effusion in the ventricles. The membranes Which envelope the spinal cord have been occasionally found vascular, the substance of the medulla spinalis being at the same time injected and soft- ened. With regard to the proportion of cases of fever in which lesions of the brain have been discovered after death, Louis, in his recent work, states that besides the case in which the inside of the dura mater presented a thin pseudo-membrane, in four tnere was a little fluid between the dura mater and arachnoid; in more than half, the sub-arach- nid cellular tissue was infiltrated with serosity, and in one half the pia mater was injected with blood. In three-sevenths, the cortical substance was redder than natural; in six-sevenths, the me dullary matter was injected,—these latter appear- ances being most striking when death took place at an early stage; in six cases, the density of the brain was slightly increased ; in five, it was di- minished. Of fifty-four cases examined at the London Fever Hospital, thirty-seven exhibited evident traces of previous inflammation of the brain. 2. Morbid appearances in the chest.—The structure of the larynx in fever is generally healthy, unless, as occasionally happens during the period of convalescence, laryngitis or trachei- tis supervenes. In the former case, the glottis is found contracted in consequence of cedematous swelling or serous infiltration of the submucous cellular tissue of the epiglottis, or rima glottidis: sometimes the larynx is lined with a thin layer of recent lymph, extending into the trachea. In the latter, the peculiar membrane of croup is ob- served. Inflammation of the pharynx, followed by ab- scess, occasionally takes place, and when the puru- lent collection occurs in the vicinity of the glottis, the pressure gives rise to the ordinary symptoms of laryngitis. We have known these cases termi- nate fatally. In examining the state of the lungs, it is neces- sary to guard against a source of fallacy. The blood appears chiefly in the posterior portion of the lungs ; this circumstance has given rise to the idea that the patient had pulmonary engorgement during life. This pseudo-morbid appearance is readily pro- duced by the gravitation of the blood after death, favoured by the position of the body ; indeed, were the body placed immediately after death in any other, we should find a similar congestion in the portion of lung which is most dependent. When bronchitis has existed during fever, the mucous membrane exhibits more or less vascu- larity ; this is most perceptible in the trachea and larger bronchial tubes, though, perhaps, throughout the whole extent of one lobe, the bronchial mem- brane has a more or less dark red swollen appear- ance, very different from the pale pink colour observed in its healthy state. When the sympto- matic bronchitis has been severe, the bronchial membrane of both lobes appears red, and often considerably swollen and thickened, while the smaller tubes are filled with mucus or muco-puru lent fluid. In fatal cases of fever complicated with pleuritis, adhesions between the pleura pulmonalis and costalis, with or without effusion of coagulable lymph on the inflamed surfaces, are the usual mor- bid appearances. Sometimes there is effusion of serous fluid into the pleural cavity, the fluid.being frequently mixed with portions of coagulable lymph, which render it more or less turbid. When the substance of the lung has been inflamed, the appearances vary according to the intensity of the pneumonia. When the fever proves fatal in the first stage, the lung is increased in density, and infiltrated with serous or bloody fluid. When it has proceeded to the second stage, it is solid and dense, and no longer crepitates. In a still more advanced stage, the pulmonary struc- FEVER, (CONTINUED) 167 ture assumes a granular appearance, and pale yellow colour, from purulent infiltration. In some instances that peculiar lesion known by the term pulmonary apoplexy has been observed. Lesions of the heart are very rarely observed in fatal cases of fever. In some instances, but more especially in the fevers of hot climates, which run on to a fatal termination with great rapidity, the muscular structure has been found softened and attenuated so as to be easily lacerated. Louis slates that this affection was uniformly greatest in the instances of rapid death, and was invariably conjoined with a hurried, fluttering, irregular and feeble pulse. This softening is generally confined to the left side of the heart, though sometimes both sides have been found affected. Other mor- bid changes have also been observed, but in those instances the organic disease has always been of long standing, the fever having supervened in the progress of the cardiac affection. The internal membrane of the aorta and some of the larger arteries occasionally exhibits a bright red colour. This redness, which occurs in patches of various sizes, is not the product of inflamma- tion, but only the effect of staining. This has been proved by the fact, that this appearance may be easily produced by filling a portion of a large artery with blood, and confining it by means of ligatures. Some pathologists have mistaken this staining for arteritis. 3. Morbid appearances in the abdomen. The occasional occurrence of abscess in the submucous cellular tissue of the pharynx in fever has been already mentioned. The oesophagus is generally unaffected. Some writers have alluded to super- ficial ulcerations in both the pharynx and oeso- phagus. Such morbid appearances however are to be regarded only as occasional secondary affections. The alterations which take place in the ali- mentary canal are chiefly in the mucous mem- brane, and follicles of the small intestines. When the cavity of the abdomen is laid open, the stomach and colon are in the majority of instances considerably distended with flatus—the diameter of the small intestines, particularly in those portions where there are lesions, being con- tracted, and of a dark colour. On examining the internal mucous coat of the stomach, it occasionally exhibits some deviation from the healthy state. Louis affirms that in thirteen of forty-six cases examined, the stomach was quite healthy in colour and consistence. In some instances it is injected in patches of various extent ; in others, it is partially and sometimes generally softened and attenuated, so that the mucous membrane is easily detached from the sub- jacent cellular tissue. In a few instances, ulceration of the stomach has been found. This occurs in a larger propor- tion of cases in the fevers of France than in those of Great Britain. Andral states that ulceration of the stomach occurred in one-tenth of the cases examined by him at the Hopital de la Charite: Louis found this lesion in one-twelfth of those he inspected at the same establishment. In the Fever Hospitals of Britain, this lesion is scarcely ever observed, though we find in many cases appear- ances indicative of previous inflammatory action in the mucous membrane, viz. redness and softening. It is seldom that the mucous membrane of the small intestines is sound through its whole extent The duodenum rarely exhibits any trace of dis- ease, and may, therefore, be considered less fre- quently affected in fever than any portion of the alimentary canal. In the remaining portion of the small intestines (jejunum and ileum) we find more uniform lesions; in the more rapidly fatal cases, or when the whole force of the disease has centred in another organ, the mucous membrane retains the natural pale pink colour. In general, however, we observe portions of a greater or less extent, uniformly reddened, the tinge differing from a light red vermilion to a deep brown. The redness is usually deeper in the valves than in the intervening spaces, so that if these valves be drawn out, the intensity of the colour very much diminishes or altogether disappears. This red injected appearance of the villous surface of the intestines is generally followed by intestinal he- morrhage. Sometimes, instead of this uniform redness, the membrane is studded with clusters of sinall red points or dots, which apparently arise from injection of the capillaries, or in some in- stances from effusion of blood beneath the mu- cous membrane. The red colour of the mem- brane, however, is by far the more common ap- pearance, and is more uniform and extensive in the portion of the ileum adjoining the ca?cum: it varies in extent in different subjects, often extend- ing for several feet, occasionally over one-half, or even the whole of the small intestines. In the more advanced stage of inflammation of the mu- cous membrane, the colour assumes a grey tinge, and when this is observed, it always indicates pro- tracted fever. Louis states that he scarcely ever saw the grey colour of the mucous membrane in persons who died before the twentieth day of fever, more generally in those who died from the twentieth to the thirtieth day, or even at a still more advanced period of the disease; hence it has been supposed that the grey colour occurs when the redness of inflammation is passing off, and the mucous mem- brane is about to resume its healthy colour. The consistence of the mucous membrane of the intestines is not always uniform. In the ma- jority of instances it retains its natural consist- ence ; in other cases the inflammation produces thickening and pulpiness of the mucous coat. Though softening has been observed in a small proportion of cases only, it is more frequently met with than thickening, and has been more particu- larly remarked when the fever had been long pro- tracted. It does no:, however, appear to be the necessary consequence of inflammation, as it oc- curs in some cases without redness ; that it occurs with both redness and thickening of the mem- brane, cannot be denied; but as it is more fre- quently noticed without either of these conditions, we must conclude that, although we are unable to explain the precise circumstances under which softening of the mucous membrane of the bowels arises in fever, it is not the product of inflamma- tion. We know that it may be produced very soon by corrosive poisons. Mr. Brodie found the stomach of a dog, to which two grains of tnc oxymuriate of mercury had been given, remark ably softened half an hour after the poison had reached the stomach. 168 FEVER, (CONTINUED) Besides these morbid states of the mucous mem- brane, vegetations of a red or brown colour, and of extremely soft consistence, are occasionally met with. They lie one above the other, projecting perhaps three or four lines above the surrounding membrane : they are not very common. We have seen only one case at the London Fever Hospital, and in this subject the vegetation occurred in the lower portion of the ileum. Andral states that he met with them only in the large intestines. Orfila met with a considerable number in the sto- mach of a person who had taken cantharides. The tendency of inflammation of the mucous membrane of the intestines to pass into ulceration, has been observed by every modern pathologist who has examined the various lesions which arise in the progress of fever. These ulcerations in some cases succeed to sim- ple inflammation of the villous coat, in which case the ulceration takes place in one or two points, generally in the centre of the inflamed patches; these points become by degrees more numerous and extensive, and at length coalesce so as to form a patch of greater or less extent. The same process may be going on in different portions of the membrane at the same time; and if it happen that the ulceration commences in con- tiguous portions of the bowel, one or more patches often cohere, and thus form an ulcer of consider- able size. The most common form of intestinal ulcera- tion, however, is that which succeeds to inflam- mation of the mucous follicles of Peyer and Brun- ner. These follicles or glands, which in their natural state are very minute, vary in number and size in different situations. At the pyloric extre- mity of the stomach they are numerous, but dis- tinct or isolated; hence called glandules solitarix, or after the anatomist who first particularly de- scribed them, glandulx Brunneri. They grad- ually diminish in number towards the extremity of the duodenum, in which situation they are larger and more apparent than in any other por- tion of the bowels. In the jejunum and ileum they become more numerous and form into groups; hence they are called glandulx agminatx or Pey- erii, (Peyer being the anatomist by whom they were first observed.) They become exceedingly numerous towards the lower third portion of the ileum. The greater vitality of these follicles, compared with other parts of the mucous membrane, ren- ders them peculiarly liable to inflammation and disorganization ; hence we find that, according to the stage of fever, hypertrophy, redness, and ulce- rations of these follicles are the only morbid ap- pearances. M. Bretonneau has distinguished this form of intestinal inflammation by the term dothi- nenteria, (from Sodir/v, pustula, and evreoov, intes- tinum.) The glands of Brunner are less fre- quently diseased than those of Peyer, and if the statement of Louis be correct, viz., that, in other acute diseases, inflammation of the villous coat, as well as enlargement of the mucous crypts or glands of Brunner, are not unfrequently observed, though not so commonly as in fever, but that dis- organization of Peyer's glands are never met with, except in some forms of fever, the changes which take dace in these follicles (glandulx agminatx) may be admitted to be peculiar to certain type, of fever, and to constitute their true pathology. With regard to the situation of these ulcera- tions, it may be stated that they occur in every part of the intestinal canal, from the cardiac ex- tremity of the stomach to the rectum. They occur, however, more frequently in some portions of the bowels than in others. For instance, they are comparatively infrequent in the stomach, still more rare in the duodenum and jejunum ; the most common situation is in the lower third portion of the ileum. In the colon they are occasionally found, though less frequently than in the small intestines. From the following table drawn up by Andral, an idea may be formed of the relative frequency of intestinal ulceration in different parts of the canal. Seat of Ulceration. Number of Cases. Stomach ................... 10 Duodenum ................. 1 Jejunum ................... 9 Ileum (lower portion of)......38 Ca?cum...................15 C Ascending........... 4 Cplon< Transverse .......... 11 (_ Descending.......... 3 Rectum.................... 1 Total........92 The ulcerations also vary in several particulars, especially as to number, aggregation, size, and shape. In the stomach there is in general only one solitary ulcer, seldom more than two. In the lower portion of the small intestines they are more numerous, and situated nearer each other than in the upper, in which situation there is often a con- siderable distance between them : in the ileo-ca?cal valve they are generally so closely situated as to form a large patch of ulceration ; they are less confluent in the ca?cum. As to size, some are not larger than an ordinary pin-head; the more ge- neral size is from a split garden-pea to half a crown; but between these sizes there is every intermediate gradation, the structure of the intes- tine being sometimes completely destroyed for several fingers' breadth above the ca?cum, where the largest ulcerations generally occur. The form or shape of these ulcerations is also various ; some are oblong, having their greatest diameter according to the length or breadth of the intestine; sometimes they are circular, occasion- ally linear. Their number, size, and depth depend on the duration of the fever. In general, when patients die within the first fourteen days, the dis- ease in the mucous membrane, or in the follicles, has not advanced to the stage of ulceration, though from every appearance this subsequent stage would soon have taken place. When the ulcerations are numerous, large, and deep, we may presume that the fever is of consi- derable duration, — that it has advanced beyond the third week. In the same portion of intestine, too, every successive change may often be ob- served: thus we find in one part the mucous membrane red and swollen; in another, the mu- cous follicles enlarged; in a third, abrasion of the membrane or follicular ulceration. Sometimes these ulceis extend chiefly in breadth, FEVER, (CO but more frequently in depth, destroying in suc- cession the coats of the bowel. When the diseased process has commenced in the follicles, a small spot of ulceration is observed on their summit; the ulcers then gradually extend both in breadth and depth, so as to expose the muscular coat, which then becomes the floor of the ulcer: in pro- cess of time the muscular coat is destroyed, the peritoneal covering alone remaining; and should the patient survive, this becomes gradually thinner by ulcerative absorption, and at length gives way, constituting intestinal perforation: the escape of the contents of the bowels through the aperture being followed by rapid peritonitis and death. The symptoms which indicate intestinal per- foration are sudden excruciating pain and increased distension of the belly ; sometimes vomiting ; small, rapid, feeble pulse; shrinking of the features ; cold sweats; and death follows generally within thirty- six hours, though some individuals have existed for a longer period. When the brain has been much affected, the patient is so insensible as not to feel pain in the abdomen, even when the perforation takes place: in such instances it may be suspected from sudden alteration in the features, rapid distension of the abdomen, and small contracted quick pulse. In some instances, the adhesion of the portion of the intestine, at the point where the ulcerative process is going on, to some adjoining viscus, has prevent- ed the peritoneum giving way, and the consequent effusion of the intestinal contents into the abdo- minal cavity. It appears, as we have already observed, that intestinal ulceration is more common in the fevers of France than in those of Britain, and that they occur more frequently at some seasons than at others. It is probable, too, that they are found in a larger proportion in populous places, as in the large towns, than in villages or the open country. Of fifty-four cases examined at the London Fever Hospital, (1828-1829,) intestinal ulcerations were discovered in sixteen ; and in ninety-two cases of two hundred and twenty-nine treated at La Cha- rite by Lerminier. On what this difference de- pends, it is not easy to determine. With regard to the cicatrization of intestinal ulcers, there is now no longer any doubt that this reparative process does take place. Besides the well-authenticated example in the case of the late celebrated Beclard, in whose stomach a cicatrized ulcer was discovered at the small curvature, we have the testimony of Troillet, Louis, and other pathologists, on this point; and though we our- selves have never witnessed an unequivocal in- stance of genuine cicatrix, the minute detail, by those writers, of the various stages observed during this process, and their accurate description of the appearance of intestinal cicatrix, leave no longer any doubt on this subject; but from the want of diagnostic symptoms to indicate the existence of intestinal ulceration, it cannot be determined in what proportion of cases this reparative process takes place. It is probable, however, that it is a rare termination of such lesions. [It has been already remarked, that the intes- tinal affection has been regarded as characteristic of one form of continued fever, the typhoid. By some pathologists, indeed, it is considered as the Vol. II___22 v NTINUED) 169 precursor and cause of all the other morbid phe- nomena. It does not, however, appear to be en- titled to the importance in the causation that has been ascribed to it. All the phenomena may occur without the intestinal lesion; and the latter may exist without being indicated by the ordinary symptoms of the typhoid affection. Hence, objec- tions may well be urged against classifying typhoid fever amongst the diseases of the digestive tube, as has been done by Andral, Piorry, and others. It is difficult to comprehend, that these folli- cles can be so intimately associated in their morbid derangements with the great vital organs, as to occasion the ataxic and adynamic fever, which has been ascribed to them. The follicular affection would appear, indeed, to be a mere symp- tom, and to be produced by the same cause that gives rise to the other symptoms of typhoid fever; but which cause, in the existing state of science, is inappreciable. As elsewhere remarked, (Prac- tice of Medicine, 2d edit. ii. 503,) the writer is not prepared to admit, from what he has himself seen, and from a careful examination of the testi- mony of others, that the typhoid affection and typhus are proved to be separate and distinct dis- eases. He regards them both as forms of adyna- mic fever, exhibiting different phenomena under different circumstances; generally, in the United States and in France, the abdominal lesion being present, whilst in England it is as commonly ab- sent ; and it is strongly in favour of this view of it, that since attention has been more directed to the represented difference between the affections in Great Britain, it has been shown, that the follicles are not unfrequently diseased in the ordinary con- tinued fever. (Watson, Lectures on the Princi- ples, Sec, of Physic, Amer. edit. p. 844, Philad. 1844.) In this country, too, epidemic adynamic fever has been described, in some cases of which the glands of Peyer were diseased; in others not. (Western Journal of Medicine and Surgery, 1843.) The singular forms of adynamic fever, which have prevailed, of late, in different parts of the Union, also exhibit the wide difference of ex- pression which it may assume.] The colon, in fatal cases of fever, is considera bly distended with flatus ; it appears to be the portion of intestine in which tympanitic distension usually occurs. The internal or mucous surface sometimes ex- hibits evidence of previous inflammation in the red, softened, or thickened state of this membrane. The mucous follicles are occasionally enlarged; and ulcerations, chiefly in the ca?cum, are now and then observed. The mesenteric glands are almost invariably diseased : when there is no intestinal ulceration, they are simply enlarged and indurated ; when ulceration of the bowels has taken place, these glands, besides being enlarged, generally contain pus. The external absorbents, especially those situ ated in the neck, axilla, and groin, are occasionally enlarged and indurated. In some epidemics pa- rotid buboes are not uncommon, indicating a ma lignant form of fever. The only alteration in the liver, which may perhaps, be deemed peculiar to fever, is softening, and this is only occasionally observed. In thoso 170 FEVER, (CONTINUED) instances, it is of a pale colour, and so soft as to be very easily lacerated. The spleen is very generally altered in structure in fever. This alteration consists in unusual softness, in some instances to such a degree that the organ is reduced almost to a pulp, and breaks down on the slightest pressure: it is generally ac- companied with enlargement, though seldom to any considerable extent, while its colour is changed to a very dark purple or a reddish black. This softened state of the spleen has been ob- served in every stage of fatal cases of fever; in those who perish early, as well as in those in whom the disease is more protracted ; it does not appear to have an inflammatory origin, since its capsule is generally sound. From this extreme softness in some forms of fever, more especially typhoid fever, and in diseases of putrescency, such as scurvy, it is probable that a morbid condition of the fluids has a peculiar effect on the structure of this organ, though we know of no symptoms which indicate this particular lesion. In one case which came under the care of the writer of this article, at the London Fever Hos- pital, a small circumscribed abscess was found in that portion of the spleen which is connected with the diaphragm. In this instance symptoms of pleurisy of the left side arose in the progress of fever, which did not yield to the ordinary treat- ment. The patient eventually died; and on dis- section, a small tumour of the size of an egg was observed in the centre of the diaphragm, which gave at first the idea of diaphragmatic hernia. On more close inspection it was discovered to be an abscess in the spleen, which had formed an attach- ment to the diaphragm, through which it had so far penetrated as to be covered only by the thin transparent pleura. It appeared just about to burst into the left side of the chest. The general structure and size of the organ were otherwise healthy. Pathology of the Fluids in Fever.— That the fluids are changed in fever is evident from the altered state of the various secretions, as well as from certain appearances which have been ob- served in the blood itself. This subject, though of the utmost importance, has been hitherto almost entirely neglected, probably in consequence of the pathologists of the present day being more dis- posed to investigate the morbid changes which take place in the solids, and consequently to trace the causes of the phenomena of fever to disease in them, rather than to any alteration in the blood itself. The doctrines of humoral pathology which pre- vailed for many centuries were not founded on direct experiments, but on vague conjectures, from observation of the constant and uniform vitiation in the fluids. Chemical analysis in those days had not attained the perfection necessary to detect the various changes which the blood and fluids were supposed to undergo; and, in later times, die acknowledged difficulty of such experimental inquiries, with the zeal with which morbid ana- tomy is cultivated, will account for the slow pro- gre<-=> of this department of pathology. That the blood does undergo changes in fever was always conjectured : that certain changes pre- cede its development, and that certain alterations in its component principles do arise in its progress, is not only highly probable, but, as has been al- ready stated, some modern pathologists do not hesitate to affirm that a vitiated state of" the blood is the origin, source, or proximate cause of the disease. It has been often observed by practical physi- cians, that the blood drawn from persons labour- ing under fever differs according to the type and the duration of the disease. In cases which beai the inflammatory character, the coagulum is firm, the fibrine abundant, or in greater relative propor- tion to the water and albumen : in some instances the coagulum is so dense that little or no serum is separated. This condition of the blood may or may not be accompanied with a huffy coat. There appears, however, in the progress of fever, to be a gradual diminution of the fibrinous principle ; the coagulum being not only small in proportion to the serum, but of a loose soft tex- ture. Upon what this diminution of the fibrine, and of the force of aggregation by which its par- ticles are kept together, depends, neither physi- ology nor chemistry has yet discovered ; all that in the present state of medical science we do know on this point, are the facts stated. Dr. Clanny has endeavoured by well-contrived experiments to determine with accuracy the relative loss or dimi- nution of fibrine at the various periods of fever, and certainly his investigations on this curious subject deserve attention. (Lecture on Typhus Fever.) [The examination of the blood drawn in the typhoid affection has not led to any decisive results. It was affirmed by M. Bouillaud that it does not resemble that of any other disease; but this is denied by M. Louis. It would seem, however, from the observations of MM. Andral and Ga- varret and M. Raciborski, that it is generally less coagulable than in other morbid conditions. The quantity of fibrin is certainly decreased. (Andralj Hematologic Pathologique, Paris, 1843; or Amer translation by Drs. Meigs and Stille, Philad, 1844.] The changes which take place in the secretions in the progress of fever, and which are so evident to the senses, depend in some measure on the general disturbance which takes place in every organ of the body, as well as on the condition of the blood. It is evident that if this fluid, from which all the secretions originate, be in a morbid state, the fluids which are eliminated from the parent source, must likewise be in an unhealthy state. The changes which the individual secre- tions undergo in fever have not been ascertained by chemical experiment, the knowledge we have of their vitiation being derived exclusively from observation. Crisis of Fever.—From the earliest periods of medicine, the termination of acute diseases, more especially fevers, was observed to be pre- ceded or accompanied by certain appearances or symptoms which indicated a favourable or unfa- vourable termination of the malady. Hence the origin of the term crisis (from KOiais, judgment), and the days on which these changes occurred were called critical days. The crisis was regarded as salutary when an evident amendment or complete cure accompanied or followed the change; perfect when there was an FEVER, (CO entire cure of the disease ; imperfect in the case of simple amelioration ; and false when certain appearances, such as hemorrhage, petechia?, colli- quative sweats, inflammation of the parotids, and carbuncles appeared, as these only portended a more dangerous and probably fatal form of fever. Those who embrace the humoral pathology of fever imagine that the termination of the symp- toms is produced by some great effort of the sys- tem to relieve itself, following the Hippocratic doctrine, that there being always a morbid matter to be expelled, nature was ever endeavouring either to attenuate this supposed morbific material, or to discharge it from the system. The solidists on the other hand contend that the solution of fever is effected by the treatment applied to the local affection, of which the fever is supposed to be symptomatic. Without entering into this dis- cussion, we may observe that the crisis of fever often takes place without sensible evacuation : in a large proportion of cases, however, it is preceded or accompanied by some change in the secretions, or by diarrhoea or hemorrhage. The urine is well known to exhibit certain alterations in the progress of fever. In the early stages it is diminished in quantity, but without any change in its colour or chemical properties. As the symptoms advance, the urine becomes darker in colour, but does not deposit a sediment till the fever begins to decline, when it is increased in quantity, and deposits a cloud or sediment on cooling. This urinary deposit, which is some- times copious, appears in the bottom of the vessel some hours after the urine has been voided : from its resemblance to brickdust it has been called lateritious, and by evaporation may be collected in minute crystals of lithate of ammonia. This sediment is by no means peculiar to patients labouring under fever, but is often observed in the urine of healthy persons, or in those whose func- tion of digestion is impaired. In other instances the sediment is of a pinkish white colour, and to this deposit, which according to Dr. Wilson Philip consists of the phosphates of the urine, the term furfuraceous, or branny, has been given. He regards both these urinary deposits as indica- tions of returning health, and particularly of the renewal of a free secretion by the skin, which in fevers is generally a favourable symptom. In some fevers terminating favourably, there is an unusual tendency to sweat which only exhausts the strength. In these the furfuraceous sediment is observed, but without removing the fever. This is the case in hectic fever.* NTINUED) 171 The connection of the favourable termii.ation of fever, more especially intermittents, with free per- spiration, was so often remarked by the ancients, that it gave rise to the practice of treating the disease by means calculated to induce diaphoresis, a practice which was followed by the most inju- rious consequences. They believed the abatement of the symptoms to be entirely owing to the free action of the vessels of the skin ; and that conse- quently, if sweating could be induced, it would have a salutary tendency. On this point it is only necessary to observe, that however beneficial moderate spontaneous perspiration undoubtedly is, permanent abatement of the febrile symptoms seldom follows diaphoresis when artificially in- duced. When the sweating is so profuse as to induce exhaustion, or when it is partial or clammy, it is unfavourable ; and though as a general rule, when critical sweats appear, little should be done, if the strength be evidently lowered, or if there be not corresponding amendment in the general symptoms, they should if possible be checked. It is remarkable, however, that in those kinds of fever in which there is great weakness, profuse long-continued sweating has been often observed to he most salutary. We are informed by Dr. Donald Monro, that in the petechial fever sweat- ing often continued with the best effects for three or four days. Hoffman also observed, as a pecu- liarity of this fever, profuse cold sweats of an acid smell, continuing for days and nights, and proving (apparently) a salutary crisis. When moderate diarrhoea comes on towards the termination of fever, it is generally a favourable circumstance, and ought not to be interfered with. When there has been a disposition to relaxation of the bowels throughout the disease, which is not uncommon in some epidemics in which gastric symptoms predominate, or at particular seasons, the irritation commonly subsides spontaneously; should it even continue through the period of convalescence, provided it do not interfere with the recovery of the patient, it is only necessary that the diet and general management be duly regulated. When the diarrhcea appears to retard recovery, and produce gradual emaciation, the practitioner should never lose sight of the possi- bility of the affection being the result of inflamma- tion of the mucous membrane of the bowels, or of other intestinal lesions, and therefore requiring the most vigilant care. From these observations it appears, that although diarrhcea does occasionally come on towards the close of fever, and in such instances may be said to be critical, yet no posi- tive conclusions can be drawn from this symp- tom—that when moderate it may oe salutary, when excessive it retards recovery, and in many cases appears to indicate some of those intestinal lesions which generally prove fatal. Though critical hemorrhages are mentioned by many of the older .authors as occasional occur- rences in fever we confess that in our individual experience we nave never witnessed such a crisis of fever. The inference is, that the occasional hemorrhagic action (more common in the fevers of hot countries) which has been observed in some cases to take place spontaneously, and to be fol- lowed by a salutary effect, has been improperly termed critical. We have repeatedly observed * Dr. Wilson Philip states that the following are the only appearances of the urine, if we except, those it assumes in consequence of morbid affections of the urinary organs, which can be distinctly marked:—the pale urine without cloud or sediment —the pale urine with a slight cloud appearing a few hours after it has been passed—the high-coloured urine remaining clear, or having a light cloud formed in it, and depositing usually, a considerable time (from four to twelve hours) after it has been passed, a red crystallized sediment — the high-coloured urine becoming turbid after it has been passed for a short time (from half an hour to two hours), and depositing a light-coloured, sometimes pinky sedi- ment, now and then (after the urine has stood for a lon- ger time) mixed with more or less, if the light-coloured sediment is copious, never with much, of the red crys- tallized sediment. In almost every disease, as well as in health, the urine occasionally assumes all these ap- pearances, i ONTINUED) 172 FEVER, (C such spontaneous hemorrhage from the nose when there was considerable cerebral affection, and al- ways remarked the great relief which followed this salutary evacuation ; but we have never met with an instance in which the fever disappeared with the epistaxis. In typhus fever, hemorrhage from mucous surfaces and from the skin (pete- chia?) at any period of the disease, but more par- ticularly in the advanced stages, is not unusual. These hemorrhages are never critical; they tend to lower the already exhausted powers of the pa- tient, and always indicate an unusually severe, if not a fatal form of fever. Enlargement of the absorbents (more especially of the cervical and parotid glands) occasionally takes place towards the termination of fever. This is more common in some epidemics than at other times, and though resolution generally takes place when the inflammation extends to the cellular tissue surrounding the gland, it terminates in sup- puration. Abscesses occasionally form in differ- ent parts of the body towards the decline of fever, and have therefore been regarded as critical. Eruptions of the skin have also been observed towards the decline of fever. The appearance of aphtha? on the tongue, lips, and inside of the mouth, has been thought an unfavourable circum- stance in fever, as indicating debility. Though we do not think the supervention of any eruption a desirable event, we have never observed an un- favourable result in such cases as have been ac- companied with aphtha?. Herpes about the mouth and ears towards the termination of fevers is to be regarded as a salutary crisis. The ancients also believed that fevers had a fixed or determinate duration, and that these ter- minations happened on certain days in preference to others. The days on which continued fevers are said more particularly to subside, are the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth, and twentieth. De Haen collected from the writ- ings which have been supposed to be the produc- tions of Hippocrates, the results of the termina- tion of one hundred and sixty-three cases of fever. Of these it is asserted that more than two-thirds terminated on one or other of the eight days above mentioned; none occurred on the second or thir- teenth day, and only one-third of the whole ter- minated on the eighth, tenth, twelfth, fifteenth, sixteenth, eighteenth, and nineteenth days. Of one thousand seven hundred and seventy- three cases, of which an account of the days of decline was kept by Dr. Stoker, two hundred and sixty-two occurred on the seventh day, two hun- dred and twelve on the ninth, one hundred and seventy-three on the eighth; on the fifth, sixth, tenth, eleventh, and twelfth, nearly an equal num- ber, (about one hundred and twenty;) from the thirteenth to the thirty-first days, the number pretty uniformly decreases from eighty-two to two. From the difficulty of ascertaining the actual commencement and decline of the symptoms of fever with accuracy, besides that the disease is more protracted in its duration at some periods than at others, we are not inclined to consider these observations of much practical value. Not only did the ancients suppose fever termi- rnted at certain determinate periods, but Galen affirmed that, after careful observation, he had been able to discriminate those days on which fever terminated favourably or unfavourably. 'Thus he asserted that the majority of fevers terminated favourably on the seventh day, a large proportion on the fourteenth: next in order he placed the ninth, the eleventh, the twentieth, or twenty-first, the seventeenth, the fifteenth, the fourteenth, the third, the eighteenth, the twenty-seventh or twenty- eighth. The sixth day, according to Galen, was always most unfavourable, fevers which termi- nated on this day being either in general fatal, the crisis imperfect, or the patient liable to relapse. Other unfavourable critical days were the eighth, the tenth, the twelfth, the sixteenth, and the nine- teenth. The thirteenth was regarded as neither favourable nor unfavourable. We do not enter into these details of supposed critical days, with the most distant wish to per- petuate what certainly appears a fiction, but tc endeavour to guard the inexperienced against doc- trines which deserve notice only from their antiquity. It should be remembered that we have no grounds for ascertaining how time was calculated in those early days; besides the difficulty of ascertaining the precise hour or period of invasion, and the time occupied by the gradual and often impercep- tible changes which announce the crisis. We know also that the duration of fever varies accord- ing to climate and the particular character of the epidemic: besides, we have endeavoured to show that there are, comparatively, very few cases of fever in which some local inflammation does not exist at the beginning, or arise at some period of its progress, and which most materially interferes with any supposed regular duration. It must be apparent, also, that the symptoms of fever may be not only mitigated, but their duration shortened, according to the treatment which has been adopted : indeed, fever is often rendered ex- ceedingly tedious, either from neglect in its early stage, or from the sufferer being placed under cir- cumstances which preclude the possibility of those means being applied which are most effectual in checking the progress of the disease. These remarks are intended to apply to the various forms of continued fever. We admit that in periodic fevers the symptoms have a certain du- ration, and that in the eruptive fevers, (small-pox, measles, and scarlatina,) the symptoms have also a fixed period of cessation or decline, unless their regular course be interrupted by the supervention of some local affection, or some peculiarities in the epidemic itself. These circumstances certainly, at first sight, give countenance to the doctrines we are now impugning; but when we consider the many circumstances in which eruptive fevers differ from every other form of acute disease, their almost invariably fixed duration cannot be adduced as an argument in favour of the doctrine of critical days in continued fever. Prognosis. —Although a considerable propor- tion of cases of fever recover, it is to be regarded as a dangerous disease. For the first few days its character may be mild, but symptoms often arise in its progress which place the patient unexpect- edly in danger; while, on the other hand, the patient may recover from a combination of the most unfavourable circumstances. FEVER, (CONTINUED) 173 In the first place, the prognosis will depend on the type of the fever, and the complications which arise in its progress. Simple fever, being the mildest, is the least dangerous form ; indeed it sel- dom proves fatal, unless from the supervention of some local inflammation. Of the probable issue of complicated fevers, it may be said that this de- pends both on the importance of the organ affected, and the intensity or degree of the local disease.— Cerebral is more dangerous than pulmonary or abdominal inflammation ; and the various intes- tinal lesions are more dangerous than any form of pulmonic affection. If there be local disease in more than one organ, the prognosis must, of course, be less favourable than when the affection is con- fined to a single organ. Of the prognosis of typhus fever, it may be stated that it is the most dangerous form of fever. Its fatality is materially influenced by the symp- toms which arise, by the character of the prevailing epidemic, and the mode of treatment pursued. Indeed, every species of fever varies in severity in particular years, and even in particular periods of the same year. It is not easy to account for such variation in epidemics, nothing beyond the fact having been hitherto ascertained. In the second place, the prognosis will also, in some degree, be influenced by the age of the indi- vidual. It is more fatal at some periods of life than at others. The following table will give a com- parative view of the mortality of fever at different ages. It is abstracted from the records of the London Fever Hospital. Under 10 years of age there died 14 From the age of 10 to 15............. 40 15 to 20.............118 20 to 25............. 84 25 to 30............. 73 30 to 35............. 25 35 to 40............. 39 40 to 45............. 30 45 to 50............. 29 50 to 55........,..... 14 55 to 60............. 12 60 to 65............. 6 65 to 70............. 9 70 to 75............. 5 75 to 80............. 2 500 In the third place, the constitutional powers and previous habits of the individual will also materially influence the probable result of the case. Persons of a robust vigorous frame and sanguine temperament in general pass through fever better than those of a melancholic temperament and feeble powers; and those who have led a tempe- rate life are more likely to escape the ravages of fever than such as have impaired their constitution by intemperance and excess. In the fourth place, particular symptoms indi- cate a favourable or unfavourable prognosis. In acute diseases, and more especially in fevers, it is of great consequence to examine into the various conditions of the pulse. In fever we are to be guided chiefly by its frequency and volume. If it do not exceed 100 or 110 at any period of the twenty-four hours; if it be at the same time soft though not very compressible, and if the pulsa- tions be regular, the indication, so far as the circu- lation is concerned, may be considered favourable. The state of the respiration is also to be con- sidered. If it be of natural frequency, or only a little accelerated towards evening, or at those periods of the day when an accession of fever comes on, resuming its natural state when the ex- acerbation abates, and is not attended with cough, it is favourable. Auscultation generally indicates the presence or absence of pulmonary disease; and as we have already seen that latent pulmonary affections may be going on without any external signs — cough or alteration in the respiration — frequent examinations of the chest by the stetho- scope should be made. In detailing the symptoms and explaining the causes of fever, we have seen the prominent im- portance of the nervous system: its condition, therefore, must in every instance materially influ- ence the prognosis. If the headach, or giddiness, which almost invariably accompanies the disease, continue moderate, or when in its progress they have become severe, but have yielded to appro- priate measures — when moderate delirium does not come on till towards the middle of the second week of the disease, and appears chiefly towards the evening — when the patient enjoys intervals of refreshing sleep—or, if the steep be protracted, he be easily roused from his slumber — if with these symptoms the state of the eyes and expres- sion of the countenance be natural — or should moderate deafness without pain in the region of the ear supervene, a favourable result may be an- ticipated. In no disease does the appearance of the tongue afford more satisfactory information than in fever. If, after it has been covered with thick moist fur, it appear cleaner at the edges, or after having been dry and parched, it become clean and moist round the margin, it is a favourable circumstance—more particularly if this change be accompanied with desire for food and abatement of the thirst, heat of skin, and other symptoms. Another favourable symptom is the appearance of a warm general perspiration: it must, how- ever, be distinguished from a cold, clammy, or partial sweat, or from that occasioned by external heat. A moderate spontaneous diarrha?a is ofttu a salutary crisis of fever, and if it do not prove ex- hausting, should not be interfered with. The prognosis may in some measure be formed from the posture of the patient. When an indi- vidual labouring under fever is able to change his position, and to retain it for any length of time, it is a favourable circumstance, showing that a degree of muscular vigour still remains, and that the powers are not unduly exhausted. The state of the blood, should there arise neces- sity for venesection, affords an important indica- tion : if it flow readily when the vein is opened, and if on cooling the coagulum be firm and abun- dant, it is favourable, showing that the system is in a vigorous state. The unfavourable symptoms of fever may be classed under two conditions — those of undue or excessive excitement, and those of failure of the vital powers. 174 FEVER, (CONTINUED) Under the first, may be classed those symptoms tvhich characterize great febrile excitement, more particularly violent action of the heart and arte- ries, pungent heat of skin, hurried breathing, headach, excessive thirst, and general functional disturbance. These symptoms are more particu- larly observed in the fevers of warm climates, in which all acute disorders run a rapid course, and are often very fatal. In such cases the excite- ment may be general, without any marked dis- turbance in any organ; and although this general excitement has been known in some instances to prove fatal without inducing any inflammatory complication, more commonly some organ be- comes, sooner or later, inflamed, and according to •die extent of the lesion produced, the danger of the patient is to be estimated. When symptoms denoting inflammation of the brain come on, viz. acute pain in the head, deli- rium, suffusion of the eyes, throbbing of the caro- tid and temporal arteries, rolling of the head from side to side on the pillow, drowsiness or coma, the prognosis is unfavourable, especially if such symptoms occur in an enfeebled constitution, which forbids the adoption of such active measures as are necessary to subdue the local disease. Again, if inflammation of the lungs or pleura, or of any of the abdominal organs, supervene, the particular lesion being recognised by particular symptoms, the prognosis is unfavourable, unless the local affection be speedily arrested. The safety of the individual in all such cases depends on the promptitude and judgment with which the treat- ment is pursued, and on the powers of the patient being adequate to contend with the disease and the treatment it requires. The prognosis, however, is not to be deduced from general symptoms alone, but in connection with the condition of the vital functions. Hence an unfavourable prognosis may be drawn from the following circumstances. Extreme frequency and feebleness of the pulsa- tions, exceeding 120 in the minute, indicate danger; when they exceed 130, the case may be considered nearly hopeless. Intermission or irre- gularity of the pulse is also a bad symptom. This state of the pulse no doubt depends on spasmodic action of the muscular structure of the heart arising from the same causes which induce muscular tre- mor and subsultus tendinum, as we have observed irregularity or intermission of the pulse accom- pany the general muscular affection, and subside at the same time under a cordial plan of treatment and opiates. On the other hand, it may happen that fever has supervened on some organic disease of the heart which has given rise to the irregular action: these cases can only be ascertained by stethoscopic examination and the previous his- tory. The condition of the brain in fever affords many indications both favourable and unfavourable. We nave already adverted to those symptoms which niay be regarded as favourable. Of those which are dangerous, we may mention early delirium, which, although by no means a fatal, is always an unfavourable symptom. Coma indicates great danger. Muscular tremor of the hands, tremulous motion of, or inability to thrust out, the tongue, starting of the tendons, spasm of the diaphragm indicated by hiccup, great failure of muscular power, so that the patient cannot sustain his posi- tion on either side, but lies on his back sunk in the bed; involuntary evacuation of the urine and stools; or the opposite condition — retention of urine and difficulty of swallowing, indicate much danger. Though the low or typhoid fevers are generally accompanied with symptoms of impaired energy in the brain, it should be kept in mind that sub- acute cerebral inflammation sometimes supervenes under circumstances of great general debility. Such a combination generally proves embarrass- ing, the practitioner having to contend with in- flammatory symptoms, while the general powers are enfeebled and exhausted, or, as Dr. Bateman remarks, " the nature of the one affection abso- lutely contra-indicating the treatment, which the nature of the other as decidedly requires." When convulsions occur (which they do rarely) they always indicate speedy dissolution. Loss of sight, although it seldom occurs, is in- variably a fatal symptom. Partial paralysis of the retina, indicated by the appearance of black spots, called musca? volitantes, floating before the eyes, picking at the bed-clothes—or endeavouring to catch or drive away imaginary objects—closure of the upper eyelid, which arises from debility of the levator palpebra? superioris; or the patient going to sleep with the eyelids half closed, may be regarded as alarming if not fatal signs. Dropping of the lower jaw, so that the patient lies with his mouth open, the jaw-bone falling down from its own weight, in consequence of • paralysis of the temporal and masseter muscles— grinding the teeth, which is produced by spasmo- dic affection of the muscles of the lower jaw, de- note great danger. Another set of unfavourable symptoms which may be referred to the disorder in the brain are, great restlessness, tossing the arms about, and un- covering the body, though the skin be cool. Any remarkable deviation from the natural state of the respiration or voice in fever is always to be considered unfavourable. The alteration in the tone or strength of the voice, not depending on the dry state of the mouth, throat, teeth, and lips, which prevents the free use of the organs of speech, arises from loss of power in the muscles of the larynx. When the breathing is hurried without any corresponding disease in the respira- tory organs, it is a bad omen, showing that there is great debility. When there is intense pulmo- nary inflammation, either bronchitis, pneumonia, or pleurisy, there is considerable danger. That form of pulmonary disease to which the French writers have given the term latent bronchitis is always a dangerous and often fatal complication. It is not indicated by any pathognomonic symp- tom, and is only detected by auscultation; and when it occupies both lungs, it speedily destroys the patient. The obscurity of pulmonary disease in fever is often owing to the condition of the brain, and hence the indispensable necessity of the frequent application of the stethoscope in the progress of fever. The symptoms in the alimentary canal which give an unfavourable aspect, are fiery redness of the tongue, its middle or root, as well as the teeth FEVER, (CONTINUED) 175 being covered with dry, black sordes; or a preter- naturally clean, red, dry, or fissured tongue — tympanitic distension of the belly, with or without pain on pressure — exhausting diarrhcea, the eva- cuations, consisting of light yellow, serous fluid, being passed unconsciously — hemorrhage from the bowels or bladder. These symptoms are al- ways of themselves exceedingly unfavourable, as they indicate severe lesion of the mucous mem- brane of the intestines, and when accompanied with sympathetic sensorial disturbance, the issue of the case is seldom doubtful. Another very alarming and always fatal symp- tom is sudden acute pain in the abdomen, follow- ed by vomiting, rapid distension, collapse of the features, and extremely small, quick pulse. The pain at first is confined to a limited space, but it soon becomes diffused over the abdomen. These symptoms indicate intestinal perforation, which, it is unnecessary to add, is always a fatal event. There are certain external symptoms in fever which assist the physician in determining the probable issue. The expression of the countenance always affords an indication of much value; so much so that those who are familiar with the disease can often pronounce with, great accuracy as to the condition of the patient from attentive observation of the countenance alone. It is difficult, if not impossible, to describe the various changes in the countenance in fever : they are known only to those who have had much experience in this dis- ease ; and a knowledge of them can only be ac- r quired at the bed-side. In mild cases, there is , little alteration from its natural aspect, and should any circumstances arise in the progress of fever sufficient to produce change in its expression, a sure indication of amendment is improvement in the expression of the countenance. In almost every instance patients become thin under fever; and unless the emaciation be exces- sive, it is a more favourable symptom than when there is comparatively little wasting of the flesh. When the patient emaciates rapidly, so that he becomes almost a living skeleton, it is generally owing to lesion of some internal organ, very often of ulceration in the bowels. In these cases the prognosis is unfavourable. We have already alluded to the fetor of the body in some forms of fever. This sometimes arises from inattention to cleanliness when the patient passes his evacuations unconsciously, but more commonly from a vitiated state of the secre- tions, and consequently of the perspiration. It is always a bad symptom. Exudation of blood from the vessels of the skin giving rise to petechia, or vibices, is an unfavour- able symptom, showing great general debility and relaxation of the capillaries, the blood being at the same time deficient in fibrin. Huxham ob- serves, (On Fever, chap, viii.) " that when black, livid, dun, or greenish spots appear, no one doubts their malignity; the more florid, however, the spots are, the less is to be feared: it is a good sign when the black or violet petechia? become of a brighter colour. The large black or livid spots are almost always attended with profuse hemor- rhages. The small dusky brown spots, like frec- kles, are not much less dangerous than the livid and black, though fluxes of blood do but seldom accompany them. The vibices, or large livid or dark greenish marks, seldom appear till very near the fatal period." When parts which are subjected to pressure show a tendency to gangrene, it is an unfavoura- ble sign: in some cases large sloughs form on the sacrum or hips, and produce so much constitu- tional irritation as ultimately to destroy life. Cold- ness of the extremities, denoting failure in the nervous energy, though often observed two or three days before the patient dies, indicates the near approach of death. The same indication may he taken from cold sweats, which are often referrible to failure of the circulation and relaxa- tion of the capillaries. When the -extremities become cold, the surface bedewed with a cold, clammy sweat, the countenance collapsed, the respiration short, interrupted, or laborious, the fatal issue is not far distant. Causes of Continued Fever. — It has been well remarked by Dr. John Hunter, in his work on the Diseases of the Army in Jamaica, that the great improvements to be made are not so much in the cure as in the prevention of diseases, which depends altogether upon the knowledge of their causes. The causes of fever have been usually consider- ed under two divisions. The first comprehends those circumstances which predispose to, or ren- der the body susceptible of the operation of the causes which produce the disease: they are termed predisposing. The second includes such causes as immediately excite the fever, and are consequently called exciting. 1. Predisposing Causes.—From this distinction it may appear that a certain predisposition is ne- cessary before the exciting causes can produce their effect; or, in other words, that a predisposi- tion must exist, or be engendered before symptoms of fever can be established. Although a certain condition of the system renders the operation of the exciting causes more efficient, and in some cases contributes essentially to bring on the dis- ease, the exciting causes frequently operate, with- out the intervention of the predisposing. It has not unfrequently happened that individuals in perfect health, on being exposed to infection, have almost immediately been seized with fever. A woman admitted into the fever-wards of the Whitworth Hospital stated that on a certain day (Wednesday) preceding the day of her admission, a person not yet recovered from fever came into the house where she then was, and sat down close beside her. She became immediately sensible of a heavy, disgusting odour arising from the person of this individual; was instantly affected with headach, and became very weak; and on the same evening, long-continued rigors, followed by heat and perspiration, came on. She afterwards passed through a severe form of fever. A clergyman, having enjoyed during the morn ing his usual health, and having performed the customary church - service of the day, visited, before dinner, a small parochial fever hospital. While speaking to a woman recovered from fever, he discovered that he was standing on a straw just removed from the bed of a fever-patient, in which there was much feculent matter. The i: FEVER, (CONTINUED) odour from thence struck him with force; he im- mediately felt pain in his head, sickness, and prostration. The same evening he shivered, and fever of unusual severity ensued. Though little hopes were at one time entertained of him, he ultimately recovered. (Marsh on the Origin of Fever, Dubl. Hosp. Rep. vol. iv.) A child, on being discharged from a fever hos- pital, was admitted into a charitable institution, and brought with her a small bundle of clothes which had not been disinfected. The bundle was opened by a woman resident in the institution, who perceived an extraordinary disagreeable odour to issue from it. In a few minutes the woman became ill, felt sick at her stomach, and afterwards passed through fever. (Barker and Cheyne's Reports, vol. i. p. 472.) Nurses, too, have become so powerfully affect- ed on removing the evacuations of a fever-patient, or from applying dressings to gangrenous sores, as to sicken with fever almost immediately after. Instances of this kind are familiar to the writer, and have no doubt been often remarked by other physicians. It has been confirmed by experience, however, that when the system is in full health and vigour— when all its functions are duly performed and nicely balanced, it is enabled to resist any power- ful morbid impression. As soon as this equili- brium is disturbed—when the powers are enfeebled from any cause which tends to break up the strength, or to destroy that harmony of relation which constitutes health, the same causes which were formerly innocuous, become powerful agents in the production of disease. It is on this princi- ple that attendants on fever patients are enabled to resist infection so long as they continue in full health. Hence an important practical principle is deduced, that those who are engaged in attend- ance on fever should not approach the sick while any symptoms of even slight indisposition are felt. In all the instances of medical practitioners who have become the subjects of fever, which have come under our notice, there have been al- most uniformly, for some time previous to the ori- gin of the disease, evident signs of disordered health. It very generally happens that when pre- cursory symptoms of fever appear, the struggle made against its insidious approach too often ren- ders the subsequent progress formidable, while un- der early judicious management the primary symptoms might have soon subsided. It may be useful to point out a few of the more striking and important circumstances which ren- der the system susceptible of the influence of the exciting causes of fever. The first to be noticed is the particular period of life at which fever most frequently occurs. That some idea may be formed of the comparative frequency of fever at different ages, the following table has been constructed from the register of patients admitted into the I .ondon Fever Hospital during one year. Lnder 10 years............... 18 Between 10 and 15 ............. 68 15 and 20 ............. 130 20 and 25 ............. 178 25 and 30 ............. 100 30 and 35 ............. 44 Between 35 and 40 ............. 44 40 and 45 ............. 31 45 and 50 ............. 14 50 and 55 ............. 10 55 and 60 ............. 8 60 and 65 65 and 70 70 and 75 75 and 80 Ages not ascertained..... 17 324 mates 352 females Toal 676 From this abstract it appears that fever is most common between the ages of twenty and twenty- five, and next between fifteen and twenty. It decreases in frequency from the age of puberty downwards; and as a general rule it may be af- firmed that children, and particularly infants, are peculiarly exempt from the exciting causes of idio- pathic fever—the febrile ailments to which they are subject being almost invariably symptomatic of some local disturbance, such as dentition and disorder of the bowels. The frequency of fever between the ages of fifteen and thirty may be ex- plained by the development which takes place, and the tendency to plethora in young persons. It may also be stated that the type of fever is appa- rently influenced by the particular period of life__ inflammatory or acute fevers being more common from puberty to the age of forty. It is also modi- fied by individual temperament, persons of the san- guine being most liable to the acute, those of the melancholic to the low forms of the disease. We have already noticed how much a vigorous state of health contributes to protect the system against the influence of the exciting causes of fe- ver: it consequently follows that whatever tends to impair the health becomes indirectly a predis- posing cause. Those circumstances which induce plethora on the one hand, or inanition on the other, may therefore be regarded both as predi* posing and exciting causes, according to the du- ration of their application and the condition of the system at the time they are applied. Of the two however, scarcity or famine is the most powerful indeed, in all ages famine and disease have been observed to be coexistent. Hence, it may be con> sidered as an axiom, that scarcity of food, as well as food of a bad quality or improper kind, power fully predisposes the system to the influence of the exciting causes of fever. In tracing the records of epidemics, it will be found that they have almost invariably been pre ceded or accompanied by distress among the lowei orders, either from the high price of provisions, oi from some commercial causes, throwing the manu facturing portion of the community out of employ ment. In the epidemic fever which has at various times visited Ireland, all the medical practitioners allude to the inadequate supply of food among the inhabitants of the towns or districts where it raged. Insufficient and unwholesome nutriment, by im- poverishing the blood, not only brings on emacia tion, but depresses the nervous energy; hence, the system, under such circumstances, is readily acted on by the exciting causes of fever. In times of pestilence, therefore, due attention should be paid to the quality as well as quantity of the food, FEVER, (CONTINUED) 177 avoiding on the one hand too scanty an allowance, while on the other, the stomach should not be overloaded, especially with stimulating food. We consider a moderate but liberal allowance of ani- mal food to be a good preservative against the ex- citing causes of fever. This observation is strength- ened by the fact, that during the plague which raged in London in the seventeenth century, the butchers of the metropolis were observed to be re- markably exempt from the disease, and in our own experience butchers are rarely the subjects of fever. The moderate use of wine, by strengthening the body, obviates a predisposition to fever, and therefore, during the prevalence of epidemic fever, has been recommended. It should, however, be strongly impressed on the mind, that the immode- rate use of wine or intoxicating liquors, under such circumstances, actually renders the body more susceptible of the exciting causes. Dr. Chis- holm remarks that those who were addicted to intemperance, were most subject to the fever of Grenada; and as every kind of ardent spirits ope- rates as a slow but sure poison, producing great debility, and sapping the powers of the system, it is the duty of every one to discourage their use in the time of epidemic visitations. Bodily fatigue may be mentioned among the causes which tend to impair the natural vigour of the body, and thus render the system more suscep- tible of the exciting causes of fever. This may be either excessive and of short duration, as in violent exertion, or it may be prolonged, as in long journeys. It is well known to army surgeons, that soldiers very readily fall into fever, when ex- posed to its causes after a long march or severe and continued exertion in the field ; and, in times of scarcity and privation, the journeys which whole families are not unfrequently compelled to take in quest of employment and support, render them more liable to be attacked with fever than they otherwise would be. Another set of predisposing causes are those which give a severe shock to the nervous system. The various kinds of mental emotion—fear, grief, anxiety, disappointments, long-continued watching on a sick bed, intense study, want of steep, may individually be ranked among the predisposing causes of fever. As Dr. W. Philip observes, therefore, few things are better preservatives against infection than fortitude and equanimity. Nothing, we are informed by those who voluntarily exposed themselves to the contagion of the most pestilen- tial fevers, was found so great a preservative against its effects, as a steady adherence to what they be- lieved their duty, banishing from their minds, as much as possible, all thoughts of danger, and avoiding every kind of passion, particularly the depressing passions. Every body knows how much fear predisposes to infection : on this account it is of consequence to strengthen the faith of the ignorant in the efficacy of any thing they believe capable of preserving against infection. (On Fe- brile Diseases.) 2. Exciting Causes.—The exciting causes of fever form a most important and interesting sub- ject of investigation, though it must be acknow- ledged that notwithstanding all that has been done in this department of etiology, the subject is still involved in obscurity. Vol. II. —23 | There can be little doubt that the opinion enter tained by many, of the exclusive origin of a" forms of continued fever in contagion, has tended much to limit our knowledge of its other causes. That fever does occasionally originate in conta- gion few persons of experience or unbiassed judg- ment will now deny ; but there are other causes which operate with equal certainty, a knowledge of which it is exceedingly important to attain. The records of medicine contain abundant proofs of the origin of fever in the poison gene- rated by the decomposition of vegetable and ani- mal matters, though it seems probable from some facts, that the exhalation from vegetable substances in a state of putrefaction is more injurious than that from animal; and from the circumstance of the prevalence of fever in some particular places, and the number of persons who have become affected from residence, even for a short time, in those situations where it has been found to pre- vail, it has been concluded that fever may arise from a terrestrial or atmospheric poison generated in such localities. To the febrile poison, however produced, the term miasm, (from the Greek word importing pollution, corruption, or defilement gene- rally,) or malaria, (from the Italian term implying bad or impure air,) has been applied. It is well ascertained that vegetable as well as animal sub- stances, in a state of decomposition, emit effluvia or exhalations which prove extremely hurtful to the human body, and when applied in a state of sufficient concentration are productive of most severe illness, or even of instantaneous death. On this account, all febrile poisons have been sup- posed to originate in one or the other of these sources, or in a peculiar unknown pestilential con- dition of the atmosphere, to which, from the num- ber of persons simultaneously affected, the term epidemic has been given. We know very little about the physical quali- ties of these emanations or vapours beyond their noxious effects on the animal body : they are invisible and without taste or smell: chemistry has failed to unfold their nature, as on submitting them to the test of chemical analysis, nothing be- yond the fact that tney contain a considerable pro- portion of hydrogen and carbonic acid gas has been discovered. Hence some ingenious persons have endeavoured to deduce the unhealthiness of low damp situations in the warm season, to a sup- posed deficiency of oxygen in the atmosphere, though, as Dr. Bancroft has very justly stated, were we to assume this principle, fever should be produced by every crowded assembly, and in a multitude of situations where no such effects have been observed. It would appear from fever arising in particular localities, ■fiat noxious exhalations are generated from some soils only, and that the combination of heat and moisture is also necessary for their pro- duction. We find, accordingly, that in the same district, one place or spot is unhealthy, while at a very short distance, perhaps, the inhabitants are remarkably free from disease; and that, in som>i seasons which have been remarkably dry, even when the heat has been unusually great, fever is either little prevalent, or entirely unknown. Though every soil contains an admixture of animal matters in a state of decomposition, it is 179 FEVER, (CONTINUED) probable that the deleterious principle which gives rise to fever is derived from vegetable substances almost exclusively. This opinion is strengthened, if not confirmed, by what is observed to take place during the process of preparing hemp, flax, and indigo for the various purposes for which they are used in commerce. These plants in their preparation are steeped in water, and during their decomposition ex- tremely offensive emanations arise. Lancisi gives the history of an epidemic fever, which for seve- ral summers infested and almost depopulated a town situated in an elevated and salubrious part of Etruria. This fever arose from the emanations from ponds or stagnant waters in the lower part of the town in which hemp and flax were mace- rated : on the process being afterwards prohibited, there was no recurrence of fever. Dr. Bancroft states he was informed at Naples that in several places near that city, and particularly in some beyond the Grotto of Posilippo, sleeping in houses contiguous to ditches in which hemp or flax was macerating had been almost constantly followed by fever. Similar effects have been observed from the fermentation which the indigo plant undergoes in the process for extracting the colouring matter. It appears that, after the extraction of the dye, large heaps of the plant are formed near the man- ufactories and houses of the work-people, for the purpose of undergoing decomposition so as to form manure. After being frequently moistened by the heavy rains, and heated by the rays of a scorching sun, copious exhalation takes place from these beds of putrefying vegetable matters, in con- sequence of which the workmen, and persons who live near, were constantly attacked with danger- ous fevers. This circumstance having of late years attracted the attention of the indigo plant- ers, the plant, after the extraction of the dye, is not permitted to be formed into heaps near the works or dwellings of the labourers. Fevers are consequently now comparatively rare among the workmen. (Bancroft on Yellow Fever.) From these facts it would appear that there are some deleterious emanations emitted during the putrefactive process of vegetable matters. [It will be seen, however, under the article Malaria, that none of these processes produce disease except in soils which are known to be malarious. In some recent sanitary reports (Local Reports on the san- itary condition of the labouring population of England, in consequence of an inquiry directed to be made by the poor law commissioners: Lond. 1842,) great stress is laid by most of the medical reporters upon the influence of the effluvia from animal and vegetable remains in stagnant pools, &c, in the production of the typhus. Yet it may admit of question, whether the typhus was fairly referred to such miasmata.] Some have endea- voured to show, however, that moisture alone, applied to the living body, produces fever. This position has been again and again disproved by the most conclusive facts; indeed, the argument adduced by Dr. Bancroft, of the remarkable health- iness of the men employed in the Newfoundland fisheries, where they are generally enveloped in the dampest fogs for several months together, af- fords the least ambigous proof, that the atmosphere •when loaded with moisture only, has no greater power in causing fever, than it has when in any usual state of dryness. It would appear that a combination of cir- cumstances, more particularly heat and mois- ture, is necessary to give potency to putrid emana- tions. Miasmata generate very slowly in a perfectly dry situation ; and it has been generally remarked that fevers are not prevalent in dry seasons. Dr. Bancroft states that it is found on the west coast of Africa, and in some of the West India islands which are liable to long droughts, as Barbadoes, and more particularly Antigua, that marsh fevers occur very seldom in dry seasons; but that they become very prevalent whenever these droughts are suddenly terminated by frequent rains. Dr. James Clark, in his Treatise on the Yellow Fever, observes that when there was much rain in the months of May and June, and dry sultry wea- ther prevailed in the following months of July and August, fever raged much among the troops and strangers. This is precisely what is observed to take place in the fevers of temperate countries. The effect of heat in promoting putrefaction, and the consequent generation of emanations, is evident from the variation observed in the putre- factive process in different temperatures. A very low or a very high temperature is unfavourable to the decomposition of dead inorganic matter, pu- trefaction being entirely suspended at the freezing point, and proceeding very slowly at any degree under 4-5° of Fahrenheit: it gradually increases from this point, and appears to take place most readily about 100°, but to be checked when the temperature exceeds 100°. It has been remarked that in districts, where marsh fevers are prevalent, their progress is arrested, and in many cases they entirely disappear during a continued frost: when spring advances they reappear in a mild form ; in summer they prevail more extensively ; and in autumn the cases not only increase in number, but assume a more severe form. Precisely the same thing happens with regard to the continued fevers of temperate countries, so that the combi- nation of heat with moisture must be admitted to be a powerful circumstance in the production of fever. It is necessary, however, to state that paludal emanations are generated in greater quantity, and probably in a state of greater concentration, when there is only such a degree of moisture as facili- tates putrefaction. It is well known that in marshy districts fevers do not appear in the rainy season till the water has nearly evaporated or drained off; and, as Dr. Bancroft states, attention to this important fact will enable us to understand, why in some coun- tries frequent and heavy rains render marsh fevers prevalent, while in others the deprivation of rain for two or three months produces equally morbid effects. The fact that in very dry seasons fevers are seldom observed has been already noticed ; in very low situations where the ground is much moistened and often inundated in the rainy sea- sons, the inhabitants remain free from fever till the water evaporates from the heat of the weather, so as to leave the ground in many places unco- vered. The comparative insalubrity of situations FEVER, (CONTINUED) 179 in the vicinity of stagnant waters compared with running streams is thus explained. In the third volume of the Journal de Physio- logic, an interesting account is given of a fever which occurred in the autumn of 1822 ; its origin was ascribed to exposure to the emanations of stagnant waters, and using the same water in food. The symptoms of the fever were pain in the epigastrium, purging, distension of the belly, feeble pulse, thirst, black furred tongue, fetid sweats, and great prostration. The convalescence was remarkably tedious. Hence the expediency of occasionally inundating a marsh in hot weather, when any deleterious exhalation arises. There is considerable difference in the various kinds of soil as regards the generation of emana- tions. Fevers have been generally remarked to be more common when clay constitutes a considera- ble proportion of the soil. Whether this is owing to the greater humidity of a clayey soil, or whether it favour the putrefactive process more than other kinds, is yet a matter of conjecture. We may here allude to the singular exemption of persons who Jive near peat-bogs or moors from marsh fevers ; this has been observed to be re- markably the case in some districts of Scotland and Ireland. The cause of this apparent salubrity in the districts referred to has not been satisfactorily explained, but it is well known that peat-bogs have the remarkable property of preserving both dead animal and vegetable matter from putrefac- tion. According to Dr. Bancroft, not only plants and trees, but even human bodies with their cloth- ing, when completely immured in the peat soil, will scarcely undergo any change during a long course of years ; and it is probably owing to this peculiar property that they do not exhale, and perhaps do not generate, miasmata similar to those which arise from marshes. Some chemists who have made experiments with a view to discover the nature of peat, are of opinion that its antisep- tic powers are derived from tannin, though from a certain quantity of iron being always found in peat, it is probable that this metal may have a con- siderable share in contributing towards its antisep- tic properties. From what has been stated, it is evident that not only the origin but the propagation of fever depends on a great variety of circumstances, which, in tracing the causes of the disease in any particular locality, should be minutely investigated. It is often found that fever is confined to a limited district, so that one part of a town is sickly while other districts are healthy. This has been repeatedly remarked in the malarian fever which prevails in the summer and autumn at Rome, the disease appearing chiefly in the low parts of the city near the river, while the other districts are quite free, unless when the wind blows in the direction of the Pontine Marshes. Particular streets have been observed to be more unhealthy than others; and it has been said that fever has run through every house on one side of the street, white the inhabitants of the opposite side escaped. Ample proofs of the injurious effects of emana- tions from vegetable substances in a state of pu- trefaction on the living body having been adduced, let us next examine into those arising from the decomposition of animal matter. It would appear, however, from the immunity of persons exposed to the effluvia of dead animal matter, that its ap- plication to the living system is rarely followed by any injurious consequence. Persons who are much exposed to animal putrefaction, such as the men who are employed in particular trades, skin- ners, parchment-makers, catgut and glue-makers, nightmen, and students of anatomy, who are en- gaged for several hours daily in prosecuting their anatomical studies, are seldom known to suffer from their occupation. The same immunity is not enjoyed by persons who are long enough exposed to the effluvia from putrid vegetable sub- stances. It is true that persons who have been engaged in the removal of corpses from burying- grounds, and nightmen, have suffered from their occupation ; but the disease occasionally induced in them does not appear to have any resemblance to fever. Fourcroy states that in some of the burial- grounds of France, when the grave-diggers in opening the ground penetrate graves in which bodies have been recently placed, they become affected with vertigo, sickness, tremors, and a feel- ing of oppression ; in some instances they become asphyxiated : it has also been observed that num- bers of those who live in the vicinity of cemete- ries labour under dejected spirits, sallow counte- i nances, and febrile emaciation. The human body, not only when affected with disease, but under certain circumstances in a state of health, generates a poison which gives rise to fever. This principle, notwithstanding the reason- ing of ingenious disputants, has been incontrover- tibly established by a multiplicity of facts. There can be no doubt that the most potent febrile poisons are the exhalations from the bodies of persons labouring under some form of fever. The proofs on this point are so clear and satisfac- tory, that few persons deny that fever originates in contagion. To assert that contagion is the only principle capable of producing the disease evinces a very limited notion of the circumstances under which fever is generated ; and yet this opi- nion was taught by Cullen, and is implicitly be- lieved by many even in the present day. It is almost as absurd as the idea still entertained that fever cannot be propagated by contagion. Sir John Pringle states that he has observed the hos- pitals of an army, not only when crowded with * sick, but at any time when the air is confined, and especially in hot weather, produce fever of a peculiar kind which is often mortal. The same thing has been observed in almost every hospital, and shows that the congregation of sick persons does, under some circumstances, produce fever. It is not necessary however that such exhala- tions, in order to generate fever, should anse from the bodies of persons in a state of disease : it is well known that fever is readily produced by the accumulated emanations of healthy persons. Sir John Pringle mentions that he had observed fever arise in full and crowded barracks, and in transport-ships when filled beyond a due number, and detained by contrary winds, or when the men had been long kept at sea under close hatches in stormy weather. We have frequently observed that the febrile poison becomes so virulent in a confined atmo 180 sphere, that everv person who has been exposed to its influence has "been attacked with fever; and as if to show the agency of a specific poison, the symptoms in every individual who has received the infection have been remarkably similar. It is this concentration of human effluvia which is so productive of fever in crowded ships, prisons, and workhouses, more particularly in warm wea- ther, and when little attention is paid to ventila- tion ; for it should be remembered that the febrile poison may be so diluted by pure air as to be ren- dered almost innoxious. Few parish workhouses, when overcrowded with paupers, especially in the summer months, escape the visitation of fever; end when an epidemic appears in a large town or manufacturing district, the ravages which it com- mits in the crowded, ill-ventilated dwellings of the poor are often appalling. The facts which have been accumulated from the most authentic sources prove that fever may be communicated from person to person by con- tagion. It does not require actual contact to pro- duce the disease; exposure to the atmosphere of the apartment, but more especially to the exhala- tion from the body of a fever patient, being suffi- cient. In the article Contagion, (to which we refer for more ample details,) such abundant illus- trations have been brought forward, that the most sceptical must be convinced of the origin of fever in this source. We certainly think that Dr. Marsh, in his paper on the origin of fever, (Dub- lin Hospital Reports,) has brought forward a body of evidence which should alone decide the ques- tion. The facts there collected are corroborated by the experience of every fever hospital as to the medical officers, nurses, and immediate attendants on the sick, and every inmate of the establish- ment, of whatever description, being with few ex- ceptions affected with fever. We have known many instances of nurses pointing out the very patient from whom they received the infection; others have been sensible of a sudden and parti- cular impression at the moment the poison was received. This impression has been sometimes from the fetor of the body, not unfrequently from the stools, or in removing the linen of the patient. [The writer has elsewhere (Practice of Medi- cine, edit. cit. ii. 488) referred to many analogous cases, some of which were observed by Drs. Ger- hard and Pennock at the Philadelphia Hospital. It would not seem that the dead body of a typhous subject is apt to communicate the disease. In an epidemic of unquestionably contagious fever, which occurred at St. Bartholomew's Hospital, London, and which has been described by Dr. Roupell, (A Short Treatise on Typhus Fever, Amer. Med. Lib. Edit. p. 31, Philad. 1840,) seventeen bodies of those who had died of the fever were submitted to dissection. On an ave- rage, eight pupils were engaged on each; so that one hundred and thirty-six were thus occupied. Six of the whole body of students were attacked with fever ; but of these six, two only devoted their time to dissection ; and these two had been exposed to the infection of the living body in the wards of the hospital. In the epidemic at the Philadelphia Hospital, both Dr. Gerhard and Dr. Pennock, with several of the resident physicians, were engaged nearly every day during the most FEVER, (CONT J.JN U fcD) intense prevalence of the disease, in making long and laborious anatomical investigations, without suffering from the fever. '(Amer. Journ. of the Med. Sciences, Feb. 1837, p. 299.) If it be granted that typhus is capable of being communicated from individual to individual, it is clear that the poison cannot be very virulent, and that if due attention be paid to cleanliness and ventilation, and to avoiding prolonged exposure in the immediate vicinity of the patient, it may be rendered almost harmless, except in the case of unusually susceptible persons. Dr. Christison (Tweedie's Library of Pract. Medicine, 2d Amer. edit. i. 169, Philad. 1842) remarks, that among numerous instances known to him of young prac- titioners and medical students who had caught fever, not a single case had occurred where the disease was communicated to their families at home, or in their lodging-houses; and the expe- rience of the writer has been the same.] Persons in a state of full health and vigour are much less likely to become affected with fever, than those whose powers are exhausted. It is on this principle that the nurses and attendants in fever hospitals resist for a time the febrile poison; but after a longer or shorter exposure, more espe- cially if the strength has been impaired by bodily fatigue, want of sleep, and close confinement to the sick room, they almost invariably lapse into fever—a convincing proof that whatever weakens the general strength tends to render the operation of the exciting causes of fever more certain and effectual. Any undue mental fatigue also powerfully aids the operation of the exciting causes of fever; and we have often verified the remark of Dr. Marsh, that in such cases the violence of the disease falls on the brain and nervous system, producing what is emphatically termed brain fever. In the same manner we may explain satisfac- torily the rapidity with which contagion spreads in times of scarcity or famine. The poor under such lamentable visitations are generally exposed to circumstances, which render them readily af- fected by causes which under more favourable events would be inoperative. Fatigue, exposure to cold and wet, insufficient or improper kind of food, are the too general attendants of epidemic fever among the poor. Though mental emotion of a depressing kind powerfully predisposes the system to fever, it is singular how much an unusual degree of excite- ment acts apparently as a preventive. It is not unusual to observe that, during the painful anxi- ety and suspense, between hopes and fears as to the recovery of a valued relative and friend, the body is as it were armed against the effects of contagion. When this state of excitement is withdrawn, it is frequently followed by the same disease which was the cause of such intense anxi- ety, as if, in short, the system became relaxed so as to receive the influence of the infection to which it had been exposed. From what has been stated, it is evident that when there is any indisposition, exposure to con- tagious fever should be avoided. The means of guarding against contagion must at once suggest themselves. These consist in ventilation, separating the healthy from the sick, FEVER, (CONTINUED) 181 avoiding the effluvia from the skin, from the breath, and more especially from the evacuations; in adopting a nutritious but not stimulating diet; and in preserving moral courage, — fear, as we have stated, always predisposing the system to infection, so much so, that during the prevalence of an epidemic disease the terror it induces tends materially to increase the number of its victims. The following brief sketch of fever originating in long-continued mental anxiety, by Dr. Cheyne, vividly describes a not infrequent and somewhat peculiar form. " The causes are loss of property, of character; wounded pride. Invasion insidious, in- distinct, patient generally unable to assign the date of the commencement of the attack ; for some time before he has been complaining of bad nights, or has had symptoms of a common cold, which almost insensibly degenerate into the proper symptoms of fever; then, from an ignorance of the nature of his illness, he neglects himself, perhaps for many days ; and at last when visited by a physi- cian, he appears utterly unconscious of the formi- dable nature of his disease, and probably says he has no complaint—he is merely very weak: the symptoms are those of the typhus gravior of noso- logists; a red suffusion of the eye; prostration of strength; subsultus tendinum; quick and weak pulse; hurried breathing; dun petechia?, or a mottled or morbillary state of the surface. Of such patients a great proportion die. The most re- markable part of the disease is that it does not spread." Dr. Cheyne has no recollection of a second case of this kind of fever occurring in a family, and he has never been able to discover that the patient had been exposed to contagion. It would seem to arise solely from mental causes. (Marsh on the Origin of Fevers, Dub. Hosp. Rep.) Few circumstances connected with the causes of fever have attracted more attention than its tendency to become epidemic, and to prove malig- nant and fatal at particular times, while at others the disease is little prevalent and of a mild char- acter. These variations in febrile diseases have existed in all ages; they were particularly re- marked by Hippocrates, who ascribed them to something divine, in which idea he was followed by Galen. In more modern times, these differ- ences have been ascribed to the influence of some atmospheric or terrestrial agency, of which little or nothing is known except the effects it produces in the propagation and malignity of diseases. The notion that such pestiferous causes depend on planetary influence has been long exploded, though they appear to have an intimate connec- tion with sudden and extreme variations of tem- perature, more especially excessive heat combined with moisture. It is by no means uncommon to observe the prevalence of fever sensibly checked when the air is dry and cold. Other contagious diseases as well as fever be- come epidemic and malignant at particular periods. This has been more especially observed with re- gard to small-pox, measles, and scarlatina, which, though never extinguished, are more frequent at some periods of the year, as well as more malig- nant at certain seasons than at others. It is probable, therefore, that the circumstances which contribute to the prevalence as well as ma- lignity of febrile diseases, operate by increasing the predisposition, or by rendering the body more susceptible of the influence of their various ex- citing causes. Hence the obvious effect of living in confined places, or of scarcity, or of any causes that undermine the powers of the system, in ren- dering the exciting causes of fever operative. Not only is there a great difference in the num- ber of persons affected with fever at particular times, but there is often, also, a remarkable simi- larity in the symptoms. Thus in the winter and spring months, the fever is of a more acute char- acter, and generally complicated with cerebral or pulmonary inflammation. In the autumn they are of a less active kind, and accompanied with more or less gastric irritation. It is impossible, in the present state of our know- ledge, to account for these various modifications in the character of fever, though it is of the great- est importance to observe them with the view of regulating the treatment. Climate has an important influence, not only in giving a predisposition to fever, but in modify- ing its character or type. The inhabitants of warm climates are more liable to fever than those who reside in cold or temperate countries. The symptoms also are generally more violent, and the progress of the disease more rapid, while the type of the fever is very liable to change. The predis- position to fever, however, diminishes by continued exposure to its causes, and hence the immunity frequently observed in the natives of warm cli- mates, while strangers or new comers are almost invariably attacked, soon after their arrival, with the peculiar fever of the country. We have already alluded to the effect of heat in the production of fever. The negative princi- ple of cold has been usually placed among the exciting causes. Though, undoubtedly, cases of mild fevor may be traced to exposure to cold, it is more probable that it acts as a predisposing cause, especially when the body is weak, and little able to resist its effects. Dr. Marsh is of opinion that cold, like contagion, is an impression made on the sentient extremities of the nerves; its effects are in like manner instantaneous; its action, though powerful, is resisted when the body is vigorous and strong, but its impression upon those who are exhausted, fatigued, or relaxed, is followed very frequently by consequences formidable and even fatal. It appears from some facts which have been noticed, that while some individuals are enabled to resist the operation of the exciting causes, others are only indisposed in a peculiar and indefinite manner after exposure to them, as if there were a struggle in the system to obviate their effects. Fever, moreover, has been apparently induced by exposure to other acute diseases. Dr. Marsh mentions the case of a nurse in Stevens's Hospi- tal, who was suddenly seized with illness while in the act of turning in the bed a boy labouring under confluent small-pox. She remained ill but not incapacitated for business for three days. She then had rigors followed by severe fever, the or- dinary typhus of this country. Dr. Johnson as serts that he observed in some instances that the ward-maids of the lying-in hospital caught typhu* fever from the patients then affected with puerpe- ral fever. 182 FEVER, (CONTINUED) It would be exceedingly important if the mode in which the various febrile causes produce their effects could be satisfactorily demonstrated. It appears evident, from attentive observation of the general characters of fever, that there is occasion- ally a very remarkable difference in its forms or types, as well as in the particular symptoms on which its distinctive varieties have been founded. The local lesions or complications, we have seen, assume remarkable variation in certain sea- sons and in particular epidemics, both in respect to the organs individually affected, and in the de- gree or intensity of such local inflammations. Thpse circumstances lead to the belief, either that the febrile poison is different at different times, or that it is so modified by the state of the system as materially to alter its effects. The former is the more probable explanation, though from the na- ture of the febrile poison, such difference cannot be demonstrated, but is only rendered probable from its effects on the human body. Though it is impossible to explain the operation of all the exciting causes of fever, there appears to be a very close analogy in the action of many to that of other poisons. We know that this class of agents (poisons) affect different structures : the narcotics, for instance, act on one organ — the nervous system ; others have a two-fold action, as in the instance of the acro-narcotics, which evi- dently operate both on the nervous system and on the mucous membrane of the bowels, giving rise in the former to peculiar symptoms of narco- tism, while a more severe effect is produced on the latter—inflammation and its consequences. It cannot be demonstrated, but it seems more than probable, that some of the febrile poisons, whether originating in animal, vegetable, or atmos- pheric miasmata, operate on particular structures. In some cases it would appear that the brain and nervous system are the only organs affected by the febrile poison ; at all events, the nervous system appears to be early, if not primarily dis- turbed, as is evident from the shock which the whole system receives on exposure to some of the causes alluded to. The symptoms in the brain are not, however, always the effect of the primary action of febrific causes on this organ. The nervous system is so susceptible of distant sympathetic impressions, that there is often great difficulty in distinguish- ing primary from secondary cerebral disease in fever. When there is intestinal affection more especially, the brain always sympathises ; in which case it is often very difficult to determine whe- ther the cerebral disturbances arise from the pecu- liar operation of the febrile poison on the nervous system, or whether it be only sympathetic of the morbid condition of the alimentary canal. Again, fever assumes particular forms at differ- ent seasons of the year. It is well known that in some epidemics, and at certain seasons, the mu- cous membrane of the air-passages is affected, the existence of this form of fever being indicated by the catarrhal symptoms which accompany it. There seems every reason to believe, that at those periods when epidemic catarrh or influenza ap- peared, and of which Sydenham, Huxham, and Hakei have given faithful and valuable reports, some peculiar condition of the atmosphere pre- vailed. In like manner, in the autumnal months, the symptoms of gastric disorder form the prominent character of the fever. We have seen also that intestinal affections are not only more common at particular times, but occur in a larger proportion of cases in some localities than in others. This evidently arises from some circumstances peculiar to those situations. The effect of terrestrial ema- nations, rendered virulent by long-continued rains in hot climates, in producing dysentery, has been remarked by many writers and army-physicians. We shall next consider how far morbid states of the blood are to be regarded as exciting causes of fever. The ancient writers ascribed with great truth the origin of many diseases to a morbid condition of the blood and humours; and though the culti- vation of anatomy has led to the investigation of the solids as the great source of diseases, yet that many arise from a morbid state of the blood, is admitted even by the warmest adherents of solid- ism. No one doubts that scurvy depends on vitiation of the blood, in consequence of improper diet, or living in an unwholesome atmosphere, and that in its progress (whatever cause may have produc- ed the alteration in the blood) various local dis- eases take place; showing, as Andral remarks, " that many lesions, apparently inflammatory, are far from depending simply on a local morbid state, but being connected with certain conditions of sanguification, can be removed only by a return of that process to its natural condition." Sir John Pringle mentions a remarkable fact which came under his personal observation, of a person being seized with dysentery by making experiments upon human blood, which had be- come putrid by standing some months in a close phial. M. Gendrin injected one ounce of blood, drawn from the veins of a patient labouring under putrid fever, into the cellular tissue of the groin of a cat. Copious vomiting, dyspncea, small, frequent, irre- gular pulse, dry brown tongue, great prostration, and slight convulsions before death, were the effects which followed this experiment. The animal died within seven hours after the operation. Duhamel has related the case of a butcher who suffered from a most malignant disease, and which proved fatal in four days, from putting into his mouth the knife he had employed in slaughtering an ox that had been over-driven. An innkeeper wounded himself with a bone of the same ox in the palm of his hand ; the arm mortified, and he died in seven days. In two women who had re- ceived some drops of blood of the same animal, the one on her hand, the other on her cheek, the parts to which the blood was applied were seized with gangrenous inflammation. It is well known that specific febrile diseases, small-pox, and even measles, can be produced by inoculation ; and that these diseases, as well as the syphilitic poison, may be communicated through the umbilical circulation from the mother to the fetus in utero, while a healthy infant after birth may become affected with syphilis from the dis FEVER, (CONTINUED) 183 eased milk of an infected nurse. It has also been asserted, " that in females who have died during pregnancy from the effects of some deleterious poison, the same specific agent which the mothers had used has been found in the blood taken from the heart of their dead infants." (Observations on the Healthy and Diseased Properties of the Blood, by Wm. Stevens, M. D.) In females who are chlorotic, the blood is alter- ed in its physical characters, and is apparently the cause of this singular disease. It is deficient in the solid or fibrinous principle, and consequently it is thin and pale, and scarcely tinges linen. The symptoms in this affection are so general, that we may safely affirm that every organ and function of the body suffers more or less. It is not uncommon also for leeches to die im- mediately after they have sucked the blood of some persons. Cases of this kind have been oc- casionally recorded. (Christison on Poisons. Me- dical Gazette, February, 1831.) In these cases the presumption is, that some deleterious agent has been mixed with the blood, which has proved fatal to the leeches. The following is a singular instance of a vege- table poison entering the circulation, and pro- ducing no injurious effect on the animal, but afterwards producing fever, and even death in those who use its milk. A plant, which is called by the natives the Indian Hachy, grows in Tennessee, on the banks of the river Cumberland, and in other parts of the western district of the United States of America, and is so poisonous, that a small quantity of the milk of cows that have fed upon it, mixed with tea, produces most violent fever, and in some cases even death. The following account of the disease produced by this poison is given by Dr. Macall:— " After swallowing the milk, the person in a short time suffers from thirst, nausea, vertigo, confused or imperfect vision; vomiting often ensues, succeed- ed by violent fever, the exacerbations subsiding at irregular intervals. The pulse is extremely varia- ble, sometimes strong and full, at others, tremulous, small, and corded. Constipation, which exists from the beginning, becomes more obstinate to- wards the third or fourth day. The skin also about this time is more hot and parched, the eyes are red and suffused, there is very great restless- ness, and all the secretions are scanty. Towards the sixth and seventh day excessive debility takes place, with very often paralysis of the tongue and other parts; and soon after ensue stupor, cold clammy sweats, convulsive hiccup, and often offensive cadaverous odour, and death." (Phila- delphia Journal, 1822.) Dr. Haines, in his account of this disease, which the natives call the trembles, [milk-sickness,] ob- serves, << that the heart beats with such violence in some cases as to excite horror in the physician and bystanders. When they lay the hand upon the patient's breast, it seems to labour convulsively, and as though it were clogged in its action by a superabundance of blood. The patient feels no- thing he can strictly call pain ; but the sense of heat, the oppression, the palpitation of the heart, and the violent efforts to vomit, constitute an ex- treme degree of distress." It is also stated that the milk and flesh of ani- mals killed while labouring under this disease will produce disease in other animals. Sucking calves, which have had no food but the milk of an affected cow, show the peculiar symptoms, and often die of the disease. Persons also making use of the milk or butter from the same cow have be- come affected. In an instance of a whole family becoming sick with this disease (some of them in a few hours after dining upon a loin of veal), it was after- wards satisfactorily ascertained that the calf, which was sold in the market by an unprincipled person, laboured under the disease at the time it was butchered. In another instance several persons became severely affected from incautiously eating of a pig, which had been fattened upon the milk of a cow that was known to be affected with the disease: all of the family who ate of it were seized, some of them in a few hours. These facts lead to the conviction, that many diseases are produced by a morbid state of the blood. We formerly adverted to the revival of the opinion among modern pathologists, that a certain class of fevers arise from this source. Many writers who have observed the fevers of hot climates (Warren, Hume, Hillary, Stevens, and others), describe the altered state of the blood in the ardent malignant fevers, and from the accounts given by some physicians of the fevers of hot climates, it is more than probable that the diseased state of the blood precedes, and is the cause of the febrile symptoms. In the Genesee country (the lake country of the United States) there are extensive swamps, so that in the hot months there are certain localities in which fever prevails extensively. Dr. Stevens states that during his residence in that country he bled several individuals who resided in some of the most sickly places, but who had not yet been attacked with the fever. The blood was very dark in colour, and evidently deranged in its pro- perties. Dr. Potter, with the view of proving the non- contagious nature of the yellow fever, which had been very fatal at Baltimore, observes, « it was remarkable in all cases in which it was deemed expedient to bleed, the blood wore the same gene- ral appearances. After a separation had taken place, the serum assumed a yellow shade, often a deep orange, and a portion of the red globules was invariably precipitated. It occurred to me that if the remote cause resided in the common atmo- sphere, the blood of all who had inhaled it a cer- tain time would exhibit similar phenomena. It accorded with the patnology I had conceived to conclude, that all who lived in an atmosphere so inquinated were constantly predisposed, and that an additional or exciting cause only would be re- quired to develope the symptoms in form. To ascertain the appearances of the blood in subjects apparently in good health, I drew it from five per- sons who had lived during the whole season in the most infected parts of the city, and who were, to every external appearance and inward feeing, in perfect health. The appearances of the blood could not be distinguished from that of those who laboured under the most inveterate grades of the disease. As this experiment might have been 184 FEVER, (C< considered inconclusive, unless the blood could be compared with that of those who lived in a purer atmosphere, remote from the evolution of mias- mata, I selected an equal number of persons who dwelt on the hills of Baltimore county, and drew from them ten ounces of blood. The contrast in the appearances was so manifest, that no cause for hesitation remained. There was neither a pre- ternaturally yellow serum nor a red precipitate: the appearances were such as we find in the blood of healthy subjects. A young gentleman having returned from the western part of Pennsylvania, on the 10th of September, I drew a few ounces of blood from a vein on that day ; it discovered no deviation from that of other healthy persons. He remained in my family till the 26th of the month, and on that day I repeated the bloodletting. The serum had assumed a deep yellow hue, and a co- pious precipitate of red globules had fallen to the bottom of the receiving-vessel. Of the six per- sons whose blood assumed those indications of the remote cause, four were seized with fever during the epidemic; the other two escaped any formal attack, but complained occasionally of headach, nausea, and other indications of disease. Hun- dreds who were not confined, and who never took medicine, experienced the effects of the general cause, under a variety of forms, such as nausea, giddiness, headach, constipation, a pale or yellow face, tinnitus aurium, pains in the extremities, and some other light shades of incipient indisposition. In some there were premonitory symptoms of a formal attack; in others they vanished, leaving the subject in his usual health. Many were list- less, complaining of universal languor, indisposed to muscular exertion, yet did not surrender to the disease. They were neither sufficiently indis- posed to be placed on the sick-list, nor well enough to pursue their ordinary occupations."* With respect to the state of the blood in fevers of temperate countries, Dr. Mead says, « Pestilen- tial fevers, in fine, I call all those which are ac- companied with some sort of poison. Now of whatever nature this happens to be, it not only infects and corrupts the blood, but seizes upon the subtle nervous liquor. Hence it is, that these fevers act with greater rapidity and violence, and are much more fatal than the common sorts." Dr. Stoker conceives typhoid or adynamic fever to be generally symptomatic of morbid changes in the physical character of the blood. He states that the crassamentum is dissolved, or broken into fragments, tinging the serum with its colour, which is sometimes of a very dark brown, and sometimes of a greenish hue. These changes he considers to be intimately connected with disturbance or failure of the vital power in the process of san- guification ; and that the morbid changes which take place in the blood become, in proportion to their degree, the source of morbid action. (Re- port of the House of Recovery and Fever Hos- pital, Cork-street, Dublin, 1829.) Dr. Clanny has adopted views nearly similar, from observation of the gradual changes in the blood from the commencement to the decline of fever. (Lecture upon Typhus Fever.) He has * Memoir on Contagion, more especially as it respects the Yellow Fever, by Nathaniel Potter, M. D Baltimore l&ljs p. 53. NTINUED) shown the difference in the component principles of the blood according to the stage of the disease, that the blood loses a proportion of its solid in gredients as the fever advances, which it after- wards gradually regains as the fever declines. He firmly asserts his belief, however, in these various changes in the blood being the effect of disease in the solids. The idea that certain forms of fever originate in a morbid condition of the blood, is further sup- ported by the peculiar symptoms which follow from poisonous wounds in dissection, or in the preparation of putrid game. The symptoms in these cases closely resemble those of typhus fever, and the description given of the effects of intro- ducing putrid fluids into the veins of animals. Whether the opinion of the old writers, that in fevers originating in tontagion the contagious principle alters the properties of the blood, be cor- rect or not, we certainly think the strong anal- ogy in the cases alluded to tends to confirm the supposition of typhoid fevers originating in dis- eased blood. There has been much ingenious disputation on the question, whether the alteration in the blood be the cause or the effect of the disease in the solids. It appears probable, if not certain, from what has been advanced, that in a certain class of fevers (typhoid) the blood is primarily diseased, and that certain changes in one or more organs take place as a consequence, or secondary effect. On the other hand, from various circumstances, as well as from some recent experiments (by Du- puytren, Mayer, and Dupuy), it may be inferred that the solids, more particularly the nervous sys- tem, effect most important and sensible changes in the constituent principles of the blood. On this subject Andral remarks that " no line of demarcation can with strictness be drawn be- tween the blood and the solids. Physiologically speaking, it is impossible to conceive that one of these two parts of the same whole could be modi- fied without the other being so likewise. On the one hand, inasmuch as the blood nourishes the solids, and as, without its presence, they cannot support life, the state of the solids cannot but be influenced by the state of the blood. The chem ist might as well say that the nature of a body does not depend on the nature of the elements that compose it. On the other hand, the solids, considered with respect to their relations to the blood, form but two classes ; the one contributing to make the blood, such as those concerned in the actions of absorption, digestion, arterial circula- tion, and respiration; the other contributing to unmake it, those, namely, concerned in the ac- tions of venous circulation, secretion, and nutri- tion. No one solid, therefore, can undergo the slightest modification without producing some de- rangement in the nature or quantity of the mate- rials destined to form the blood, or to be separated from it. Physiology then leads us to the conclu- sion, that every alteration of the solids must be succeeded by a modification of the fluids. View- ed in this light, there is no longer any meaning in the disputes between the solidists and humor- ists ; the system appears to constitute but one great whole, indivisible in the state of health as well as in that of disease. The division of the FEVER, (CONTINUED) 185 parts of the body into solids and fluids seems to j be a distinction of small importance, and one that is not always just, since it ceases to exist in the intimate structure of the organs, in which all the grand vital phenomena take place, and in which also occur all the changes that constitute the mor- bid state." It is probable that when certain external agents alter the properties of the blood, and thus induce fever, the changes take place in a very gradual and almost imperceptible manner. If, for exam- ple, an individual who has been accustomed to a pure air, be exposed to an unhealthy tainted at- mosphere, or to marsh miasms, or if his food be of an unwholesome kind, or insufficient as to quantity, he is observed gradually to droop, to 3maciate, and to lose his natural energy: he may for a long time struggle against this incipient form of disease, but at length symptoms of fever be- come developed. Under these circumstances, it is very probable that the blood has been undergo- ing gradual changes from the time that the sys- tem was first exposed to the causes adverted to ; in the one case, the unhealthy atmosphere has altered the qualities of the blood; in the other, the unwholesome kind or scanty supply of food has produced bad chyle, which, by entering the circulation, taints the general mass of the blood. It would thus appear, that when the various exciting causes produce fever by their action on the solids, the febrile phenomena take place speed- ily, while those acting on the blood produce their effects in a gradual, slow, and often imperceptible manner. Treatment of Continued Fever. — Before deciding on the measures to be adopted in the treatment of any disease, it is requisite that the practitioner should have correct ideas of its nature in order that the principles or indications of cure may be successfully applied.* In no class of maladies is this more essential than in continued fever, which we have seen, as- sumes so many modifications, arising chiefly from the various circumstances in which it originates, and the local inflammations with which it becomes complicated. When those points are considered, it will be evident, that the treatment must be adapted to the circumstances of each case. Not only are the precise form of the fever, and the presence or absence of local congestion or inflam- mation to be ascertained, but the duration of the disease, the age, the sex, and the constitution or powers of the individual—the previous habits or mode of life, the effects of remedies which may have been previously employed, and the character of the prevailing epidemic. Sydenham's remark should ever be imprinted on the practitioner's mind, that the same method which cures in the middle of the year may possibly prove destructive at the conclusion of it; and when he had fallen on the method of treating any species of fever, he was always successful till that species became extinct and a new one arose, when he was again doubtful how to proceed ; and, notwithstanding * Sentio anteni, nostra? artis incrementum in his con- fistere, ut habeatur historia sive morborum omnium de- scriptio, quoad fieri potest, graphica et naturalis, praxis «eu methoous circa eosderu stabilis ac consummata.— tydenham V)l. II. —24 a* his utmost caution, could scarcely ever preserve his first patients from danger, till he had thorough- ly investigated the nature of the disorder. The ancients entertaining the opinion that the phenomena of fever were the result of certain efforts of the system to expel some noxious agent, observed most carefully the various changes which took place when the symptoms were allowed to run their natural course. They, consequently, watched the spontaneous efforts of the system, and the supposed salutary effects of certain critical evacuations in controlling or removing the various morbid actions. Founding their indications on attentive observation of the various means by which the system apparently effected a natural cure, they did not attempt to interfere with its operations, but were contented to assist these natural efforts by such measures as they con- ceived most likely to conduce to this end. Accordingly, the older physicians attempted the cure of fever by promoting, by artificial means, such evacuations as are occasionally noticed to occur when the disease is allowed to pursue its own course, uninterrupted by the interference of art. The symptoms or evacuations which are observed in the spontaneous resolution of fever, and which physicians have attempted to induce by remedies, are vomiting, diarrhcea, sweating, and hemorrhage. Another mode of treatment has been proposed on the principle that, as fever is frequently a fatal disease, the attention of the practitioner should be directed chiefly to combat the more dangerous symptoms which arise in its progress; and we confess, that, in our judgment, this plan is not only more philosophic, but that which is most successful in practice. We have just stated the indispensable necessity of ascertaining the form of the fever before the in- dications of treatment are considered ; and, as the measures to be pursued are essentially different, according to the type of the disease, we shall treat of the management of each variety in the order of the description given in the history. Treatment of simple fever.—In the manage- ment of the milder as well as the more severe cases of the common epidemic fever, the practi- tioner would often be more successful in his en- deavours to cut short the disease, or to lessen its duration, were medical aid resorted to on the first feeling of indisposition. It too often happens that the primary stage is altogether neglected ; the pa- tient, hoping that the symptoms will pass off, and unwilling to believe, that he is seriously indisposed, continues to pursue his usual avocations, until he is compelled by increasing illness to resort to medi- cal aid. In investigating the symptoms of fever, how- ever apparently mild, the condition of the several organs should, in the first place, be carefully ex- amined by every means within our reach, that we may be certain there is no lurking disease to keep up the febrile excitement. The patient, his rela- tives, and sometimes his medical attendant, are too apt to suppose, that if there be no pain to attract attention to any organ, there is no local disease going on. A very short acquaintance with acute disease, however, will convince the practitioner, that, besides pain, (which in many cases of locaJ 186 FEVER, (CONTINUED) inflammation is entirely wanting,) there are other symptoms, the presence of which indicates both the seat and intensity of the local affection. Again, when we find one organ more particularly affected than another, although the disturbance be merely functional, this over-action, which often depends on irritation or congestion, should be watched and controlled, test it should pass into inflammation. Having ascertained the condition of the several organs, and being satisfied that there is no local complication, the modified antiphlogistic treatment is to be adopted. Strict quietude should be en- joined ; consequently confinement to bed, or at all events to the horizontal posture, abstinence and cessation from all mental effort, are indispensable; fortunately, indeed, the lassitude and languor which attend the very first approach of fever, ren- der the patient averse to exertion either of body or mind. In every form of fever, the expediency of blood- letting is to be considered. This remedy is not to be indiscriminately employed ; but the circum- stances of each case weighed, before the practi- tioner decides on employing or withholding the lancet. We shall therefore consider the circum- stances which should regulate the employment of this remedy, as we treat of the measures to be pursued in the various forms of fever. In the milder varieties of simple fever, blood- letting is seldom required, unless the patient be of a full habit, or the symptoms indicate unusual ex- citement. Under these circumstances, a mode- rate bleeding at the commencement of the disease is often of much service in mitigating the symp- toms, and preventing local inflammation. Indeed, there are few cases of the acute fever of temperate countries, in which, at the onset, a moderate bleeding is not advisable ; and in the fevers of hot climates, which often run their course with alarming rapidity, this evacuation is indispen- sable. Physicians of observation and experience have often remarked the different characters of epi- demic fever, and are therefore aware that at one period, or in some epidemics, the type of the fever renders the bold use of the lancet necessary, while at another season, or from some peculiarity in the epidemic, which is quite inexplicable, the system will not bear with safety the bold treat- ment which the previous epidemic required. The character of the prevailing fever, as well as the stage and symptoms of the case, must determine the propriety of bloodletting, and the extent to which it should be carried. Even when, from the nature of the prevailing epidemic, bloodletting is indicated, it should be restricted to the early stages, unless some symptoms arise in the later periods to require it. This remedy is also to be prescribed with great circumspection when the patient is of a feeble constitution, or advanced in years, of intemperate habits, or if there be chronic visceral disease. In such cases, unless there be symptoms which require bloodletting, the modified antiphlogistic treatment is to be adopted, viz. strict est, antimonials, and purgatives; and should local congestion or inflammation arise, they are to be. arrested by the topical abstraction of blood. The freedom with which some physicians spec- ulate on the safety of large bleedings in fever has led to very improper notions on this point of practice. A little experience at the bed-side, and attentive observation of the ever varying circum- stances which individual cases of fever present, will soon enable an observing, and what is of more importance, a candid practitioner, to form a true estimate of this powerful remedy. Were every patient who is seized with fever to be bled indiscriminately, without regard to age, constitu- tional powers, previous habits, and mode of living, and more especially to the prevailing character of the epidemic, many lives would be sacrificed by a remedy, which, when judiciously employed, is an anchor of safety. The action of full vomiting, by the shock given to the system, and by determining the blood to the surface, being frequently followed by marked relief of the general symptoms, has led to the ad« ministration of emetics in the early stage of fever. They are therefore to be employed in cases in which bloodletting is considered unnecessary, or in conjunction with this remedy. There are few circumstances which forbid their exhibition, so that, unless, as sometimes happens, the disease be ushered in by spontaneous vomiting, or epigastric tenderness, the patient be plethoric, or there be determination to some organ, more especially to the head, or marked prostration, a scruple of ipe- cacuanha, with one grain of tartar emetic, may be given in a draught, and its operation promoted and rendered as little distressing as possible by copious draughts of tepid fluids. The exhibition of purgatives in fever requires as much discrimination as bloodletting. Before the excellent practical work of our much respected friend and preceptor, Dr. Hamilton, appeared, the minds of physicians were fettered by the fear of debility, one of the supposed direct causes of death in fever, and purgatives were prescribed with great diffidence, lest by their operation the spasm of the extreme vessels, and the consequent debility, might be increased. This venerable phy- sician pointed out, in his admirable work, and illustrated by his practice, the advantages of a more liberal employment of purgative medicines in fever. The successful result of this method of treatment, and the inferences which Dr. Hamilton deduced, tended materially to withdraw the minds of physicians from the erroneous theory of Cullen, and certainly laid the foundation of the more ex- tended views of the nature and treatment of fever which have been recently introduced. The principles upon which this method of treatment should be employed have been misun- derstood. If Dr. Hamilton's observations be studied it will be apparent, that while he recommends the free evacuation of the bowels in the early stages of fever, he deprecates their indiscriminate admi- nistration. After detailing the circumstances which first led to his adopting the treatment of fever by purgatives, he states, «if this be a just view of the case, the plain inference is, that, while purgative medicines preserve a regular state of the body, they do not aggravate the debilitating effects of fever. The complete and regular evacuation of the bowels, in the course of fever, is the object to be attained. Within this limit, I have had much satisfaction in prosecuting the practice ; nor have FEVER, (CONTINUED) 181 [, in a single instance, had occasion to regret any injury proceeding from it; for I am not an advo- cate for exciting unusual secretion into the cavity of the intestines, and for procuring copious watery stools; these, while they are not necessary, might increase the debility so much dreaded." (Obser- vations on the Utility and Administration of Pur- gative Medicines in several Diseases, by James Hamilton, M. D.) With these precautions, no class of remedies is more beneficial in relieving the primary symptoms of fever, in preventing the accession of more formidable symptoms, and thus shortening the duration of the disease. In the more advanced stages, however, purgatives are injurious by draining too much from the system through the bowels; it is sufficient that the alimentary contents be expelled; and should the secretions, which ought to be daily inspected, ap- pear to be vitiated, mild aperients, containing small doses of mercurial preparations, should be from time to time exhibited. We cannot deprecate too strongly the practice of administering active cathartics in fever without reference to the circumstances of the case, and more especially to the powers of the patient. Such indiscriminate use of purgatives originates in mis- conception of the principles on which they should be employed. These remedies should not be pre- scribed merely because fever exists. In some epidemics and at certain seasons, we have seen that there is a tendency to diarrhrjea. It is almost unnecessary to state that under such circumstances aperients are to be withheld, or those only given which tend to correct the morbid secretions. The doctrines of Broussais as to the pathology of fever have had a salutary influence in checking the abuse of purgatives in the treatment. There is, no doubt, a material difference in the type of the fevers of France compared with those of Bri- tain ; there is a greater tendency to gastric irrita- tion, and to those changes in the mucous mem- brane of the bowels which result from inflammation. We do not, therefore, wonder at the proscription of purgatives by the French physicians, and their extravagant denunciation of the British treatment of fevers. The fact seems to be, that if British physicians were called upon to undertake the treatment of fever in France, they would be less lavish of their purgatives; and on the other hand, after the French physician had seen the character of fever in this country, and thrown aside his pre- conceived notions and scholastic prejudices, he would acknowledge the utility of the judicious administration of purgatives in the treatment of the fevers of Britain. The choice of the aperients employed is of less moment than their due regulation. In the begin- ning of fever, especially when there is considerable excitement, the more active purgatives, such as calomel combined with rhubarb, or senna with a neutral salt, may be given. Afterwards, such as ensure a full evacuation of the bowels, according to the indication to be fulfilled, are to be employ- ed. In cases in which purging is required, we have found a powder, containing three grains of calomel, two of James's powder, and eight of rhubarb, given at bed-time, during the stage of excitement, answer every purpose ; and if a more free action of the bowels be necessary, half an ounce of castor oil, or ai. aperient draught, may be given in the morning. When the skin becomes cool, and the tongue begins to clean, the calomel and antimonial powder may be omitted, and the regulation of the bowels managed by rhubarb, castor oil, or senna, so as to ensure one or two moderate evacuations daily, while any symptoms of fever remain. Sometimes the stomach is so irritable, that ordinary aperients are rejected, and even increase the irritation; in such cases the bowels are to be opened by injections, by which the large intes- tines are unloaded, and the peristaltic action of the upper part of the alimentary canal is promoted. When the fever is fully developed, the skin becomes steadily warmer than natural, especially towards the evening. The abatement of the fe- brile heat being generally followed by marked relief in the symptoms, and in the patient's general sensations, various means are employed with the view of reducing it. Those means which induce perspiration have been employed with this object. This attempt to imitate nature was strongly in- culcated by Cullen. Spasm of the extreme vessels being the supposed cause of the phenomena of fever, it was imagined that every measure which tended to diminish or remove this state of the cu- taneous exhalents would have the effect of subdu- ing the disease. Upon these grounds, the employ- ment of diaphoretics in fever was suggested, and these remedies now constitute a part of the treat- ment of all febrile diseases. It should, however, be observed, that although a spontaneous or natural diaphoresis has always a salutary effect in reducing not only morbid heat, but the other febrile symptoms, and occasionally accompanies the crisis of fever, the same relief is scarcely ever observed to follow diaphoresis in- duced by artificial means; and if it be attempted by stimulating or heating drugs, or confining the patient to a warm room, and loading him with bed-clothes, the febrile symptoms, instead of being allayed, are increased. If, however, moisture of the skin can be promoted by saline preparations, such as the acetate of ammonia, with antimony or ipecacuanha, assisted by tepid diluents, the morbid heat of the skin is generally reduced, and the feelings of the patient and general symptoms are ameliorated. The employment of refrigerants is another mode of diminishing the morbid heat of the skin in fever. Various internal remedies are prescribed with this view. The mineral and vegetable acids being useful in quenching thirst and cooling the surface, either may be employed according to the feelings of the patient; the most agreeable and convenient form of the latter is, the native vege- table acids contained in fruits, such as the lemon, orange, and tamarind. These may be taken in moderation if they agree or the bowels be not purged. Sometimes the saline refrigerants, such as the citrate or the nitrate of potash, are employ- ed in preference to the acids. Not unfrequently the patient has a desire for cold drinks; the most grateful during the first few days of the fever being cold spring water, which, if preferred, may be freely allowed, and the diluted sulphuric or nitric acid occasionally added. 188 FEVER, (CONTINUED) Very little dependence, however, should be plactd on diaphoretics or refrigerants ; their effi- cacy is very doubtful, while they often seduce the practitioner from more active measures. A more effectual mode of reducing the morbid heat is by the free external application of cold. The admission of cool air is of much importance in all acute diseases, but more especially in fever. Those who are conversant with the treatment of fever among the poor, are well aware of the fa- vourable changes in the symptoms which are often rapidly produced, after patients are removed from their filthy abode to a well-ventilated chamber, or to the ward of an hospital. The whole complexion of the disease is frequently altered in a few hours. In every case of fever the temperature of the apartment should be duly regulated; the air re- newed from time to time, the linen (both of the bed and of the patient) should also be frequently changed (once a day if practicable), and the bed- clothes adapted to the heat of skin and feelings of the patient. A more direct mode of applying cold in the treatment of fever is the application of cold water. Though this practice appears to have been known to the ancients, and to have been occasionally employed in modern times, it was not generally adopted as a remedy in the treatment of fevers till Dr. William Wright, formerly of the Island of Jamaica, published an account, in the London Medical Journal for 1786, of the successful treat- ment of some cases of fever, by the ablution of the patient with cold water. He first adopted this practice in his own case, and states that he was encouraged to try it from personal experience of the effect of cool air in mitigating his pains. He succeeded in arresting the progress of the fever after twice applying the cold effusion. The suc- cessful issue of this case induced other physicians to give the plan a fair trial. To the late Dr. Currie, of Liverpool, however, is due the merit of having first attempted to regulate this practice from accurate observation of its effects. When the cold affusion is to be employed, it is proper to ascertain with accuracy the temperature of the patient. The instrument best adapted for this purpose is the mercurial thermometer with a small bulb, and curved at the end. The bulb is to be introduced under the tongue with the lips close, or under the axilla, the heat in these two situations being found by experiments to corre- spond exactly with, and to give a just indication of, the heat of the surface of the body. The mode of applying the cold affusion is to have the patient stripped naked, and three to five gallons of water, at the temperature of 40° to 60° (Fahrenheit), thrown over him. The tem- perature of the water, however, must depend on the season of the year. The average temperature of water may be taken from 40° to 50°—during the summer months it varies from 60° to 70°. The degree of cold, however, is of less conse- quence in abating the symptoms than is generally supposed. Water alone may be used, or vinegar or com- mon salt may be added. There may be some slight advantages in the addition of these ingre- dients. Dr. Currie was of opinion that salt water, pesides being more grateful to the feelings of the patient, might be applied to the surface for a length of time with much less hazard. This may be true; but we apprehend the chief advantage of the application of cold in any form, is the rapid abstraction of heat, and the sudden, general, and powerful shock given to the whole system, which induces a sudden salutary re-action. The effect of the cold affusion, when it is ap- plied with due precaution, is to diminish the mor- bid heat of skin, lower the pulse, and to induce perspiration and sleep. As a general rule, the sooner the affusion is ap- plied after the irregular chills of the first stage is over the better, provided the heat of the skin is steadily above the natural standard. According to Dr. Currie, the safest and most advantageous time is, when the exacerbation is at its height, or immediately after its declination is begun. The heat at this period rises one or two degrees in the central parts of the body, and still more on the extremities, above the average heat. Dr. Currie, therefore, generally directed its employment from six to nine in the evening, though it may be safely used at any time of the day under proper regula- tions. The following precautions are recommended by Dr. Currie, when the cold affusion is contem- plated. 1. This remedy should never be used when there is any considerable sense of chilliness, al- though even the thermometer indicate a morbid degree of heat. If the affusion of cold water on the surface of the body be employed during the cold stage of the paroxysm of fever, the respira- tion is nearly suspended, the pulse becomes feeble and fluttering and of incalculable frequency, the surface and extremities are doubly cold and shri- velled, and the patient seems to struggle with the pangs of instant death. Under such circum- stances, as Dr. Currie states, the repeated affusion of a few buckets of cold water would extinguish life. 2. Neither ought the cold affusion to be em- ployed when the heat, measured by the thermo- meter, is less than, or equal to, the natural heat, notwithstanding the patient feel no sense of chil- liness. This is sometimes the case towards the last stages of fever, when the powers of life are weak. 3. It is also necessary to abstain from the use of this remedy when the body is under profuse sensible perspiration; and this caution is more important in proportion to the continuance of this perspiration. In the commencement of sweating, especially if it has been brought on by violent exercise, the affusion of cold water on the naked body, or even immersion in the cold bath, may be hazarded with little risk, and sometimes may be resorted to with great benefit. After the sweating has continued some time and flowed freely, espe- cially if the body has remained at rest, either the affusion or immersion is attended with danger, even though the heat of the body, at the moment of using it, be greater than natural. Sweating is always a cooling process in itself, but in bed it is often prolonged by artificial means, and the body prevented from cooling under it to the natural degree by the load of heated clothes. When the heat has been thus artificially kept up, a practi- FEVER, (C( doner, judging by the information of his thermo- meter only, may be ted into error. In this situation, however, Dr. Currie states that he has observed that the heat sinks rapidly on the exposure of the surface of the body even to the external air, and that the application of cold water, either by affusion or immersion, is accompanied by a loss of heat and a deficiency of re-action which are altogether inconsistent with safety. (Currie's Me- dical Reports.) According to the experience of Dr. Currie, if employed on the first or second day with the pre- cautions recommended, the progress of the fever is often checked ; but it is seldom successful when applied so late as the third or fourth day, though when administered about the eighth or tenth day, or even later, it moderates the symptoms and shortens the duration of the fever. When the fever is advanced, the heat of the water should not be more than 15° or 20° below the heat of the body. Indeed, when the patient is weak, or when the fever has run on to the ninth or tenth day, sponging the body with cold or tepid vinegar and water is preferable to the cold affusion. The advantages of the cold affusion in the acute or inflammatory forms of fever have been acknowledged by almost every writer or practi- tioner who has adopted the practice. Our own experience of it certainly accords with that of others as to its efficiency in reducing the febrile heat and moderating the symptoms. We freely confess, however, that there are few patients who can be induced to submit to a remedy so inconve- nient and so repugnant to their feelings ; and un- less the practitioner can show urgent reasons for its adoption, he will generally find both the patient and relatives resist the practice. We have cer- tainly never had the opportunity of witnessing a single case out of a considerable number, to which the cold affusion was applied, in which the fever was cut short, though all the patients felt after- wards greatly relieved, and in some the duration of the fever was probably shortened. The prac- tice is best adapted to inflammatory fever (syno- cha), and more especially to the fevers of hot cli- mates, which are accompanied with much greater excitement than those of temperate countries. It should, however, be ascertained in every case, be- fore such a powerful remedy is administered, that there is no visceral inflammation : were such a powerful shock given to the system under such circumstances, dangerous and even fatal conse- quences might ensue. We are, for the reasons stated, disposed to recom- mend in preference the cold sponging or washing of the surface, either with cold water or with vinegar and water, whenever the skin is decidedly hotter than natural. This mode is easily applied, gives the patient no fatigue, and checks those irregular feelings of heat, especially in the palms of the hands and soles of the feet, which are so annoying to the patient, besides, what is of some consequence, producing no alarm. It may not, we admit, be so permanent in its effects as the cold affusion, and certainly cannot be expected to cut short or even to moderate the duration of the fever, but as a grateful means of relieving morbid heat, reduci ig the pulse and tranquillizing the patient, NTINUED) 189 we submit that it is equally efficacious. This cir- cumstance, with the advantages already stated, has always led us to give the cold sponging a de- cided preference to the cold affusion. Dr. Currie applied the cool affusion in cases where, from the continuance of the fever or the debility of the patient, the cold affusion was inad- missible. The temperature of the water employed for this purpose should be from 75° to 87°. It is, however, liable to so many objections, and has so few advantages, that in the present day it is almost entirely abandoned. The warm or tepid affusion (from 87° to 97° Fahrenheit) has been proposed in feeble habits, and when the heat is little above the natural stan- dard ; and, according to Dr. Currie, the heat is lowered as speedily by the tepid as by the cold affusion ; indeed, he asserts that in some cases the heat is more speedily lowered by tepid water. The tepid affusion is applicable to every case of fever in which the cold affusion is recommended. Its effects, however, are less permanent than those of the cold affusion, besides that it is admitted, even by Dr. Currie, that it never succeeded in shortening the duration of fever ; so that, from the fatigue and inconvenience attending its application, and its doubted utility, it is now scarcely ever recom- mended. Washing or sponging the body with tepid vine- gar and water is much employed to reduce the morbid heat of fever, and certainly, so far as the feelings of the patient are to be consulted, it is decidedly more agreeable than the application of cold. Some patients prefer cold, others tepid sponging, the former being more grateful in the summer, the latter in the winter months. The choice may, therefore, be left to the patient, either mode of aspersion being preferable to the affusion. The effect of mercury as an alterative, improving the secretions in fever, is so beneficial, that unless there be some special circumstance in the case to forbid its administration in fever, it should never be omitted, more especially in the fevers of warm climates, or in the more acute forms of fever of temperate countries. The large quantities of calo- mel (ten grains every three hours) mentioned by Chisholm and other writers, as necessary in the fevers of warm climates, are never to be attempted in the treatment of the fevers of this country.— Mercury is more especially useful when the tongue is much coated, the secretions of the mouth clammy and unpleasant, and the stools dark and offensive. It is frequently alone sufficient to regulate the bowels, while at the same time the tongue becomes more clean, and the clammy disagreeable state of the mouth disappears under its use. It is not ne- cessary to push its administration so as to induce salivation, a rnild action on the gums being all that is required. When this is effected, the febrile symptoms generally abate. It may be given alone or in combination with any aperient, though we prefer giving two or three grains of the pil. hydr. or the hydrargyrum cum creta, at intervals of six or eight hours; and should an aperient be required, it may be combined with the mercurial prepara. tion, or given alone, according to circumstances. In some individuals mercury induces such irrita- tion as to forbid its internal administration; in such cases it should be exhibited in the form of 190 r E V E R, ( C 0 inunction . a drachm of the ung. hydr. may be inserted once a day in the axilla, where absorption goes on rapidly without the inconvenience of fric- tion. We have often observed the singular immunity of persons under fever from the effects of mercury. This is proved from their resisting this remedy during the continuance of the fever; but as soon as the fever begins to disappear, the mercurial ac- tion often becomes perceptible ; indeed, patients who could bear the free exhibition of mercury during the fever, but in whom the remedy had been discontinued, are often easily affected by an inconsiderable quantity of this mineral in the period of convalescence. We have stated our belief that synocha, or inflammatory fever, is rarely observed in this coun- try, the few cases which occur (generally in the spring) forming a comparatively small average proportion of the ordinary epidemic fever of Britain. In the treatment of this variety, it is necessary to keep in mind, not only the more acute nature of the fever, but the greater tendency to local in- flammation. It consequently requires more bold and decided antiphlogistic measures, especially bloodletting, purging, and mercury. As it gene- rally occurs in young plethoric persons, bloodlet- ting should always be prescribed in the onset; this not only moderates the violence of the symp- toms, but diminishes the tendency to local inflam- mation. We have entered at some length into the detail of the various measures which are employed in the treatment of common epidemic fever. It is to be observed, however, that the majority of cases of mild fever do not require the several measures we have pointed out. It is impossible to lay down a general rule which will apply to every case; in one instance, the mildest measures will be suffi- cient to check the progress of the fever; in a se- cond, more active treatment, bloodletting, smart purging, and the free application of cold, are ne- cessary ; in a third, in addition to these measures, mercury may be required. In short, the applica- tion of remedies must be regulated and directed by the judgment of the practitioner, according to the symptoms and the character of the epidemic. 2. Treatment of complicated Fever.—A fever, simple at its commencement, (as far as the nega- tive evidence of symptoms warrants the conclu- sion,) may become suddenly complicated with local inflammation. The symptoms by which such complications in the several organs may be detected have been pointed out, and although, as a general rule, there can be no question as to the expediency of general bloodletting in complicated fever, it is not advisable to take away the same quantity as in common inflammation. There are modifying circumstances in idiopathic fever on which local inflammation has supervened, so that we find by experience the powers of the patient must be saved for the after-conflict, as the fever will certainly run on for some time after the local affection has been subdued. Dr. Wilson Philip states, «that when visceral inflammation supervenes on idiopathic fever, we must let blood more cautiously than where the former disease exists alone ; and in the determi- nations of blood to particular parts, so apt to oc- ! ) N TI N U E D ) cur in fevers, which more frequently consist in distension of the larger vessels of the part than actual inflammation, that is, distension of the ca- pillaries, unless the general excitement is very considerable, it is better to attempt their removal by local than general bloodletting. If there be any exception to this rule, it respects congestion in the head, because, from the nature of the cir- culation, congestion there is more intimately con- nected with a state of general excitement than in other parts of the body." While, therefore, the lancet is to be freely em- ployed if the symptoms demand it, the system is not to be drained of a single ounce of blood more than is absolutely necessary. The topical abstraction of blood in cases of local inflammation is often very beneficial, and in less urgent cases, sometimes alone sufficient to subdue the local disease. Not unfrequently inflammation creeps on in an insidious manner in feeble ex- hausted habits; or, as often happens, the local symptoms have been entirely overlooked at the commencement; in these instances general bleed- ing is inadmissible, and the topical abstraction of blood is the only mode which can with safety be employed. Again, this mode will also often re- quire to be combined with the general measures, or should local inflammation threaten to re-appear, it may be instantly checked by leeching or cup- ping, and at much less expense to the general powers. The nervous system being much involved in fever, the brain, but more particularly its investing membrane, the arachnoid, is more liable to be- come inflamed in its progress than any other or- gan ; the changes which take place in this deli- cate and important structure being, as we have seen, in many instances, the immediate cause of death. When the symptoms indicate the exist- ence of inflammatory action within the encepha- Ion, no time must be lost in adopting suitable measures. The degree of sensorial disturbance, the presence or absence of pain, the existence and kind of delirium, whether of the high or low char- acter, will point out the nature of the cerebral symptoms. If there be pain in the head, flushing of the face, hot skin, thirst, rapid pulse, acute de- lirium, (especially towards night,) and watchful- ness, we have sufficient evidence of cerebral in- flammation to warrant general bleeding, (when there is much excitement from the temporal arte- ry or jugular vein,) followed, if necessary, by the local abstraction of blood from the forehead or nape, and a cold lotion to the scalp. Another remedy of great power in subduing inflammation of the brain is the affusion of cold water on the scalp. This has been generally termed the cold douche. It is as simple in its ap- plication as it is powerful in its effects. The pa- tient is raised in bed, the head is then held over an empty vessel, and cold water from a large jug pour- ed on the scalp, the stream being gradually raised as the patient can bear it. A considerable shock is at first produced, but the patient, if he be sen- sible, expresses great relief, and generallv requests it may be repeated. We have frequently seen threatened renewals of cerebral inflammation promptly checked by this treatment, which should : always De employed, in some cases as an auxiliary FEVER, (CONTINUED) 191 to the other measures, or it is often alone suffi- cient to keep down the inflammation in weak habits, or when the further abstraction of blood is of doubtful propriety. The application of blisters to the scalp in cere- bral inflammation requires consideration. The too common plan of blistering the head in such in- stances, before the excitement is diminished by bloodletting, is reprehensible. The application of blisters to the head in fever should be confined to those cases in which there is danger of the inflam- matory action terminating in effusion, or to that particular state of the brain in inflammation, which, though there be no effusion, is attended by coma. Hence when, notwithstanding depleting measures have been judiciously applied, the pa- tient becomes drowsy and insensible to surround- ing objects except when roused, a blister may be advantageously applied to the occiput, while an iced evaporating lotion is kept on the forehead, and the system brought under the influence of mercury conjoined with digitalis and squill, so as to promote the action of the kidneys. There is a form of low delirium in fever which requires to be distinguished from that arising from inflammation of the brain or its membranes. It arises from some peculiar condition of the brain with which we are unacquainted, and may be distinguished from the acute form of febrile deli- rium, by the pallor of the face, the bloodless ap- pearance of the conjunctiva, the softness of the pulse, the cool state of the scalp, and the absence of muscular twitchings. It occurs chiefly in feeble exhausted habits, and frequently in persons who have suffered large losses of blood in the treatment. In other instances, it may be traced to intes- tinal irritation, or some of those lesions in the bowels which so frequently accompany continued fever. This sympathetic delirium is not relieved, but invariably increased by the abstraction of blood. It is best managed by small quantities of nourishment and opiates, with a blister to the nape. A similar state of the nervous system is often observed towards the termination of other acute and chronic diseases, and also in states of ex- haustion induced by injudicious bloodletting or spontaneous hemorrhage. No class of medicines is more efficacious in re- moving cerebral inflammation than purgatives ; so that, unless there be some special circumstances to forbid their employment, they should form part of the treatment in such cases. When we have succeeded in arresting the cere- bral inflammation, the patient must be strictly watched for some days, as the fever, though mo- derated, is not extinguished, so that the capillaries are very liable to resume the same action, and thus renew the local disease. Bronchitis is the most frequent form of pulmo- nary disease in fever. It is in general easily de- tected, unless it assume the latent form, when it can only be recognised by auscultation. In se- vere cases of fever, more especially when the brain is much affected, the frequent application of the stethoscope is indispensable, in order to discover not only the existence but the intensity of this complication. The milder forms of symptomatic bronchitis subside under the use of the measures employed in the general treatment. It is occa- sionally necessary in addition to apply a few leeches to the chest, and to allay the cough by demulcents. In more severe cases, more active treatment is necessary. General bloodletting possesses less control over this complication than might be ex- pected. More benefit is derived from cupping or the application of leeches to the chest, with warm fomentations diligently applied at intervals of two or three hours. The local bleeding is to be fol- lowed by antimonials and a blister. If the bron- chitis be not arrested by these measures, large doses of the tartrate of antimony are to be ad- ministered. To the efficacy of this remedy we can bear testimony from ample experience. One grain, or in more severe cases, two grains of tar- tar-emetic dissolved in an ounce of any aromatic water, may be taken every two, three, or four hours, according to the exigency of the case. The remedy almost invariably produces vomiting at first, (unless there be considerable torpor from the condition of the brain,) but after three or four doses have been taken, the vomiting ceases, and tolerance becomes established. In general this remedy moistens the tongue, and produces soft- ness of the skin, or even diaphoresis; it often, however, produces no sensible effect, except that the bronchitis abates and gradually disappears un- der its use. When the more urgent symptoms give way, the same dose may be given at more distant intervals, till the remedy be no longer re- quired. It is necessary, sometimes, to endeavour to allay the distressing vomiting induced by this medicine This is frequently effected by giving the dose of the tartar-emetic in a common saline effervescing draught, to which a few drops of laudanum may be occasionally added. If it produce purging it must be conjoined with opium ; and if, notwithstanding this combination, the purging continue, the antimony must be sus- pended. In all cases, therefore, when the bowels are irritable, this remedy must be withheld, and the pulmonary symptoms arrested by other mea- sures. If, again, the symptoms of fever be accom- panied with great prostration, or if after a fair trial it appear to lower the general powers with- out subduing the symptoms in the chest, it should be at once withdrawn. When pneumonia supervenes on fever, the treatment is to be conducted on similar principles. General bloodletting is certainly more efficacious in subduing inflammation of the substance of the lung than of the bronchial membrane, though, unless the symptoms be very urgent, we prefer free local depletion, followed by the exhibition of the tartar-emetic as just recommended, or by calo- mel and opium with counter-irritation. The calo- mel and opium may be given, in the proportion of two grains of the former and half a grain of the latter, every three or four hours, till the local symptoms are relieved, when it may be given at more distant intervals, and afterwards withdrawn. Our experience does not lead us to form a very high opinion of the efficacy of expectorants in symptomatic bronchitis or pneumonia. We have, however, observed good effects from the addition of small doses of ipecacuanha wine, or of the anti 192 FEVER, (C( monial wine, to the common saline diaphoretic draught. Still we do not place much confidence in this class of remedies. When the patient is unable, from increasing prostration, to expel the expectoration, carbonate of ammonia, in doses of eight or ten grains in almond emulsion, or decoc- tion of Senega, appears often to assist its expul- sion. The occurrence of acute pleuritis during fever is by no means frequent; and when it does take place, it is chiefly in the more advanced stage, or during convalescence. The treatment is very similar to that of pneumonia — local bleeding, ca- lomel and opium, blistering, and purging. Tartar emetic seems to possess little influence over mem- branous inflammation, and consequently is inap- plicable to pleuritis. The more dangerous form of pleurisy is the chronic, the danger arising from its coming on in an insidious manner, without pain, much accele- ration of the breathing, or cough. It is not easily recognised even by auscultation till liquid effusion to a considerable extent has taken place, when the dull sound on percussion of the diseased side, the absence of the respiratory murmur, and the pe- culiar sound of the voice, (a?gophonia,) point it out. The effect of curative measures depends on the state of the membrane, and the extent of the effusion. When the fluid is so considerable as to render its absorption improbable, the operation of empyema is the only resource. It is proper, however, to bear in mind, that in a considerable proportion of cases of fever, in which pulmonary symptoms predominate, the chest affec- tion is the primary disease, of which the fever is only symptomatic. Many of those cases com- mence by slow insidious pulmonary inflammation, which, from the comparatively little disturbance it causes, is often allowed to run on until a more acute attack brings the disease under the care of the physician, who has thus to contend with neg- lected inflammation, over which the most ener- getic measures too often exert an inefficient control. When fever is accompanied with symptoms de- noting disturbance of the gastric organs, a mode- rate bleeding from the arm, if the pulse be full, or in less urgent cases, the application of leeches to the pit of the stomach, is often sufficient to allay the irritation. Notwithstanding the relief afforded by bloodletting, it does not appear that the vomit- ing and epigastric tenderness depend on inflam- mation, as Dr. Cheyne states that in a case in which considerable tenderness of the epigastrium existed during a great part of the disease, on open- ing the body not the slightest morbid appearance could be discovered, except a small quantity of bloody serum effused into the cavity of the abdo- men, and a very mconsiderable blush in the mu- cous membrane of the stomach at the cardiac orifice. When gastric irritation continues during the course of the fever, the plan of treatment recom- mended in Dr. Cheyne's account of epidemic gas- tric fever is to be pursued. We have seen that follicular disease of the in- •estines, whether primary or secondary, may be going on without being attended by any symptom of gastric disturbance. When, in addition to the ardiiiary symptoms of fever, the bowels are irrita- iNTINUED) ble, and the tongue is morbidly clean and red, or coated at the root, we may infer the existence of gastro-enteritis, or this follicular disease. Our ob- ject must then le to prevent, if possible, the de- structive changes which take place, whether the intestinal affection be primary, or have supervened in the progress of the fever. The local abstraction of blood from the surface of the abdomen (particularly from the right iliac region) is to be pursued, to an extent proportionate to the powers of the patient, and the probable du- ration of the affection. From twelve to eighteen leeches are to be applied, and the abdomen after- wards enveloped in a warm poultice, renewed every two hours. The leeching may be repeated every day, every second day, or at more distant intervals, according to circumstances. The more early the effective measures are resorted to, the greater the chance of preventing the stage of ul- ceration, which we are convinced cannot be recog- nised by symptoms. We are aware that Dr, Bright considers the ochry diarrhcea to be diag- nostic of intestinal ulceration. We admit that in some cases in which we have found ulceration after death, the stools had this character; but in other instances the greatest variety, both as to colour and consistence, has been observed; in a few the stools were solid up to the time of death, and in examining the intestines there was a con- siderable quantity of solid excrementitious matter. In the majority of instances, however, the stools are watery, and generally contain a large admix- ture of mucus. If in this condition of the bowels laxatives are improper, restraining the diarrhcea by astringents is equally injurious, unless the pa- tient become so much exhausted by the frequency of the stools that it becomes a matter of necessity to restrain the purging ; but the circumstances in which the employment of astringents becomes re- quisite, rarely occur. It is a matter of great doubt to our mind how far this follicular disease, except in its primary stage, can be arrested by any plan of treatment, We are not prepared to deny the possibility of the cicatrization of intestinal ulceration, though we think that when it is extensive, the process of re> paration rarely if ever takes place. The indica- tion consequently is, to arrest the primary stage of this disease by local bleeding, and afterwards by a combination of mild mercurial with opium. The mercury is not to be pushed so as to affect the mouth; the evidence of the mercurial action on the gums being all that is necessary. Four grains of the hydrargyrus cum creta may be com- bined with half a grain of ipecacuanha, or, when the bowels are very irritable, with three grains of the compound ipecacuan powder. Either of these formula? may be taken every four hours. We have sometimes found, in addition to these reme- dies, the chalk mixture with laudanum, or an in- jection containing a drachm of laudanum, at bed- time, attended with good effects. Dr. J. L. Bardsley of Manchester informs us. that he has been more successful in this follicular affection with a combination of super-acetate of lead and opium than by any other remedy. He recommends three grains of the former with half a grain of the latter every four hours. In some cases he has doubled those proportions with mark- FEVER, (CONTINUED) 193 od advantage. Leeches are to be previously applied to the lower part of the belly, and alterwards blis- ters, or the tartar-emetic plaster, and the strength supported by wine and other stimulants. This gentleman adds, that in one or two cases in which the patient had recovered from ulceration, but had perished suddenly from some accidental acute dis- ease, on examination after death, not only was the site of the ulcerations most distinct, and their form and size defined, but unequivocal cicatrization had taken place. Dr. Bright considers the employment of tonic remedies a point requiring nice discrimination. >' With regard to the administration of tonic reme- dies, there is not a doubt that they are of essential importance; and that even while evidence exists of much local mischief in the bowels, it will some- times be necessary both to support and to stimu- late the system : looking indeed to the character of the ulcerations, the deep sloughs which they often form, and the dark red inflammation which surrounds them, there would be reason to suppose that such remedies might be useful: and occasion- ally the decidedly remittent form which the fever has assumed, has completely removed every scru- ple, and led to the free exhibition of the sulphate of quinine with admirable effect. At the same time there is more danger to be feared from the early use of stimulants, as long as the system is still able without their aid to support the feeble prostration, than there is risk in abstaining from stimulants a little beyond the period when they might possibly begin to act well. In a general way the system seems capable of supporting itself for a few days under that great degree of prostra- tion which is connected with advanced ulceration of the bowels; and although we cannot determine the exact state of the ulcers in these cases, yet we find that the action of stimulant and tonic reme- dies is more certainly beneficial after that state of prostration has existed for some time, than when such remedies are administered with a view of obviating or anticipating the first symptoms of collapse : for when administered too soon, they frequently kindle the inflammatory action with redoubled violence, and then it is that the most appalling combination of debility and nervous excitement is seen for one or two days to precede death." (Reports of Medical Cases.) While we are watching and endeavouring to subdue the intestinal disease, we are not to disre- gard the complications which arise in the other organs. The brain and nervous system are most likely to suffer from sympathetic disturbance, which is to be moderated by leeching, cold lotions, and blistering the occiput or nape. The diet of the patient forms a most important part of the treatment in this intestinal affection. The blandest nourishment, consisting of milk and water, or thin arrow-root, is sufficient for the early stage. When the patient becomes exhausted, chicken broth or beef-tea may be added in small quantity to the arrow-root; and should stimulants be required, a little wine may be given according to circumstances. Treatment of Typhus Fever.—Most physicians who have written on continued fever, though aware of the marked difference between the syno- choid and typhoid fevers, have not sufficiently Vol. II. —25 b insisted on the modification of treatment which the latter requires. It has been too often imagined, that because the symptoms and the morbid appear- ances observed in the organs after death are scarcely dissimilar, and that other forms of fever do occa- sionally pass into typhus, the two diseases are identical. Experience, however, informs us that not only the symptoms and progress, but the effects of remedies, are essentially different. In the milder cases of typhus fever, blood- letting is seldom necessary, and may in general be dispensed with, unless some special circum- stance arise to render it expedient; such as severe pain or sense of weight in the head, flushing, in- tolerance of light, hot skin, and other symptoms denoting a more intense form of fever. With such symptoms at the commencement, the abstraction of a moderate'quantity of blood, especially if the patient be young and of a full habit, will be pro- per. If, however, the pulse, though rapid, be soft and compressible, the tongue begin early to assume a brown tint, and there be considerable prostra- tion, the loss of blood from the system cannot be sustained. Should a low form of inflammation in the brain, chest, or abdomen, arise, local bleeding, and afterwards counter-irritation, will be the most judicious mode of treatment. The practitioner must, however, be aware, that symptoms in the progress of the disease may render the expediency of general bloodletting a nice question : for in- stance, inflammation in some important organ may come on suddenly, and place the patient in urgent danger. The inflammation may be so acute that local bleeding may fail to arrest it; on the other hand, the complexion of the other symp- toms and the duration of the fever may seemingly forbid more active measures. If the local disease be allowed to go on, the fate of the individual is inevitable: if, on the other hand, blood be drawn from the system, when either the powers of the patient, or the experience of the prevailing nature of the epidemic, do not warrant the practice, the treatment which the local disease requires may destroy life. The consideration of such a case is most embarrassing, and the result, even under the most skilful management, always doubtful. The rapidity with which the blood flows from the vein, and its appearance when drawn, will often afford assistance. If, instead of pouring in a continued stream, it comes in drops, notwithstanding the vein has been well opened; moreover, when it coagulates slowly, the crassamentum is thin and soft, and the proportion of serum abundant, it shows that the abstraction of blood is a measure of questionable expediency. In short, though bloodletting has been recommended in typhus fever from the early ages of medicine, we find even its warmest advocates acknowledge that it is occasionally productive of harm. Sydenham states, « Quoties mini cum a?gris res est, quorum sanguis vel per se imbecillior existit (ut fere in pueris) vel justa spirituum copia destituitur, ut in decli- viore a?tate, atque etiam in juvenibus diuturm.. aliquo morbo confectis, a venesectione manurn tempero." Huxham also remarked, " that in cases in which the blood was dark coloured and exceed ingly soft, the pulse often sinks surprisingly aftti a second bleeding, even indeed after the first, ami 191 FEVER, (C ) N TI N U E D ) especially so in the advanced ; at which period, such aperients as remove unhealthy secretions, without producing watery stools, are to be em- ployed, viz.—rhubarb, magnesia, or castor oil, with occasional doses of mercurial*. It is necessary to examine daily the evacuations from the bowels in typhus fever, that the appearance of the stools may be ascertained. Bloody diarrhcea is always a most alarming symptom in fever, showing a malignant form of the disease. It depends on a loaded state of the capillaries of the mucous mem- brane ; these vessels, partaking of the general de- bility, are unable to resist the congestion or afflux of blood, and consequently give way to its dis- tending force. The congestion of the mucous membrane, and consequent hemorrhage, may take place without ulceration ; but when there is ulcer- ation, the blood does not proceed from the open surface, but in the way pointed out, viz.—by capil- lary exudation. This symptom is best managed by suspending all irritating medicines, and ad- ministering occasional doses of superacetate of lead and opium. When the abdomen is tympanitic, purgatives only increase the distension. Injections of car- minatives give most relief, though it is only tem- porary. We have found an injection, consisting of equal parts of the mistura assafcetida and gruel very beneficial. As the disease proceeds, it will be necessary to allow, according to circumstances, moderate support—weak animal broths, and per- haps a little wine. We must admit, that in the treatment of fever, wine is too often administered without due con- sideration of the character of the disease, its stage, and the condition of the several organs. Dr. Wil- son Philip observes, « that the difference of opinion which prevails on this subject has, in a great de- gree, arisen from physicians having attempted to apply their rules, either for or against it, to all cases indiscriminately. Whereas it would appear that the use of wine in typhus must be almost as much regulated by circumstances as that of blood- letting in synocha. Two general observations, however, appear to me to be warranted, that more or less wine is beneficial in all severe cases of typhus; and that there are few in which large quantities are not injurions." When we see a patient labouring under symptoms of extreme de- bility, and find them almost uniformly relieved by a large quantity of wine, it is difficult at first view to persuade ourselves that it can be pernicious.— But an attentive observer will look beyond its im- mediate effects, and will often see sufficient reason to doubt the safety of carrying the practice very far. He will find that the temporary excitement he thus procures, is frequently succeeded by a greater degree of debility than that which the stimulus had removed ; and if he perseveres in the practice under such circumstances, the pulse, upon the whole, will gradually become more frequent and feeble, till it ceases altogether. Wine is seldom necessary in the early stages of fever, nor, as a general rule, at any period of the acute forms, unless, as occasionally happens, unexpected exhaustion come on, or towards the decline of the disease the powers give way. Under these circumstances, a few ounces of wine if the skin be cool, the P.,l-e soft, and the tongue moist, in individuals whose pulse indicated the propriety of a second bleeding." Sir John Pringle affirmed that many recovered from jail-fever without bloodletting, but very few who had lost much blood; and Dr. Monro con- fesses that he was often obliged to give cordials to support the strength after bloodletting. The other measures which have been recom- mended in mild fever may be adopted in typhus. The shock of an emetic is useful at the beginning, the more so if there be nausea. When the heat of the skin is above the natural standard, cold or tepid sponging is grateful, and allays the morbid heat. Frequent ventilation of the room and changes of linen are also very beneficial. If the skin be dry, diaphoretics are useful; and should at any time spontaneous diaphoresis come on, it is to be promoted. When copious sweatings appear in the advanced stage of the disease, they should not be interfered with, unless they produce exhaustion, when quinine with diluted sulphuric acid, mild nourishment, and cordials, are to be freely given. [Perhaps there is no class of therapeutical agents more uncertain than diaphoretics, although they are constantly employed, and, accordingly, ob- servant practitioners have been compelled to ex- press their doubts as to their efficacy in typhus. The main utility of most of them, of the neutral mixture, the solution of acetate of ammonia, &c, as the writer has said elsewhere, (Practice of Me- dicine, 2d edit. ii. 491,) is of a negative charac- ter. Something, it is conceived, must be admin- istered, and they are as devoid of objection as most agents that could be prescribed. Antimonials, as sedatives, on the contra-stimu- lant plan, have been recommended by Professor Jackson, of Boston, (Report on Typhoid Fever, Boston, 1838,) in the typhoid affection: but they have not met with the same favour in the hands of others; and even when antimonials are adminis- tered in much smaller doses as diaphoretics, in fever, they have been found to do harm where any decided tendency to irritation of the bowels existed.] The necessity for purgatives will depend on the ondition of the bowels. A mild aperient at the beginning is always proper, to remove any acci- dental accumulation. The mildest kinds, either castor-oil, rhubarb, or senna, may be prescribed for this purpose, and repeated according to circum- stances. When the fever is acute, and the powers are vigorous, the expediency of thoroughly evacu- ating the bowels, and of .-distracting from the mass of circulating fluids through the intestinal exha- lents, has been already adverted to. On the other hand, indiscriminate purging is most injurious in any form of fever, but more especially in the typhoid. »I have known," Huxham remarks, " a common purge, injudiciously given at the be- ginning of this fever, immediately followed by surprising languor, syncope, and a large train of other ill symptoms." Besides, from the greater tendency to inflammation of the mucous membrane and follicles of the intestines in typhus, every source of irritation, and consequently the stimulus of cathartics, should, as much as possible, be avoided. If these precautions, as to bleeding and purging, are necessary in the early stage, they are more FEVER, (CONTINUED) 195 will frequently improve the condition of the pa- tient. In determining the propriety of administering wine in fever, the decision may in some measure be regulated by the character of the disease. We have repeatedly alluded to the difference in the type of epidemic fever. This, in our own expe- rience, has been remarkably illustrated in the epi- demic constitution of the last three years. In 1829, fever required most decided antiphlogistic treatment, as the records of the London Fever Hospital will prove. In 1830 and 1831, the symp- toms assuming a low typhoid form, (which has continued up to the present time,) a more cordial or stimulant treatment became necessary. This shows that the general character of epidemic fever may at times be such as to require a stimulant plan of treatment. Besides the indications for the administration of wine, deduced from the nature of particular epidemics, there are some special symptoms which render its exhibition necessary. 1. It is sometimes observed, that when a patient in fever has been going on favourably, the pulse becomes suddenly soft and compressible, the skin cool and damp, accompanied with feeling of con- siderable exhaustion, and desire for wine. With these symptoms, there need be little hesitation in allowing six or eight ounces of wine in the twen- ty-four hours, at proper intervals. 2. When the symptoms denoting sensorial dis- turbance,—languor, low muttering delirium, coma, muscular tremor or subsultus, progressively in- crease ; if, at the same time, the patient lose his strength from day to day, the pulse be soft, and the skin cool, wine may be safely prescribed. 3. When the fever assumes the petechial char- acter, more especially if the spots be large and of a dark red or livid colour, wine is indicated. 4. In cases of sudden or unexpected collapse, which sometimes comes on without ostensible cause, though more- frequently after bloodletting, protracted diarrhcea, or spontaneous hemorrhage, wine is a most effectual remedy in raising the ex- hausted powers of the patient. 5. Wine may be necessary to promote the con- valescence in particular cases. Another circumstance with regard to the em- ployment of wine in fever requires to be noticed. Local inflammations not unfrequently arise in feeble habits, or in the advanced stage of low fever, requiring general or local bloodletting. The treatment necessary to subdue the local disease lowers the general strength : the patient does not rally, but remains stationary, and perhaps loses ground and feels exhausted. In such cases, a moderate quantity of wine, provided the pulse be soft and the skin cool, is followed by excellent effects. We have often been obliged to prescribe the local and even general abstraction of blood for some sudden emergency, and in a few hours afterwards found it ntcessary to have recourse to the administration of wine. In such cases it snould be withdrawn a.; soon as the powers have been restored. Dr. Graves is of opinion that when general symptoms indicate the propriety of administering wine and opium in fever, these remedies should he prescribed, although particular symptoms ap- parently render the propriety of their exhibition doubtful. Dr. Graves thinks advantage may often be derived from wine and opium at an advanced period of fever, when the tongue is coated with dry brown fur, and the teeth and gums covered with sordes—when there is suffusion of the eyes, —dry hot skin, heat of the scalp and flushing— a low form of delirium, with muscular tremor and subsultus — sense of weight or pain in the head, not of the acute throbbing character — and rapid, soft, or small thrilling pulse. When the symptoms alluded to by Dr. Graves are manifest at the advanced stage of fever, we apprehend they arise from some latent local dis- ease which has not been overcome, or has been partially renewed, and requires the adoption of local remedies suited to its intensity and the powers of the patient. We have admitted that a general stimulus, such as wine, is by no means incompatible with the local measures which are necessary to subdue low typhoid inflammation; and in offering these precautions we feel we are corroborating the opinion expressed by Dr. Graves on this subject. His remarks, indeed, are accom- panied with such precautions, as show he is aware of the necessity of guarding the inexperienced practitioner against the indiscriminate exhibition of wine and opium in fever. (Dublin Journal of Medical and Chemical Science, No. 3.) With respect to the quantity and mode of ad- ministering wine in fever, it may be remarked that it is impossible to give any general rule on this subject. The quantity must be regulated by its effects. Some of the older authors prescribed wine apparently without regard to quantity; we find on record cases of typhus fever, in which two and three bottles of madeira or port have been allowed in twenty-four hours. It would appear from these histories, that in certain forms of low fever, the system is nearly insensible to the effects of stimulants. Incredible quantities of wine have been taken by persons unaccustomed to wine without any signs of intoxication, or any othei perceptible effect except that of increasing the volume of the pulse, abating the delirium and muscular tremor, and restoring the heat of skin. In the present day, physicians seem less disposed to sanction extravagant doses of wine. Dr. Bale- man was not inclined to exceed a pint in twenty- four hours; and enjoined, that after the object with which it is administered has been obtained, this quantity should be diminished or withdrawn, when the first symptoms of over-excitement ap- peared. The quantity should not be less than four, nor exceed sixteen ounces, in the twenty- four hours, unless under circumstances of sudden and extreme exhaustion, when a larger quantity may become necessary. It should always be given in small quantities, (from half-an-ounce to an ounce,) mixed with water, or some light farina- ceous food, arrow-root, sago, or thin panado, the period between each dose varying according to the allowance. It is better to commence with a small quantity, and as the fever advances, or the debility increases, to augment it cautiously, and to watch- its effects. It is necessary also to bear in mind, that the quantity of wine should be regulated by the age and constitution of the individual. Young person* 190 FEVER, (CONTINUED) are njt only more easily excited than those advanc- ed in years, but in the latter the symptoms re- quiring the use of wine more frequently occur, and increase more rapidly. The previous habits of the individual must also be considered ; if he have been accustomed to live generously, and consequently to the use of wine and other stimulants, the allowance of wine must be greater, than in a person whose mode of living is more simple. If we find that the pulse is quickly raised, the heat of skin increased, and the face becomes flush- ed, and the patient restless or incoherent, we may consider the quantity is either too large, or that the use of wine is improper. Again, if its effects soon pass off; if the patient, a short time after being stimulated, lapse into his former state of ex- haustion, or seem to get weaker after each portion of wine, its longer continuance will be of little avail. On the other hand when there is a gradual and steady improvement in the symptoms, without any marked excitement after the wine has been taken ; moreover if the patient relish the wine, and especially if it tranquillize him, we may con- fidently anticipate that it will be beneficial. When the purposes for which wine has been given have been accomplished, it should be gra- dually, not suddenly, withdrawn, and the patient watched; as we have not unfrequently witnessed the train of symptoms, for which wine was first administered, renewed shortly after it has been discontinued. The particular kind of wine is a matter of less consequence than the quality of that selected. We generally prefer the dry wines; sherry or sound Madeira, which are less likely to disagree than the red wines. [Dr. Stokes (Dublin Journ. of Med. Science, Mar. 1839, reprinted in the Amer. Med. Library, Philad. 1840) has endeavoured to deduce from the state of the heart an additional rule of guidance to the inexperienced in the administration of wine in typhus. Two opposite conditions of the organ may be observed in the disease — in the one, the impulse becomes extremely feeble or altogether wanting, whilst the sounds are greatly diminished in intensity : in the other, the impulse and sounds continue vigorous through the whole course of the disease. These opposite states are not necessarily revealed by the condition of the pulse or the warmth of the surface. We may observe a hot skin, whilst the action of the heart is almost im- perceptible ; and, on the other hand, a patient may be pulseless, cold and livid for days together, whilst the heart is acting with the greatest vigour. This condition of the heart has to be determined by auscultation over the infra - mammary and sternal regions — the pulse being an uncertain guide. These physical signs are considered by Dr. Stokes to indicate a debilitated condition of the heart, which may even occur at an early period of the disease, and thus enable the practi- tioner to anticipate the symptoms of general de- bility ; and he infers from his observations, that their presence, in a case of spotted adynamic fever, may be considered to point out a softened state of the heart; — that this softening is one of the se- condary lesions of typhus,— and that the diminu- tion or cessation of impulse, the proportionate di- minution of both sounds, or the preponderance of the second sound, are direct and nearly certain in- dications for the use of wine in fever.] Brandy, largely diluted, is sometimes given in preference to wine. Brandy being about double the strength of wine, when it is prescribed as a substitute, one-half the quantity stated may be ordered. Fermented liquors are sometimes given in fever, and when a more mild stimulus than wine or brandy is wished, they are well adapted to the purpose, particularly when bottled. Yeast has been employed in fever accompanied with putrescent symptoms, when the existence of inflammatory complications seems to contra-indi- cate stronger stimuli. In some cases of extreme prostration, yeast has been given in combination with wine and other cordials. Dr. Stoker, who seems to have used it more extensively than any other physician of the present day, speaks highly of its efficacy, after a trial of its powers for upwards of thirty years, both in public and private practice. He had ad- ministered it in cases where purple extremities or gangrenous sloughing took place, accompanied with symptoms of inflammation. The result of his experience is, that barm or yeast is well suited to every stage of typhus fever in which it can be borne by the stomach. It is in general easily taken alone, or with any medicine that it may be deemed advisable to join with it; but, in the worst forms of typhus fever, when it is most need- ed, it not only is seldom rejected by the stomach, when any other medicine can be retained, but the patient, in such cases, often expresses a liking for it. According to this author, yeast, being mode- rately laxative, often supersedes the necessity of repeated doses of purgatives ; but, if required, an aperient tincture may be added to it. Should, however, the bowels be purged, a few drops of tincture of opium should be added to each dose. He ascribes its efficacy to its power of correcting the morbid contents of the alimentary canal, and consequently the symptoms of putrescence, and asserts that, in his idea, petechia? and black loaded tongue will be found more effectually remedied by it than by any other medicine. In adverting to the objection to this remedy, that it may be likely, by promoting fermentation, to increase the ten- dency to tympanitic distension, Dr. Stoker states, that in some of the most obstinate cases of tympa- nitis, enemata of yeast and assafcetida have proved the most efficacious remedies. When yeast is administered internally, two table-spoonsful may be given in water, or with an equal quantity of camphor mixture, every three hours. If the stomach be irritable, four ounces mixed with an equal quantity of barley gruel may be administered by injection. From our personal experience of yeast, we certainly think it a reme- dy deserving attention in the low forms of fever. Various other stimulants have been occasionally prescribed, alone or in conjunction with wine, in typhus. The carbonate of ammonia, combined with nitrous ether and aromatic confection, has been thought useful. We have certainly observ- ed, that in cases in which a sudden and diffusible stimulus, less permanent in its operation than wine or brandy, has been indicated, this combina FEVER, (CONTINUED) 197 tion has answered the purpose. We have seen it useful also as an expectorant in the symptomatic bronchitis of fever. Another class of stimulants of a less diffusible character has been employed in the treatment of fever, viz. tonics. Of these, the vegetable tonics have been chiefly employed, more especially the cinchona or Peruvian bark, which, after sustain- ing more varied reputation than any other remedy in the Materia Medica, was at length admitted to possess superior febrifuge powers to any drug which has been discovered. When first intro- duced, it was prescribed chiefly in periodic fevers, but soon after acquired equal reputation in the treatment of continued fever. Its indiscriminate administration, however, without regard to symp- toms or the period of the disease, has tended to diminish the confidence formerly reposed in its virtues. In the present day it is scarcely em- ployed in the acute forms of fever, unless some particular symptoms arise, or when the fever to- wards its decline assumes the typhoid character. Dr. Cullen remarks, that wherever bloodletting is proper in continued fever, bark is always pre- judicial. The opinion of Dr. Bateman on this point is exceedingly strong. He states that, in the early part of his practice, agreeably to the doctrine of the times, he resorted to the decoction of cinchona on the first appearance of languor and debility. The increase of the symptoms was easily imputed to the intractable nature of the disease, or deemed the necessary result of its progress, until it became obvious, from the repeated occurrence of the fact, that the tongue, which had been, on the day before the administration of the bark, moist, and exhibiting a moist or yellowish mu- cous fur, was on the following morning dry or even brown; that the skin was hotter or more parched, with a flush in the cheek ; that the pulse was quicker and harder ; the thirst increased, and the sleep more disturbed. Dr. Bateman was so convinced that these symptoms were to be ascribed to the use of bark, notwithstanding the patient had made some progress towards recovery, that he scarcely ever prescribed it even during the stage of convalescence. Our own experience is, that in the early stage of common epidemic fever, any preparation of bark is decidedly injurious. When the symp- toms of fever have completely subsided, no tonic or stimulating remedy is needed, unless the pa- tient be much enfeebled, and the strength slowly recovered. In such cases tonics are sometimes useful, and certainly none of the vegetable class is more powerful than bark in the form of the qui- nine. But we hold its exhibition in the early stages of fever under any circumstances improper, as tending, by its stimulant powers, to keep up or increase the febrile action in the system ; and when there is loca' complication, it is evidently so pernicious that scarcely any practitioner can be so ignorant of the common principles on which the treatment of fever should be conducted, as to think for one moment of its administration under such circumstances. When the fever is of the typhoid form, and the symptoms, as the disease advances, denote failure of the powers, more particularly if the pulse be- come soft and compressible, the skin covered with n * petechia?, and there be tendency to gangrene, bark, in addition to nourishment, wine, and other stim- ulants, may be given with the best effects. The sulphate of quinine combined with sulphuric acid is the best mode of administration. [In the typhoid affection, occurring in children, MM. Barthez and Rilliet (Archiv. de Med. 1841; and Traite Clinique et Pratique des Maladies des Enfants, ii. 413, Paris, 1843) are somewhat favourable to the use of sulphate of quinia.] Infusions of some of the other vegetable tonics, serpentaria, cascarilla, calumba, &c, have been proposed as substitutes for the cinchona. As stimulants they are less powerful, and when a light vegetable tonic is desirable, the infusion of any of these may be advantageously prescribed, with or without the addition of an aperient, accord- ing to the state of the bowels. Opium and other narcotic substances have been administered in fever with two indications: 1st, as stimulants when the powers are sinking; 2d, to tranquillize the nervous system, and to procure sleep. The use of opium, as a general stimulant in fever, has been abandoned, wine being proved more safe and durable in its effects. From the stimulant effects of opium, it is inju- rious in the acute forms of fever, more especially when local inflammation exists. In the early stages it is inadmissible, and indeed much dis- crimination is required to detect the symptoms which indicate its administration. The delirium and wakefulness of sub-acute inflammation of the brain is best overcome by topical bleeding, and the application of cold lotions to the scalp ; and when the morbid condition of the brain on which tho want of sleep depends is removed, the patient generally enjoys intervals of refreshing steep. In other cases, a state of distressing restlessness with obstinate Wakefulness remains, exhausting the patient, and adding greatly to the sufferings. If, with these symptoms, the pulse though soft be rapid, the skin cool, the face pale, the tongue moist, and there be no suffusion of the eyes, opium often acts like a charm. If, however, its exhibition be followed by increase of delirium, thirst, and heat of skin, or if the tongue become dry, and the bowels confined, it should be dis- continued. We do not however think, that in every case the opium should be withheld, if the tongue be dry and even furred, as we have often seen this remedy decidedly beneficial when the tongue was in this state, if the other symptoms indicated its exhibition. Dr. Stokes has proposed the administration of large doses of opium in peritonitis from intestinal perforation. In these cases the usual antiphlo- gistic treatment is inadmissible, from the sinking of the vital powers, which rapidly supervenes. When effusion of the alimentary contents through the perforation takes place, the fatal issue is inevi- table. In some few instances, nature, as we have already observed, makes an attempt to repair thii lesion ; adhesion of the bo'wel, at the point of pei> foration, to some portion of the intestine, or adja- cent viscus, is sometimes formed, and thus effu- sion into the abdomen is prevented. When this occurs, the peritonitis is limited in extent ; and to these cases the administration of opium is well FEVER, (CONTINUED) 198 adapted. Dr. Stokes states, that in the treatment, the first indication is to support the strength of the patient, as far as this can be done without injury ; the second, to prevent the further effusion in the peritoneal cavity, by endeavouring to induce or- ganization and adhesions of the effused lymph. This latter indication is best fulfilled by time, and bv attempting to diminish as far as possible the peristaltic motion of the intestines. For this pur- pose opium is to be given in repeated doses. Solid opium, in grain doses, or the black drop in doses of five drops, is recommended to be given every second hour till the symptoms of abdominal inflammation abate, after which the dose is to be given at more distant intervals. In one case, though unsuccessful, this treatment afforded de- cided relief. Sixty drops of the black drop were given in the twenty-four hours. In another, in which recovery took place, one hundred and five grains of solid opium (exclusive of anodyne injec- tions) were administered without the patient expe- riencing any of the usual effects of this remedy when exhibited in large doses. (Dublin Journal of Medical and Chemical Science, May 1832.) We think this suggestion of Dr. Stokes valua- ble, even in those cases in which the fatal issue is inevitable, in consequence of rapid and extensive peritonitis from effusion of the contents of the bowels into the abdominal cavity; it is the best palliative mode of treatment; and in partial peri- tonitis, when nature attempts the reparative pro- cess, it gives the patient the best chance of reco- very. The form in which opium is prescribed is a matter of less moment than a correct knowledge of the circumstances which indicate or forbid its employment. We have found a full dose of solid opium, (one or two grains,) answer every purpose. But we certainly prefer the acetate or the muriate of morphia, in doses of half a grain dissolved in distilled water. Some physicians prefer minute doses of opium at certain intervals, so as to keep the nervous system under its influence. We have tried this mode, but deem it less efficacious than a full dose administered at once. [Opium is certainly a most valuable agent in many cases of typhus fever, and is rarely found to prove injurious, notwithstanding the cautions inculcated by many writers in regard to it, who appear to have been led rather by hypothetical considerations than by the results of experience.] The other narcotics—hyoscyamus—camphor— cicuta, are very inferior in efficacy to opium. They may, however, sometimes be advantageously com- bined. The extract of poppy, in doses of eight or ten grains, is often a pleasant opiate. We have also found fifteen or twenty grains of camphor, combined with a quarter of a grain of acetate of morphia, an excellent formula. [In protracted cases of typhus in which there is general debility with or without manifestations of encephalic hyperemia, subsultus, watchfulness, muttering, delirium ferox, or even convulsions, Dr. Graves (System of Clinical Medicine, Dub- lin, 1843) praises most inordinately a combination of tartrate of antimony and potassa with opium, the discovery of the utility of which he claims to be " peculiarly his own." The circumstances, undei which the combination is applicable, are, according to him, exactly those which would for- merly have been believed to demand the fresh application of leeches to the head, cold lotions and blisters. The combination is prepared as follows: Antim. et Potass. Tart. gr. iv.; Tinct. Opii, f.jj; Aq. Camphor, f-^viij. M. Dose, f.^ij to f.Jsa every two hours.] The practice of applying blisters in fever was adopted by the older authors to produce a stimu- lating effect in the advanced or sinking stage of the disease. There can be little question of the effect of rubefacients and vesicants in exciting the system in phlogistic states, but we apprehend their efficacy in rousing the vital powers when the ner- vous system is oppressed is very questionable, and that, consequently, their value as general stimulants is doubtful. Blisters and rubefacients are, however, applica- tions of great utility in the local inflammations which occur in fever. They may be employed with this view as auxiliaries to other antiphlogistic measures ; or in cases when the vital powers are so low that even local bloodletting cannot be adopted, they may be applied at once, as near the inflamed organ as possible, with the best effects. Blisters are not, however, to be prescribed with- out discrimination, as injurious consequences often arise from their injudicious application. In the acute forms of fever with local inflam- mation, they should never be employed till more active measures have been adopted. When the capillary congestion has been reduced by local or, if necessary, general bloodletting, should pain or any other symptom indicate that the local affec- tion has not been wholly subdued, the application of a blister to the neighbourhood of the inflamed organ will often remove the disease. If it be ap- plied without this precaution, it will invariably increase the very action it was intended to subdue. Even with the circumspection recommended, we have repeatedly seen the local disease renewed by the stimulus of a blister. It is, therefore, by no means always safe to adopt counter-irritation in the more acute forms of fever, notwithstanding the too common practice of at once applying blis- ters on the first appearance of local inflammation, without the precaution of previous depletion. In the inflammations which arise in typhoid fevers, blisters are excellent local remedies, and we certainly think they are more useful in this than in any other form of the disease. In the low kind of cerebral inflammation, with tendency to coma, after leeching, the application of a blister to the occiput, with a cold lotion to the anterior portion of the scalp, is followed by the best effects. Some physicians think that in these cases a sina- pism or a blister to the lower extremities is of great service, and explain the efficacy of these applications on the principle of revulsion. We have certainly seen excellent effects result from them. Cases are recorded in which boiling water has been applied to the extremities with the object of producing sudden and powerful revulsion in se- vere cerebral affection in fever. In extreme cases this may be adopted, but from the severity of the measure it can never be generally pursued. In the secondary pulmonary affections which frequently arise during fever, local bleeding by FEVER, (CONTINUED) 199 leeches or cupping, and afterwards blistering the chest, is the best mode of treatment. When the symptoms have been overlooked on their first ap- pearance, or when the strength will not admit of any form of bloodletting, counter-irritation is the inly local treatment that can be employed. In the chronic state of the intestinal disease to vhich we have so often adverted, blistering the ibdomen is decidedly beneficial. This practice is however by no means applicable to the acute stage of gastro-enteritis; indeed the application of a stimulus so powerful would inevitably increase the inflammatory action. It is necessary to bear in mind, that in the typhoid forms of fever blisters do not always heal kindly. The blistered surface, assuming an un- healthy aspect, gradually degenerates into a trou- blesome species of ulceration, which keeps up feverish irritation in the system. When blisters either do not rise at all, or become troublesome ulcers, it is always an indication of a dangerous fever. We have certainly seen the fatal issue hastened by the effects of a blister. With regard to the milder forms of counter- irritation, we have seen, in slight cases of local disease, sinapisms very useful. The epigastric tenderness with irritation of the stomach which occasionally appears in the early stage of fever, is often at once removed by the application of a mustard poultice to the epigastrium. In the gastro-enteritis of fever, cloths soaked in oil of turpentine, and kept constantly on the abdo- men, have been applied in order to produce coun- ter-irritation and revulsion. When circumstances prevent the use of blisters, this application may be substituted, though it is much less powerful than either mustard or cantharides. In all cases of fever, more especially with cere- bral affection, it is exceedingly important to exa- mine the state of the bladder. When there is retention of urine, the catheter should be employ- ed. The practitioner requires also to be vigilant when the urine is passed involuntarily; in these instances, from the paralysed state of the muscles concerned in the expulsion of urine, the bladder becomes distended, its muscular coat ceases to contract on its contents, and from a sinall quantity being occasionally voided involuntarily, the medi- cal attendant is apt to be satisfied with the report of the nurse, that there is no accumulation in the bladder. The tympanitic enlargement of the abdo- men may prevent the distended bladder being felt, so that in these cases the catheter should be occa- sionally introduced to ascertain the state of this organ. We have already alluded to the revival of the theory, that a vitiated state of the blood is the cause of some forms of fever. A mode of treatment founded on this view has been proposed by Dr. Stevens, on the supposition, that in fever, but more particularly in the malig- nant forms, the vitality of the blood is lessened, and the quantity of its saline ingredients, especially the muriate of soda, ultimately diminished. He considers that the natural saline impregnation of the blood is the cause of its red colour, and that the diminution of its salts is the reason of its black and vapid condition in the last stage of fevei. On this theory, Dr. Stevens recommends, after reducing excitement at the commencement by bleeding, purgatives, and other antiphlogistic measures to prevent serious injury to any of the organs, the administration of a sufficient quantity of non-purgative salts, with the object of restoring to the blood the proportion of saline ingredients it has lost. After this has been done, in place of lessening the quantity, it is necessary to remedy the diseased quality of the blood, by correcting acidity, if it be present, by alkaline carbonates, and afterwards throwing into the circulation an extra supply of those stronger salts which act directly on the blood, reddening its colour, correct- ing its diseased properties, and adding to its power of stimulating the heart. For a considerable time after Dr. Stevens com- menced the saline treatment, he used (except when there were symptoms of acidity in the sto- mach) a strong solution of the muriate of soda with nitrate of potash; but he has subsequently preferred another combination, consisting of twenty grains of the muriate of soda, thirty grains of the carbonate of soda, and eight grains of the chlorate of potass. This saline powder, dissolved in water, is to be given every two or three hours (more or less frequently, according to circumstances) in the middle and last stages of fever, and to be gradually left off as the convalescence advances. These salts enter the circulation and do not irritate the sto- mach and bowels; and according to Dr. Stevens, when given before the stomach has ceased to per- form its functions, the bad symptoms soon disap- pear. A solution of the muriate of soda (two table-spoonfuls to a pint and a half of tepid water or thin gruel) may also be occasionally thrown into the bowels. The strength is at the same time to be supported by strong clear beef-tea. In extreme cases, or when the practitioner is not called in till the very last stage of fever, Dr. Stevens thinks life may be occasionally saved by injecting a saline solution into the veins. We have lately adopted this saline treatment in some cases of typhus fever. Our individual experience, however, has been so limited that we are scarcely competent to pronounce an opinion on its value. If the premises advanced by Dr. Stevens be correct, (and we have already expressed our belief that a certain class of fevers do originate in a morbid state of the blood,) the saline treat- ment he has had the merit of proposing, appears the most likely to correct the vitiated condition of the blood. It should also be observed that Dr. Stevens does not overlook the changes in the solids: when these exist, they are to be treated by active measures, and the saline treatment after- wards adopted. It would appear, also, that the nitrate of potash, which has been long used as a cooling remedy in fever, may act beneficially on another principle— that of altering the diseased properties of the blood It is well known that this salt, when mixed with dark blood out of the body, possesses the powei of instantly changing the colour to a bright red, and from its having been used with the most bene- ficial effects in cases of scurvy, it is reasonable to suppose that it will effect a beneficial change in the blood in malignant fever. It is proper to add a few observations on the 200 FEVER, (CONTINUED) diet of fever patients. The complete disrelish of every kind of food during fever points out the ne- cessity of abstinence ; and in cases where, from mistaken views of the supposed advantage of nourishment, food of an improper description is given, the stomach frequently rejects it. For the first few days the patient generally re- fuses any kind of food. While the febrile symp- toms continue, farinaceous substances, such as the different kinds of gruel—arrow-root, sago, rice, prepared barley, and oatmeal, acidulated with lemon-juice, form the most suitable nourishment. A cup of any of these gruels may be given at in- tervals, and if the patient retain the relish for it, a cup of weak black tea may also be allowed occa- sionally. We have often observed that thirst is more effectually allayed by weak tea than by any other beverage. Sometimes ripe fruits are grate- ful, and therefore may be allowed in great mode- ration, unless there be symptoms of gastric disor- der, or such fruits disagree. When the symptoms of fever abate, more par- ticularly when the tongue begins to clean, and the appetite to improve, a portion of stale bread or water biscuit should constitute the only additional nourishment, till the fever has entirely disappeared. The weak animal broths may then be substituted for the farinaceous food ; and of these the quantity should at first be moderate, that the stomach may not be oppressed. In the course of three or four days a little solid animal food, plainly dressed, may be allowed, un- less there be special circumstances to forbid it. The quantity of animal food should not exceed three ounces at first, and mutton, from its being more easily digested, should be preferred. If the patient feel any uneasiness after it has been taken, it must of course be omitted, and beef-tea or mut- ton-broth again for a time substituted. When the patient has been much reduced, more particularly if there be a natural delicacy of habit, one or two glasses of sherry wine, mixed with water, may be taken during the day ; but, in ge- neral, in convalescence from common epidemic fever, wine or fermented liquors are not required, unless the powers are feeble, or the patient has been accustomed to their daily use. As a general rule, nourishment may be given more early in typhus than in the acute forms of fever. Of Convalescence*—In no form of acute dis- ease is the management of convalescence of more importance than in continued fever ; and few per- sons among the educated — none among the ig- norant— can conceive the precision that is required in this particular. It is too commonly imagined that, when the fever has disappeared, all danger is at an end; that nothing remains to be done but to recruit the strength by nourishing food and imprudent exer- tion. If the feeble state of every organ in the oody, but more especially of those which may have been more seriously affected, and the slow and gradual manner in which they recover their natural vigour, were considered, few would be so careless of their safety as to hazard a relapse which might be fatal. Ir. is the duty of medical attendants to place these circumstances strongly before the patient, and to impress on the mind the paramount neces- sity of refraining from every thing that is likely to produce excitement. In almost every case the practitioner has to contend against the prevailing notion, that the strength can only be restored by nourishment, and even wine. The inherent restorative powers of the system, and the greater safety of leaving na- ture slowly to effect her own purposes, than to hazard a renewal of the febrile action, or to rekin- dle local inflammation by acts of imprudence, should be pointed out. When the symptoms have been severe, and consequently the treatment active, more especially when large losses of blood have been sustained, the greater is the danger of relapse. In some instances again, the local inflammation which may have arisen has not been wholly ex- tinguished, there is a lurking indisposition —a tedious recovery, as it is termed. Such cases, it should be remembered, only require the excite- ment resulting from indiscretion in diet or pro- longed exertion, to reproduce the local inflam- mation. In the management of convalescence, therefore, the patient should not be permitted to sit out of bed till the strength be considerably advanced. It is better that restriction should be imposed a little too long, than that any risk of relapse should be run. The next point is of still greater consequence — the proper regulation of the diet. This has been already minutely discussed, as well as the order in which the food should be changed. We may, however, remark that, in our experience, by far the greater number of cases of relapse take place from indiscretion in diet. It should also be strongly impressed on the convalescent, that it is as necessary to guard against the quantity as the quality of food, particularly when there has been gastric irritation in the progress of the fever. The stomach may be able to digest and assimilate a limited proportion of food; but the indulgence of an extra ounce or two may induce oppression, and a renewal of the fever. This organ in con- valescence partakes of the external or muscular debility, and the convalescent may as well expect to be able to carry a heavy load on his shoulders, as to digest an undue quantity of food, even of a suitable kind. Indeed, every practitioner of expe- rience knows, that with the best precautions, the return to solid animal food is hazardous. Besides avoiding every source of general excite- ment, it is necessary to impose restrictions accord- ing as the several organs may have been affected. Thus, when the symptoms in the brain have been severe, undue mental effort should at first be ab- stained from as much as possible. When the lungs havs been inflamed, every circumstance likely to produce recurrence of the pulmonary dis- ease must be avoided ; and similar precautions, but more especially with regard to diet, are neces- sary when the gastric organs have been impli- cated. Exposure to cold in the winter and spring must be most attentively guarded against. Many per- sons who have struggled through a most danger- ous fever, have, from imprudent exposure to cold, been seized with intense inflammation in some organ, which has rapidly destroyed life : hence the necessity of suitable clothing, and regulating FEVER, (EPIDEMIC GASTRIC) 201 the temperature of the chamber, during the period of convalescence from fever. . m A. 1 WEEDIE. FEVER, EPIDEMIC GASTRIC—The ar- rangement of febrile diseases by Sydenham was founded on the observation that such diseases, revolving in cycles, present characters which are probably owing to certain changes in the consti- tution of the inhabitants of a country, whether produced by the nature of seasons, or of exhala- tions from the ground, or of food, or by moral causes, or by a combination of all these important influences. These influences, although they act in a manner hitherto unexplained, give a stamp to epidemics ; and not only do they affect the epi- demic, the great current disease, but also those concurrent diseases which specifically differ from it, while they retain towards it a certain generic affinity. Hence it is that we have considered a passage in Sydenham, which has often been quot- ed, as the best clue to guide the physician who means to explore the labyrinth of febrile diseases; a passage which, had it stood as a solitary frag- ment, would have vindicated the claim of Syden- ham to be considered a master in the science which he cultivated. So admirable is it, that in letters of gold it ought to be inscribed in the con- sulting-room of every fever hospital in the empire, to guard physicians against the evils which flow from adopting the exclusive views of systematic writers, or following the dangerous routine of prac- tice to which they often lead. " This, however, I am convinced of from numerous careful observa- tions, that the same method which cures in the middle of the year may possibly prove destructive at the conclusion of it; and when I had once happily fallen upon a genuine method of treating any species of fever suitably to its nature, I always proved successful (proper regard being had to the constitution, age, and other particular circum- stances of the patient,) till that species became extinct, and a new one arose, when I was again doubtful how to proceed, and notwithstanding the utmost caution could scarce ever preserve my first patients from danger till I had thoroughly investi- gated the nature of the distemper, and then I pro- ceeded in a direct and safer way to the cure." Three times in the course of thirty years, gas- tric fever, or rather gastro-enteric fever, has pre- vailed under our observation ; first, about the lat- ter end of the last century or beginning of the present, in 1799 or 1800; again in 1816, and a third time in 1826-27. With respect to the du- ration of its first visit, we cannot speak with cer- tainty ; in 1816 it did not continue for many months; but the epidemic which arose in 1826- 27 is not yet over : and thus it has afforded to the medical observer an opportunity of deliberately inquiring into its character and tendencies. It is chiefly from this epidemic that the following his- tory of the disease is drawn up. The following may be considered as the most remarkable features of gastric fever. General un- easiness and restlessness, or as the patient is apt to describe his condition, " complete wretched- ness ;" a most unpleasant state of the mouth—a taste which, like the general unhappiness, cannot be described, but is intolerable ; heat, often ten- derness, or even pain in the epigastrium, and red- Vol. II___26 ness of the fauces, which often ends in an aph- thous state of that surface. This species of fever often begins in an unusual manner, and also follows an unusual course. Many patients have fallen under our notice who had been indisposed for a considerable length of time before the formal invasion of the disease : from one to five weeks : they had complained of occasional headach, languor, and irregularity of the bowels ; their tongue being white, their sto- mach flatulent, the eructations fetid; yet were they not without appetite, nor were they by dis- ease incapacitated for business, nor unable to take exercise, although it soon produced exhaustion. Seldom can the day upon which the fever com- menced be ascertained, and generally there is no regular crisis; in short, both the attack and the recession of the disease are almost insensible, the former especially often occurring without the con- sciousness of the patient or the observation of his friends. Many patients also continue for. a long time unconscious of their true state, and are astounded when they learn that they are under the influence of continued fever. During the years 1828 and 1829 the writer has often found in his study, wait- ing his return home, a patient who was under an impression that he had contracted some slight dis- order of the stomach or biliary organs, but who in reality laboured under gastric fever, and had done so for many days, or perhaps weeks. In these individuals the tongue was generally white, while there was a blush of inflammation in the fauces; they complained of an unpleasant taste, and a degree of thirst: their pulse was from fifteen to thirty beats quicker than natural, and there existed some heat of skin. They admitted that they felt uneasiness in the abdomen, and they complained of restless nights, during which their thoughts were often confused and incoherent, and yet their muscular strength was not much impaired ; and hence it was not surprising that they should have expressed no small astonishment when the nature of their illness, with the necessity of confinement to the house, was explained to them. Some were affected with headach, which completely intermit- ted in the morning, and was severe towards night; and this had been the case for many days before a rigor, which often introduced a state of aggra- vated suffering, took place. An apothecary of discrimination, explaining the case of a patient who for several weeks had been ill, added that he had been " affected with one of those walking fevers," by which he meant that he had walked about performing his business, while affected with gastric fever. The tongue in some cases is not loaded ; nay, on a cursory examination, one would often be tempted to say that the tongue was quite natural in appearance; for, although the papilla? were elongated, and the intervals between them rather glassy, it was not white, and there was scarcely any coating on it. But in other cases the tongue is covered with a thick cream-coloured secretion, like size laid on with a brush, and so also are the fauces. This, which resembles the thrush of in fants, is one of the most characteristic symptoms of the disease. We once conceived that the ap- pearance in the fauces was caused by exfoliation 202 FE^ER, (EPIDEMIC GASTRIC) of the epidermis of the mucous coat, but it is not so; for when the crust is spontaneously detached or removed by a borax gargle, or rubbed off by means of lint at the end of a probe, the surface beneath, although vascular, is not excoriated. Sometimes the coating on the tongue is dry and brown, and sometimes the centre of the tongue appears as if covered with silver paper, the edges being moist. In the advanced stages of the severe cases it is often rough, dry, shrivelled ; sometimes it seems as if covered with varnish, and cleft, espe- cially by a central line, these ragades being deep and painful, and leaving permanent furrows. There is very generally an affection of the sto- mach, which varies much in severity ; so slight is it in some cases that the appetite for food is scarcely impaired, while in others symptoms of intense gastritis are observed: nor is there any want of intermediate cases of every degree. Gen- erally accompanying the very disagreeable taste already alluded to, there exists nausea and a loose state of the bowels ; the stools being watery, of a light brownish yellow colour, and of a pun- gent odour, not unlike the odour which sometimes exhales from the discharges which take place dur- ing dysentery, or like the smell of the steam which arises when corned meat tending to putrescency is boiling : these stools are not unfrequently mix- ed with mucus. Sometimes large discharges of blood from the intestines take place, which gen- erally are followed by a mitigation of all the symp- toms of the disease, the blood being generally fetid and dark, almost as dark and much more fetid than the discharges in mela?na. After such discharges, however, the patient will often sink and die. The urine is mostly high-coloured : great thirst usually exists. In a protracted case of gastric fever, a patient attended by the writer drank fifty dozens of soda water. Considerable heat of surface exists, especially towards evening. The pulse varies; its most usual property is hard- ness : often it will for a great many weeks exceed 120, while in many cases it never exceeds 80: even then the other symptoms are alarming; as, for instance, when the stools and urine are passed involuntarily. Sometimes the disease ends fatally without any tenderness, pain or inflation of the abdomen : but frequently as the disease advances, the intestines become distended with flatus, and tympany occurs, which in this disease is a more alarming symptom than it is in most other febrile disorders. And sometimes also in its advanced stages, this variety of fever is attended with stu- por, low muttering delirium, hiccup, subsultus tendinum, floccitation : in short, with all those symptoms, bootless to enumerate, which attend typhoid fevers. Moreover the fever is often attend- ed with bronchitis, which gains the ascendant over the proper symptoms of the disease, and sometimes appears to be the cause of the patient's death. There is great variety in the state of suffering. Some individuals appear to be scarcely conscious of illness, while very many are miserably wretch- ed and impatient, passing their nights in a state of unhappy and discontented delirium, and de- claring themselves ineffably wretched, and in the early period of the disorder are liable to acute headach, which closeiy resembles intermittent he- micrania : in truth, the disease is often productive of a degree of suffering which is not often ex- ceeded. There is often a remission of the symptoms after midnight, which continues until morning, when the heat becomes inconsiderable and the extremities cold ; then an exacerbation takes place, and the febrile symptoms increase as the day advances : in the evening they are most se- vere. There is often an aggravation of suffering on every alternate day, the disease being as it were a tertian remittent: the type is not very distinctly marked, yet it is sufficient to lead the attendant to observe that a good day and a bad day regularly succeed each other. In females symptoms of hysteria are often mani- fest during gastric fever, such as attacks of faint- ness, palpitation, sobbing, pale urine being passed in profusion. We would remark with respect to these symp- toms, when they are discovered in this or any species of continued fever, that they enhance the perils to which the patient is exposed; whereas when hysteria is an adjunct to any other disease, we are led to subtract from the estimate which we might otherwise have formed of the amount of the danger. In successive seasons we may remark a conside- rable variety in the symptoms of the fever; for example, the state of the surface of the body varies considerably. For two or three years, from 1827 to 1829, there was an entire absence of eruption of the skin, with the exception of the white mi- liary rash, which in many patients was to be found in the hollow above and below the clavicle, and in the sides of the thorax over the false ribs. This rash, probably, belongs to the gastric more than to any other species of fever; we do not include rheu- matic fever, whether common or puerperal, which has its own miliary rash, but limit this observation to epidemic fevers. During the first quarter of the present century, the miliary eruption was very rare; with a slight exception during all that time, the miliary rash was nearly absent. During the last five, but more especially during the last three years, the miliary vesicle has been very common. During the winter of 1830, if the red miliary rash be pa- pula?, with minute suppurating heads, that erup- tion was observed ; about the same time petechial eruptions re-appeared (after an absence of several years) as symptomatic of the fever under con- sideration : the petechia?, however, were rather clear, diffused macula? than the florid or purple stigmata, to which, perhaps, the term ought to be limited. No precise duration can be assigned to gastric fever. We have seen it observe a septenary period, although obscurely. Sometimes it extends not be- yond one week ; we have known it exist for three months, but its course is sometimes even much more extended. It is exceedingly under the influ- ence of regimen. When pursuing its course si- lently and unobserved, it may be roused so as to be attended with both suffering and great dangei by stimulating ingesta, fatigue, or anxiety. In like manner, also, relapses are very often produced. There is much obscurity with respect to the infectiousness of gastric fever. To us it has ap- peared that this species of fever is sometimes infec-y FEVER, (EPIDEMIC GASTRIC) 203 tious and sometimes not. For several years the fever appeared in families only in solitary instances, or if more than one were affected, they were seized nearly at the same time; but it did not extend so as to lead us to think that it propagated itself. We were unable to assign the cause of the disease further than that we observed, in several houses in which our patients lay, that fetor which is dis- coverable when a sewer is choked, and in some instances upon inquiry it was found that the sewer leading from the house had been improperly con- structed and neglected. In one patient the disease commenced in the middle of the Atlantic Ocean, and a fortnight before he reached land. But it would not be safe to affirm that in the winter of 1830 the fever did not possess an infectious pro- perty ; in virtue of which, and exclusive of every endemic influence, it spread through families. Thus the family of a gentleman of fortune, part of them from England and part from Ireland, met in the latter end of autumn in a large mansion in the most airy part of the city of Dublin. One of the young people from the county of Cork, who had been indisposed for several weeks, was obliged to betake himself to bed shortly after his arrival; then one of his sisters fell ill, then a second; then a footman who had attended his young master; then a housemaid; then a third sister; then a brother; then a fourth sister; and lastly a fifth and sixth sister, both of whom had come from England during the confine- ment of the first patient. These individuals were sickening in succession during a period of upwards of three months, and the cases differed only in se- verity. One of the patients, the footman, died, and the eldest of the young ladies did not require to go to bed ; yet were the symptoms of the same kind in all these cases. Many instances of the extension of this fever in families occurred within our observation during the winter of 1830 and 1831, which, although not so conclusive as that just related, induced us to think that gastric fever is sometimes an infectious disease. This disease depends upon an excited state of the stomach and intestines, which would seem to have been inflamed ; but this state is by no means identical with common inflammation. After death, the mucous membrane of the stomach is found thickened, unusually vascular, in many places of a bright or deep red colour, sometimes with blood effused underneath; the vascularity of this mem- brane is often rather that which would indicate congestion in the veins than in the arteries. There are, however, cases in which ulceration and even perforation of all the coats of the intestines have taken place. The following case and dissection will illustrate many of the foregoing observations :—W. V., who had been ill for many days, was visited by his me- dical attendant for the first time on the 13th of November, 1829. He had a sunken expression, his face was covered with perspiration, pulse 120, and weak. He complained of pain in the back of the neck and head, which was removed by some mild opening medicine, and never returned. For the next four weeks he was confined to the house, and engaged in business which harassed him much. He had all the time the same expression of coun- tenance, a strong tendency to perspiration, par- ticularly after the smallest dose of antimonial or Dover's powder. His bowels were at all times very free, having three or four evacuations every day without medicine ; his sleep was without re- freshment ; his appetite at first unimpaired; his tongue morbidly clean ; his pulse quick and tole- rably firm ; he chiefly complained of debility, and never of the smallest pain in any part of the body. During the last ten days of his life he was con- fined to bed. About the 12th of December he be- came slightly delirious, but still was sufficiently collected to know every one about him, and occa- sionally to speak on business. He was sunk in strength, his pulse was quick and weak, tongue dry and chappy, great thirst; two or three times he vomited a small quantity of fluid the colour of verdigris. On the morning of the 14th he had a profuse discharge of blood per anum, when he became nearly exhausted; his face was covered with a clammy sweat, extremities cold, and pulse at the wrist imperceptible. Involuntary discharges of clotted blood, slight tenderness of the abdomen— death. Throughout the attack, medicine appeared to exert too powerful an influence. A few grains of rhubarb produced numerous fluid stools; a few grains of Dover's powder occasioned profuse per- spiration. On one occasion he got a little quinine, which disagreed and was discontinued. Dissection twenty-four hours after death.—On opening the abdomen a great quantity of the same kind of fluid which he had passed per anum flowed out and ran about the floor. The intes- tines were largely distended with flatus of insuf- ferable fetor. The liver was of a dark green co- lour ; the gall-bladder greatly distended with bile. The lesser omentum was black and gangrenous; its structure giving way under the finger. The stomach of the usual size. On opening it, the mucous membrane presented a singular appear- ance; it was thickly coated with lymph, which appeared in masses resembling small glands, of the size of half a split pea ; towards the cardiac orifice and at the greater extremity of the stomach, the sur- face was very dark-coloured, almost black, and had much the appearance of gangrene. There was a large ulcer, of more than the size of a shilling, which penetrated through the substance of the stomach ; its edges were thick, elevated, and rough on the internal side, more smooth on the peritoneal side, but still thickened : the viscus appeared more healthy towards the pylorus, which was greatly contracted in size, and scarcely permitted the pas- sage of the little finger. Along the tract of the lesser intestines very vascular patches were ob- servable on the peritoneal surface. A portion of the intestine close to the termination of the ileum, about eight inches in length, was removed and slit open. On the mucous surface there were seven or eight ulcers, elevated at the edges and hard. One of them was sloughy, and penetrated through all the coats of the intestine into the cavity of the peritoneum; the surface was smeared with the same kind of bloody fluid already men- tioned. The great omentum was thickened, of a dark mahogany colour, evidently in a state of in- flammation approaching to gangrene. There is one consideration which vindicates the publication of this case of gastric fever, namely, that it illustrates an important peculiaritv in th* 204 FEVER, (EPIDEMIC GASTRIC) disease. Extensive mischief often takes place in the abdomen without there being any symptom, such as great heat, tenderness, pain, or tumefac- tion, till within a very short time before death, to indicate that a disorganizing process is going for- ward. Treatment.—The morbid action of the mu- cous coat of the intestines does not terminate as common inflammation does, but produces exces- sive secretion; yet this increase of secretion does not, at least in the first instance, relieve the irrita- tion of the surface from which it proceeds : fre- quent copious watery stools are often productive of no relief, and yet they may not safely be checked — we may moderate, but we must not suppress these discharges. If these discharges do not re- duce the strength of the patient, if they occur not more than three or four times in the day, the less we do the better. We may prescribe mild gfys- ters, light and nourishing drinks in small quanti- ties, barley or rice water with a little isinglass, or gum-water with syrup of capillaire : we may moderate the heat of the surface by tepid affusion or sponging, equalize the circulation by fomenting the legs, and applying cold water and vinegar to the head : white we ensure ventilation, we must not reduce the temperature of the apartment below fifty degrees ; and, finally, we are not to employ internal medicines, whether purgative or astrin- gent, without a very clear indication. In truth there are many cases in which nothing can be done by the physician, but to ascertain, at each successive visit, that there is no aggravation of any of the symptoms of the disease. And yet it is of great importance to recollect that there is no disease in which he is in greater danger of losing the confidence of his patients, unless he explains the probable duration of the fever, and the danger which often suddenly arises even in the mildest cases. In reference to the great proportion of cases in which* the practitioner is not required to interfere, the writer cannot help alluding to a physician, originally a man of very energetic measures in the treatment of fever, who, it is said, became, within the last two or three years of his life, remarkable for his " milk and water practice." Now if the physician alluded to was treating the disease under consideration, as there is reason to believe he was, he evinced his skill; for had he in most cases employed either depletory means or stimulants, fewer of his patients probably would have recovered than actually did. Long and watchful practice confers no greater boon than in enabling a physician to be inactive without loss of character, or the danger of being supplanted by those who think it necessary to practise, not only for the benefit of their patients, but on the credulity of the attendants or friends of their pa- tients. If the discharges exhale a pungent or fetid odour, we may give charcoal, recently and finely levigated, in doses of fifteen or twenty grains. If the discharges are very frequent or excessive in quantity, they may be checked by means of ene- mata of laudanum and mucilage. The enema, for an adult, consisting of fifteen or twenty drops of laudanum in two ounces of mucilage of gum- arabic or starch, administered immediately after a stool, and kept from passing off by means of a towel pressed against the anus, will often check the discharge for many hours. In this state of the bowels a quarter or one-fifth of the grain of the watery extract of opium, with two or three grains of rhubarb every fourth or sixth hour, will often be found useful. If, on the contrary, tht bowels have ceased to act, and the patient become heavy and oppressed, a mild aperient glyster, gruel with soft sugar, and a small quantity of Glauber's salt, or an aperient draught of the mildest kind, by resuscitating secretion will relieve the whole system from oppression. It is very remarkable in this disease how small a dose of any medicine, whether aperient or astringent, will produce a sensible effect; and hence it would appear highly important, as our object is often merely to avoid extremes, not to give medicines in an over-dose. When the bowels are not in a state to require either purgative or astringent medicines, (and this will very often be the case,) the mineral acids may be given generally with great benefit. The writer has in general preferred the nitro-muriatic acid : two drops of the nitric, and four of the mu- riatic, in a large wine-glassful of water, may be given every second or third hour; in general this draught will prove not only beneficial, but very agreeable to the palate and feelings of the patient, tending to quench thirst, remove the disagreeable taste, and allay fever and irritability. As the disease advances, very weak chicken- broth or beef-tea will be useful, and the patient will sometimes require wine, but it must be given very sparingly ; an ounce, or even half-an-ounce of claret diluted, and given every third or fourth hour, generally will prove a sufficient quantity, or a table-spoonful of sherry in a little soda water, or one or two table-spoonsful of Hoc or Barsac in Seltzer-water. No point of practice more requires to be well considered than the exhibition of wine in this species of fever. There is a species of de- bility produced by an excited state of the mucous membrane of the stomach which wine will not re- lieve, but which will yield to topical bleeding; this often attends the earlier part of the disease, when indeed it will very seldom be necessary to give wine ; in its more advanced stages, when much exhaustion is complained of, when the pulse is characterized by smallness, irregularity, or in- equality, and when the circulation in the extremi- ties is languid, we must give wine, but very cau- tiously ; and we must be prompt in withdrawing the allowance of wine upon any general re-action or local determination taking place. There are two principal terminations of fever, one by a change in the distribution of the fluids, the other by those vessels which have been in a state of congestion returning to a more natural condition. In both of these there is increased or altered secre- tion ; in the former, from a part of the system dis- tant from that principally affected ; in the latter, often from the affected surface. In catarrhal, gas- tric, and enteritic fevers the disease very generally terminates by secretion from the affected mucous membrane, and the resolution of the disease is al- most insensible. Now, as a general rule, it will be found that wine is little needful in this class of fevers; indeed in most of the cases it may alto- gether be dispensed with. In gastric fever with a dry tongue and tympa- FEVER, (EPIDEMIC GASTRIC) 205 nitic abdomen, chicken-broth, or Seltzer water with j milk, will be preferable to wine; at all events wine ought not to be given at the first appearance of these symptoms. The tympany may often be removed by means of spirit of turpentine, but will generally soon return; and turpentine, at each successive dose, will be found of less and less efficacy. Emollient enemata, terebinthinate fo- mentations, blisters to the abdomen, nitre largely diluted, from gss to 31 to sixteen or twenty ounces of almond or arabic emulsion, taken in the course of the day, with small doses of rhubarb, was the treatment most applicable to this state. When the tension is removed, wine is sometimes need- ful, or a tea-spoonful of brandy in a small cupful of warm milk or gruel every three or four hours,. may be given with advantage. When the patient is restless and uneasy, a change of bed will often prove most tranquillizing. When the circumstances of the individual will permit, there ought always to be two beds in the chamber. There ought also to be an easy-chair, in which the patient, when able to leave his bed, may sit, half recumbent, during part of the day; in which position, with his tegs on a footstool, fomentations may conveniently be applied to the whole of the lower extremities. Is bleeding requisite in this form of fever ? Very often it is. When in a young and healthy patient there is early in the disease much vascular re-ac- tion, nothing will prove so useful as the loss of eight or ten ounces of blood ; and when tenderness and heat of the abdomen are discovered at any pe- riod of the disease, from eight to eighteen leeches may be applied. So also ought we to proceed when there is excessive irritability of the stomach, with unquenchable thirst. But we are not to bleed as if the disease were to be extinguished by bleeding; this it cannot be—we may expect to moderate the severity of the symptoms by bleed- ing, to restore secretion if it be suspended, to mo- derate secretion if it be excessive; but as the dis- ease generally has a long course to run, and as the issue will depend upon the strength of the patient being husbanded, if there is nothing in the intestinal tube which indicates inflammatory irri- tation, our part will be, not to bleed, but to allow the disease silently to wear itself out, unless in those cases in which inflammation is kindled up in the progress of the fever in other organs, in the lungs for instance, which was often the case while an influenza prevailed in the winter of 1829. In one of many such cases the writer directed 60 ounces of blood to be taken within five days from a lady in the third week of gastric fever, to subdue a bronchitic attack which was superinduced; he has also been obliged to employ the lancet freely, in order to relieve encephalitic attacks. It may not be useless to remark, that within the last ten years the lancet has not been in such requisition as it was during the preceding decade : the fevers in general have had less of an inflam- matory character. Irish physicians of the present Jay, who are eminently skilful in the treatment of acute diseases, are almost all eclectics, have no fixed routine of practice, but are equally ready to act with the decision which those dangerous con- tingencies above alluded to may require, or to re- msi" calm spectators of a distemper which often requires nothing more than the dieta aquea from the beginning to the end. This is not a fever which requires a mercurial every night and a drench of infusion of senna and salts in the morning. It would be most mis- chievous to give purgatives daily ; you thus in- crease the peristaltic movement, and disturb the bowels when it is of the greatest moment to keep them at rest. There are three points to be at- tended to in gastric fever, as contra-indications, before we prescribe a purgative : first, the outline of the abdomen — when the ribs are prominent and the belly soft; secondly, the condition of the stomach — when the stomach is irritable, the pa- tient complaining of nausea and sickness, with tenderness of the epigastrium ; thirdly, the quality of the discharges from the bowels — if these be serous or mucous, or rendered such by purgatives, then let us withhold these medicines, or adminis- ter them with the utmost caution. The purgatives which the writer generally employed, were rhu- barb with manna, phosphate of soda in weak broth, Rochelle salts, or a solution of soda taken with lemon-juice; citrate of magnesia, or sulphate of magnesia in infusion of roses. When there was evident deficiency of bile in the stools, blue pill or quicksilver with magnesia, with or without Dover's powder, in minute quantity, were often prescribed. The management of the surface of the body is of considerable importance. Every evening, (so long as the patient retains sufficient strength) when the heat of skin and anxiety are greatest, the writer is persuaded, from trials made under his own observation, that the tepid shower-bath will be found a valuable remedy. Tepid fomenta- tions to the limbs, renewed frequently, for at least an hour at a time, two or three times in the day, and especially before the usual time of going to rest, will often remove the febrile irritability and dispose the patient to sleep. John Cheyne. FEVER, INTERMITTENT, or AGUE.— This disease may be conveniently considered un- der the three following general heads :— 1. sim- ple or mild intermittent; 2. complicated or malig- nant intermittent, equivalent to the fievres inter- miltentes pernicieuses of the French writers, the febres intermiltentes comitatx of Torti and others, and the cpiala of Galen; 3. masked intermittent, or the febres intermiltentes larvatx of authors. 1. Simple on Mild Intermittent Fever.— This disease consists of a series of febrile parox- ysms recurring at times more or less regular, and alternating with apyrexia? nearly if not quite per- fect. There is generally but one fit in the space of twenty-four hours. The time intervening from the commencement of one paroxysm to that of the paroxysm next succeeding is called an interval, whilst an inter- mission comprises the period from the cessation of one fit to the beginning of the next. Ague displays itself under three principal fonns, which may be considered as genera, if the disease constitute an order, as it does in the nosology of Dr. Cullen, or as species, if it be considered merely a genus. These are — 1. Quotidian, having an interval of tvventv-iom FEVER, (INTERMITTENT) 206 hours, the accession of the paroxysm being early in the morning. 2. Tertian, having an interval of forty-eight hours, the paroxysms occurring at or about noon. 3. Quartan, with an interval of seventy-two hours, the fit commencing in the afternoon, gene- rally from three till five o'clock. There are sundry deviations from these leading types, but to narrate them all would be a burden to the attention and memory of the reader without proportionate instruction. It will be sufficient to point out those varieties which are of most frequent occurrence. The double tertian is very often met with. A paroxysm occurs daily, and hence the disease would naturally be supposed to be quotidian; but on observing its course and comparing the parox- ysms, it will be found that those of alternate days only correspond in duration and violence, and that they commence about noon. It appears as if the fits of a milder disease were inserted between those of one more severe. A triple tertian occurs daily with two parox- ysms on one day, and on the other one only. A duplicated tertian returns only on alternate days, but on these days has two paroxysms. The double quartan has a paroxysm, generally slight and of short duration, on the day succeed- ing that of the regular quartan recurrence, so that on the third day only is there a perfect intermis- sion. The duplicated quartan has two paroxysms on the day of attack, with two days of intermission; thus strictly resembling the duplicated tertian, al- lowance being made for the difference of the pri- mary type. A triple quartan has a light febrile paroxysm on each of the days usually allotted to a perfect intermission. Agues having intervals of five, six, eight, or ten, &c. days' duration are mentioned by authors of repute, but they are acknowledged to be rare. Some of these probably belong to the ordinary types of the disease, and either by the effect of medicines or some spontaneous change in the con- stitution certain paroxysms appear to be presented, and hence arises the duration of the intermission. Others do not admit of explanation on this princi- ple, but are really what they appear to be, inter- mittent diseases recurring at intervals of many days; but these are much more frequently masked intermittents, (that is, the symptoms of other dis- eases, such as hemicrania and various neuralgia?, or even apoplexy, returning periodically,) than icgular agues. Of the three primary types, the tertian is by much the most frequently met with ; the quartan stands next; whilst the quotidian is in some de- gree rarer than the latter. The types frequently pass into each other; but we oftener observe that those whose interval is short assume the more lengthened forms than in- versely ; for instance, the tendency of quotidians to change into tertians is very great. But the contmry mutation, that of a disease of a long in- terval into one of a shorter, is often observed, and It denotes the increasing severity of the malady, it never is but by the fault of the patient or his physician, it is then very dangerous. (Lib. iii. cap. 15.) Intermittents, too, not unfrequently assume the remitting form, and this is occasionally attributable to the untimely employment of certain medicines. We very often observe the contrary order, remittents changing into intermittents, and this is the safer change for the patient, as it shows the diminishing intensity of the disease. Agues are much more frequent in the spring and autumn than during any other season of the year. Those occurring in the former period are generally tertians and quotidians, and are found to yield readily to remedies, whilst those prevail- ing during the latter are more intractable; and quartan, the most obstinate form of all, (so much so indeed that it is said by Celsus rarely to ter- minate before the following spring,) is found to constitute a more considerable proportion of the cases. Symptoms. — The disease rarely displays itself at once under the form of ague in an indi- vidual who has not previously laboured under it. The patient feels indisposed, has headach, weari- ness, and pains of his limbs, thirst, inappetency, white tongue, frequent pulse, high-coloured urine, and dark discharges from his bowels. This fever- ish state displays its periodical tendency by well- marked exacerbations and remissions, the former generally occurring daily about noon. After this febricula, or fever, for though sometimes slight it is occasionally severe, has endured for a time varying from four days to a fortnight, the patient is seized with a severe rigor, and the ague which the medical attendant, if experienced in this class of disorders, had been expecting, manifests itself. The paroxysm commences with a sense of creeping or coldness running down the back, the nails turn blue, the features become pale and shrunk, the skin wears the appearance of what is called goose-skin, and the pulse is small and rapid. The coldness soon becomes general, and amounts to shivering with chattering of the teeth; cough, dyspnoea, and oppression of the pra?cordia occur; there is a sense of painful constriction round the temples; severe aching in the back; nausea and often vomiting. This, when it occurs, seems to have the effect of bringing on the hot stage more speedily ; though, without such an occunence, it succeeds the first stage after it has lasted for a period varying generally from half an hour to two hours and a half. The hot stage is denoted by great heat of the surface, a forcible pulse, intense thirst, dry tongue, headach with throbbing of the temples, and scanty and high-coloured urine; in short, by all the indications of an ardent fever. The mean duration of this stage is from three to eight hours. At its close a gentle moisture, which soon amounts to a profuse sweat, appears on the skin ; the pulse becomes remarkably full without losing much of its frequency ; the headach and thirst subside; the urine, which during the cold stage had been deficient, pate, and limpid, and in the period of excitement had almost ceased to be secreted, is discharged copiously, and deposits « Iateritious sediment; and the bowels are cither evacuated spontaneously or are readily amenable tor it is a remark of Celsus that quartan kills no to cathartic medicine. At the termination of the one. but if it be converted into a quotidian, which ', sweating process the patient feels as if restored to FEVER, (INT ERMITTENT) 207 health, a sense of exhaustion excepted. On the following morning, should the case prove a quoti- dian, about noon of the third day, if a tertian, and in the afternoon of the fourth, should the disease be a quartan, the coldness again commences, and there is a repetition of the symptoms which have just been described. The duration of a paroxysm varies in the differ- ent types. It will be very near the truth to estimate the mean length of the whole paroxysm of a quo- tidian at sixteen hours, whilst a fit of tertian com- pletes its stages in ten hours, and a quartan in six, of which fully two are occupied by the cold stage. Any considerable excess beyond these periods constitutes a protracted paroxysm of the respective diseases. When this protraction takes place in a quotidian, it is manifest that there can be little or no intermission, and most modern ob- servers would perhaps term such a disease remit- tent fever, between which and intermittent the boundary line is often very faint. The Greek writers named it amphemerina, and the Latins quotidiana continua. The paroxysms of all the forms are apt to vary the time of their recurrence, that is, to commence at an hour somewhat earlier or later than those which preceded them. It may be remarked that retarding are generally to be preferred to antici- pating fits, the former showing the power of me- dicinal agents over the disease, the latter that it is still uncontrolled. Though it appears certain that ague, like other febrile diseases, has a tendency to undergo a spontaneous cure, or, as it is expressed, to wear itself out, yet this disposition is counter- acted by so many circumstances, and our oppor- tunities of witnessing the unassisted power of the constitution over any disease are in the present day so rare, that it is impossible for us to give from observation any suggestion as to the time generally required for this natural cessation. The ancients, whose opportunities of estimating the unaided or imperfectly aided influence of nature over disease were infinitely greater than ours, give us little more information on this point than that already quoted from Celsus, and which has frequently been confirmed by others, that quartans, which generally commence in autumn, rarely cease till spring, and an intimation that a tertian might cease spontaneously, or at least without the employment of anti-periodic remedies which they were ignorant of, at the third paroxysm. (Lib. iii. cap. 14.) «*It has sometimes, though but rarely, occurred to the writer to see quotidians and tertians cease without the employment of any re- medies of that description, after three or four fits, the cessation coinciding with the appearance of an abundant herpes labialis, an appearance always of the best omen in this class of diseases, whether intermittent or remittent. But he has never ob- served this in quartans, which are much less yielding than the other forms of the disease, and are more frequently complicated with those visce- ral affections which, from being effects of the dis- ease, become its perpetuating causes, and invest it with a character of great obstinacy. These complications, it must be remarked, not unfre- quently occur in the course of tertians and quoti- dians, and render them intractable, but they are less essentially a part of them than of quartans The tendency to relapse is great, and it is very apt to take place on the days corresponding to that of the paroxysm, and hence great caution should be observed after the interruption of the disease, as to avoid exposure to cold and fatigue, and respecting diet, particularly on these days. A gentleman who had recovered from ague had a relapse at Lisbon from drinking a glass of iced lemonade on the day corresponding to the tertian period, which was the form he had laboured under. Causes apparently slight may occasion a recurrence of the disease at periods so remote that the term relapse would scarcely be applicable. The late Dr. Gregory of Edinburgh was in the habit of relating in his lectures the case of a young West Indian, who, having at some former period suffered under ague, struck his shin against the scraper in going into the class-room of the Insti- tutes of Medicine, and had immediately a paroxysm of the disease. The writer was stationed at Can- terbury in August, 1814, with the corps of cavalry of which he then had medical charge, and which had recently returned from the Peninsula, where very many of the officers and soldiers, perhaps the majority, had laboured under ague. The wind set in suddenly and coldly from the east, and im- mediately his hospital, in which for months there had been no cases of the disease, was filled with intermittents. Complications and sequelx of the disease.— It may appear inconsistent to speak in the present department of complications, but it is intended that only such lesions of structure shall be no- ticed here as result from a long continuance of a mild disease, those dangerous organic changes which are almost essential to the nature of malig- nant intermittent being reserved for future notice. The tendency of the simplest kind of intermittent to affect the viscera of the abdomen is very great, as is shown by the following fact: if any cathartic be given to a patient immediately after even his first fit of ague, a quantity of dark bilious matter is discharged from his bowels. During the cold stage the blood seems to be largely accumulated in the veins of the viscera generally, and very much so in those of the portal system, so that we find the functions of the alimentary canal and the liver disturbed early in the disease ; and merely by its long continuance, even should its general character be devoid of all malignancy, serious or- ganic affections are occasionally produced. That the accumulation of blood in the viscera during the cold stage is considerably instrumental in en- gendering them, is shown not only by general reasoning of a very obvious nature, but by the fact that these morbid affections arise more fre- quently in the quartan, which has the longest cold stage, than in the other forms of intermittent. The following case may serve to illustrate the effect of venous accumulation in generating struc- tural changes. It once occurred to the writer to see a person die in what appeared to be the cold stage of a first fit of ague. Heat applied in va- rious modes, ammonia, ardent spirits, ether, and other stimulants, failed to bring on re-action. He lay as cold as marble, and shivering violently, without any pulse at the wrist, and his heart ac- ing very feebly for eighteen hours, and then ex pired. his intellect remaining unclouded till within 203 FEVER, (INTERMITTENT) a few minutes of his dissolution. The principal morbid appearance discovered was in the liver. This viscus was very much enlarged, and extend- ing below the cartilages of the ribs towards the umbilicus, had a lobulated appearance, and was gorged with blood ; it seemed, indeed, as though it had yielded in those few hours to the pressure of the fluid which distended its vessels. The man had not previously complained of indisposition, but had undergone cheerfully the toils of the Peninsu- lar war, performing his duty as groom to an officer. To this cause, the remora of blood in the veins of the viscera during the cold stage, is superadded the arterial congestion of the same organs during the stage of excitement; the word congestion, which it must be observed has been used in va- rious senses, being here employed in the signifi- cation, now we believe the most usual, of deter- mination of blood, a part of the state of inflam- mation, but which may exist independent of it, though its long continuance or frequent repetition has a tendency to induce it. The disposition to these affections of the abdo- minal viscera is early displayed by a furred state of the tongue and a considerable degree of epigas- tric tenderness increased by pressure. They are occasionally fully formed during the persistence of a long-continued intermittent, and sometimes, their rudiments being then laid, they attain a fuller development after it has ceased or been subdued by medicine, especially if the patient remain in the climate where the disease commenced. Their existence is indicated by the following signs. The countenance of the patient is pale and bloodless, and if the disease be of some standing, appears puffed and cedematous; occasionally it has a yel- low tinge, and yellowness is almost always percep- tible in the conjunctiva?; there is great debility, and the patient is breathless on slight exertions; the epigastrium and both hypochondria appear and feel full and distended, and are tender on pressure, but independently of pressure there is a sense rather of weight than of pain, or at most of very obscure pain extending from the epigas- trium to the spine. Pain or aching is experienced, too, about the right shoulder or shoulder-blade. The discharges from the bowels are found to be clayey ; the urine is high-coloured, with occasion- ally a jaundiced stain ; the tongue has the exan- guious appearance of the countenance, and is co- vered with a white or cream-coloured fur; and the pulse is generally small, feeble, and frequent. If these symptoms remain unsubdued or undi- minished, diarrhoea or more frequently chronic dy- sentery and general dropsy supervene, and finally death closes the scene, though generally at a long interval from the commencement of the disease. In many cases, instead of this complicated state of derangement, in which the spleen, liver, and occasionally the pancreas are involved, we find an affection of the first of these organs only, consti- tuting what is commonly called ague-cake. This is denoted by a hard swelling in the left hypochon- dnum, always indolent at first, and sometimes re- maining very long so, and influencing little the ge- neral health; but occasionally attaining a great size, becoming extremely painful, and, in climates warm- er and more infested with intermittents than our Dwn, inducing rapid death by rupture of the organ. Persons labouring under these enlarged spleens are observed to be very subject to foul ulcers of the legs. (Morgagni de Sedibus et Causis, Epist, xxxvi. 18.) Post-mortem Appearances.—The milder forni of the disease we are now considering is fatal only by means of the consequences of its long conti- nuance which have just been described. The morbid changes generally discovered in fatal cases are, the cellular membrane and serous lining of the cavities distended with fluid, and organic dis- ease in the liver, spleen, and intestines. The change discovered in the liver consists fre- quently of augmentation of the bulk of the organ and of the density of its texture, as if from inter- stitial deposition. In other cases its consistence is diminished, the whole organ appearing to be converted into a dark-coloured pulp resembling a mixture of effused and coagulated blood and shreds of membranous matter. Both the indurated and the softened state are sometimes found coexisting with tubercles dispersed through the viscus. Oc- casionally the texture is merely more friable than natural, not in the extremely softened state men- tioned, and contains small and detached purulent deposits. The only change discovered is some- times in the bulk of the organ, the texture remain- ing natural, as in a case related by Grottonelli, in which it had acquired such a size as completely to mask the stomach and intestines, the left por- tion extending into the left hypochondrium and adhering to the spleen, so that it could not be separated without tearing, the substance being nevertheless perfectly sound.* The spleen is often found much enlarged, sometimes to quadruple its natural size, and to the weight of six or eight pounds. Morgagni, indeed, mentions a case in which it attained the weight of eight pounds and a half, and occupied nearly the whole of the left side of the abdomen. (Epist. xxxvi. p. 17.) Such enlargements coexist with affection of the liver, but, as already stated, aie found to be consistent with a healthy condition of that organ. The density of the viscus is occa- sionally increased; but in the majority of instances its interior texture is remarkably soft, and it be- comes evident that the hardness felt in the left hypochondrium before death had arisen from the extreme distension of the tunic of the spleen from the quantity of fluid effused into the organ; and the pain felt in a viscus possessed of little sensi- bility appears to arise from inflammation of its covering induced by the same distension. This inflammation is often visible after death, the tunica propria being highly injected, as if by art. When the organ is examined, it is hard, tense, and resist- ing; but on being cut it is found to consist inte- riorly of fluid, sometimes greyish-black, some- times having the deep purple of lees of wine, in- termixed with mere shreds of fibrous or mem- branous matter. Should death take place from rupture of the spleen, it is preceded by lancinating pain of the abdomen, small and frequent pulse and cold extremities ; and on opening the cavity it is found to contain a quantity of dark-coloured fluid which has flowed from the spleen, in which * Ad acutas et chronicas splenitidis eidemque eucce- t^ilfilInorboru,n hist0"as animadversiones. Floren- FEVER, (INTERMITTENT) 209 either one or more small crevices, or round and ulcerated apertures, are found. A case is men- tioned by Professor Morelli, of Pisa, in which an enlarged spleen had contracted an adhesion to the left extremity of the colon, where it turns to form the sigmoid flexure, and its contents had thus been discharged by stool, the patient being sup- posed to labour under mala?na. A case is related by M. Gaste in the Bulletin de la Societe Medi- cate d'Emutation, in which there was found in the left hypochondrium a large peritoneal pouch circumscribed outwardly, above, and posteriorly by the diaphragm, within by the stomach, and below by a small portion of the colon and the left kidney. This sac contained two pints of a sanies resembling wine-lees, and the spleen occupied the lower part of it. This organ was of its natural size, but its surface was tuberculated, and its con- cave part displayed several irregular ulcers from half an inch to two inches in diameter. Should dysentery have existed before death, there will be found ulceration of the great intes- tines. Remote Causes.—The most uniformly opera- tive of these is, unquestionably, malaria; indeed, it may be doubted whether any case of idiopathic intermittent can occur independently of its agency, either as a predisposing or exciting cause. (See Malaria.) Other circumstances may co-operate: an individual, for instance, debilitated by priva- tions of food or sleep, by debauchery or fatigue, is more susceptible of the influence of this poison than one whose strength is unimpaired, and should he be attacked with ague, some of the circum- stances enumerated may be considered as the pre- disposing causes of the disease, and marsh mias- mata its exciting cause. On the other hand, an individual who has been exposed to the efflu- via of swamps, may suffer a fit of ague at once from some trifling circumstance, such as drinking a glass of iced lemonade, (an example of which occurred in the person of the writer,) exposure to cold, &c. when the effluvia should be regarded as the predisposing cause. Some authors have supposed ague contagious. This was the opinion of Baunarez and Cibat in Spain, Bailly and Audouard in France, and Cleg- horn and Fordyce in our own country. Cases have fallen under the writer's observation which have led him to entertain at least a suspicion that such was the fact; but the most forcible case for the affirmative of the question which he has met with is one related by Bailly. " A lady arrived in Paris with an intermitting fever, which she had contracted in the country in a marshy situa- tion. This fever was accompanied by violent vomitings and other serious symptoms, which dis- played themselves at every paroxysm, and forced me to give bark. Scarcely was she cured, when her husband, who had never quitted Paris, but who had had the imprudence not to keep himself apart from her during her illness, was struck with the same symptoms and in a manner altogether similar." The proximate cause or nature of intermittents will be considered after the symptoms and morbid appearances of the complicated and malignant form have been presented to the reader. Treatment. — This will be best understood Vol. II.—27 s* by our examining into the merits of the various remedies employed for the cure of intermittents, and endeavouring to indicate the circumstances of the disease to which they are respectively ap- plicable. 1. General Bloodletting.—Though frequently useful and often imperiously demanded in the complicated form of the disease, this remedy ap- pears to be one of doubtful value, or even safety in mild intermittent. At the commencement of ague it is very usual to find the intermissions too imperfect to admit of tfie anti-periodic remedies, such as quinine or arsenical solution, being re- sorted to for terminating the disease ; but anti- phlogistic diet, mercurial purgatives with antimo- nials, and local bleeding to the epigastrium if there be tenderness in that region, will generally suffice, without the assistance of general bleeding, to bring the patient into the condition required for their administration. Should, however, ague in any part of its course be complicated with in- flammation, existing, not only during the paroxysm but in the intermission, in such intensity as would under other circumstances indicate the propriety of general bleeding, then it should be employed with- out hesitation. The writer can state from expe- rience, that cases which had resisted the usual anti-periodic medicines, the disease being kept up by a local inflammation, have been made amena- ble to their action by bloodletting. But the pro- priety of practising it indiscriminately as a remedy for ague seems more than questionable; nor, should circumstances render its employment ad- visable, does it appear to be established that the cold stage of the paroxysm, which is the time se- lected by Dr. Mackintosh for its employment, pos- sesses any advantage over the intermission, when it is generally performed. The latter period, on the contrary, seems better suited for giving the physician a precise knowledge of the extent of the local disease, and for enabling him to adjust the quantity of blood to the necessity of the case. The gentleman above mentioned published, in the 27th and 28th volumes of the Edinburgh Me- dical and Surgical Journal, two papers, advising the employment of this remedy in the cold stage of ague, and containing eight cases illustrative of the efficacy of the practice. Of these cases, four certainly appear to have owed their recovery prin- cipally to the bleeding, but in the remaining four the cure was accomplished by quinine ; and there is great reason to think that it would have taken place sooner had that remedy been employed ear- lier, though the bloodletting had been omitted. The four cases in which the practice was success- fully employed were of very long standing; and there is every probability that in them the disease was perpetuated by chronic inflammation of some viscus, though only in the eighth case are the symptoms so detailed as to enable us to fix on the site of the inflammation. In this case it was in the spleen; and all these cases fall under the de- scription of cases to which we have argued that bleeding is applicable. The practice of Dr. Mackintosh, as a general remedy of ague, was subjected to a full and candid trial by Dr. Stokes and Mr. Gill, a narration of which will be found in the 31st volume of the Edinburgh Journal ■ and if the reader will refer to it, he will probably 210 FEVER, (INTERMITTENT) agree in the sentiment expressed by the former of these gentlemen, that the result is calculated to convey an impression unfavourable to the indis- criminate or even frequent use of bleeding in the cold stage of this disease. Local bleeding is a safe remedy, and the appli- cation of leeches to the epigastrium or either hy- pochondrium is often of great benefit in the slighter gastric, hepatic, or splenic complications which are so frequently met with, and may be with propriety substituted for general bloodletting in the inflammation of an? organ, if not of a suffi- cient degree to keep up constitutional excitement during the intermission. It may be remarked, too, that there is no inconsistency in these mode- rate depletory measures being promptly followed or even accompanied by anti-periodic remedies, such as arsenical solution or quinine. It should be observed that the intermittent fevers of warm countries require and bear more free depletory measures, both local and general, than those of temperate climates. So decidedly is this the case, that many persons familiar with the agues of Rome and Sienna, where they are pro- bably more prevalent than in any part of the world, always commence their treatment by bleed- ing from the arm. Purgatives.—These are important remedies in the treatment of this disease, and circumstances counter-indicating their employment are of very rare occurrence indeed ; a very unusual degree of debility alone forbidding their exhibition, should other symptoms render it advisable. Those con- taining a proportion of calomel, or some milder mercurial preparation, should be, preferred, from the tendency which the disease displays to derange the biliary system. It was the writer's practice always to empty the bowels by such a purgative after a paroxysm previously to giving bark or arsenical solution, and to repeat it occasionally throughout the disease if it appeared advisable ; and the result generally showed the propriety of the plan. Irritation or even inflammation of the gastro-enteric mucous lining should not be con- sidered a reason for withholding this class of medi- cines, for the worst cases of ulceration or other disease of this membrane have been found in the practice of those who abstained from them ; and it may be considered as ascertained that their ju- dicious exhibition neither tends to induce such disease nor to aggravate it if existing; though it certainly is possible to excite considerable irri- tation there, by needlessly tormenting the bowels with purgatives. Emetics.—It is the practice of many medical men to give an emetic at the commencement of the cold stage, or a short time prior to the period of its expected recurrence, provided this be ascer- tained. Its administration in the first mode has generally the effect of shortening the cold stage, and rendering the whole fit milder ; whilst the giving of it before the fit occasionally prevents I his altogether, and breaks the catenation of the fever. Its exhibition in either mode should be considered only preparatory to the employment of anti-periodic remedies; but with this view it may be usefully adopted where there is no tenderness of the epigastrium, the existence of which should be considered as counter-indicating it Mercury___The use of this mineral should be directed rather to the comphcations of the disease than to the disease itself. Ague is almost uni- formly suspended by mercurial action ; but be- sides that we can in uncomplicated cases generally attain the same object by milder methods, it must be remarked that the cures effected by its agency are rarely permanent, the disease occasionally re- appearing immediately on the cessation of its action, or shortly after. But in the treatment of the gastric and hepatic complications of intermit- tents it is of great value; and no experienced medical man would withhold it in such cases. Its employment may proceed pari passu with that of quinine or other anti-periodic remedies; or the complications being removed, and the recurrence of the paroxysms being suspended by its action, those remedies may be administered as a security against relapse of the primary disease. The subject would be left imperfect did we not mention the vigorous employment of calomel in intermittent fever by our practitioners in India. They administer it in scruple-doses for one or two nights, giving a purging draught on the following morning to carry off the vitiated secretions; and it is subsequently continued in more moderate doses till the tongue becomes clean, when bark is administered. (Annesley, Sketches of Diseases of India, p. 491, &c.) By the same authority we are recommended to give a scruple of calomel combined with two grains of opium, to allay the irritability of stomach which so frequently attends the paroxysm. Opium.—This medicine has been recommended in the treatment of ague from the days of Galen downwards. It may be given either during the intermission, at the very commencement of the fit, or in the hot stage. The first method is that adopted by practitioners who rely upon opium for the cure of the disease. Its employment in this way is little known in this country, but has ob- tained considerable notice in France from a me- moir published by M. Jourdain (Journal General de Medecine, torn, lxxxvi. p. 305, and Bailly, Traite de Fievres Intermittentes, p. 438) on the potion stibio-opiacee of Peysson, which is a com- bination of opium and tartar emetic. The infer- ence we should draw from what has been stated of the effect of opium given in this combination, and from what we have seen of its employment in any form during the intermission, is, that it should not supersede the exhibition of the usual anti- periodic medicines, particularly that of quinine. But small doses of opium will even be found a useful addition to the preparations of bark or arsenic in ague occurring in irritable habits, and particularly when it is complicated with an irrita- ble stomach. The second mode of giving it, just at the commencement of the cold stage, shortens this stage very much, and renders the whole pa- roxysm milder; facts of which patients are so conscious that our soldiers in the Peninsular hos- pitals regularly applied for an ague-draught (sixty drops of laudanum and a drachm of ether) when they saw their nails turning blue, which is gene- rally the first sign of the commencement of a pa- roxysm. Lind attributed the following good effects to opium given in the hot stage:—1st. It shortened and abated the fit; and this with more FEVER, (INTERMITTENT) 211 certainty than an ounce of bark. 2d. It generally j gave a sensible relief to the head, took off the burning heat of the fever, and occasioned a pro- fuse sweat, free from the burning sensation which affects patients sweating in the hot stage. 3d. It often procured a soft and refreshing sleep to a pa- tient tortured in the agonies of the fever, from which he awoke bathed in sweat, and in a great measure free from all complaints. The same ex- perienced physician was of opinion that the em- ployment of opium during the paroxysms tended, by lessening their force and duration, to render the patient less prone to liver-disease and conse- quent dropsy. Various other stimulating matters have been given during the cold stage, with the view of abridging it, and of thus cutting short the whole paroxysm. Oil of turpentine, in doses of half an ounce, has been thus administered, and frequently with advantage. The old means of this kind mentioned by Celsus were the eating of garlic and swallowing pepper suspended in warm water. (Lib. iii. cap. 12.) An active principle of the lat- ter article, piperin, has been recently adopted by Dr. Meli, of Novara, as a cheap and, as he assures us, a very efficacious substitute for sulphate of qui- nine. He advises that it should be given in doses nearly the same as those of the sulphate, repeated at intervals of three or four hours during the inter- mission. Mechanical means have been recommended for the attainment of the same object, viz. abridging the cold stage, and diminishing the severity of the whole paroxysm. These are the application of tourniquets or ligatures to the limbs. It is obvi- ous that the effect of a moderately tight tourniquet and of a ligature will be the same, that of detain- ing the blood in the limbs compressed by them; and certainly the former, which was originally re- commended by Mr. Kellie, in Duncan's Medical Commentaries for 1794 and 1797, is the more convenient mode of accomplishing the object. Mr. Kellie informs us that if a tourniquet were applied in the cold fit on one thigh and one arm of oppo- site sides for two minutes, a mild hot stage was induced, and the patient felt himself quite relieved. The instruments were allowed to remain for about fifteen minutes, and then on their removal the cold symptoms did not return. The same gentle- man is of opinion that if the tourniquets be applied previously to the accession of the paroxysm, the cold stage will be entirely prevented, and that whether the cold stage be either shortened or alto- gether prevented, the following hot stage will be rendered both milder and of shorter duration. This practice is not much employed ; but a recent writer, M. Bailly, strongly urges its being adopted in malignant intermittent where there is much to be dreaded from a recurrence of the paroxysm. (Traite des Fievres Intermittentes, p. 451.) If any explanation can be given of this singular effect from such a proceeding, it must be found in the impediment presented to that afflux of blood to the interior, which forms so important a feature of the cold fit, by its confinement in the extre- mities. Anti-periodic Medicines.—We shall now con- sider that important class of medicines which are given during the intermission for the purpose of preventing the recurrence of the fits, and of thus curing the disease. We have named them anti- periodic medicines, because the property of curing diseases which recur periodically seems the only one which is common to all of them. That many of them are tonics is true; but their power over intermittents does not appear to be in proportion to their tonic quality, nor is it well ascertained that all of them possess such a quality. No prac- titioner employs arsenical solution, one of the most powerful of the class, as a mere tonic, nor does it seem certain that it is one; for to infer that it is so from the fact that it cures ague would be reason- ing in a circle, and we are not aware of any other whence it could be drawn. Mr. Jenkinson, who has extended its use to painful affections of the bones, recommends its employment only in those cases in which there are regular intermissions; and hence it would appear that in these diseases too it is as an anti-periodic that it is selected. Upon the whole, it seems proper to designate these medicines by the general term here employed, till a fuller investigation of their nature, and of that of the diseases for which they prove a remedyj gives us more precise ideas on the subject. Of these remedies, the first in importance is certainly the Peruvian bark. A few years ago, a disquisition on the comparative powers of the dif- ferent species of this drug, yellow, red, and pale, would have been requisite; but as one substance, sulphate of quinine, unquestionably the most val- uable gift which modern chemistry has bestowed on our art, now represents them all in practice, such a disquisition would be superfluous. Those only who were in the habit of treating many cases of ague prior to its introduction, and had often witnessed the disgust, nausea, and vomiting caused by loading a patient's stomach with many ounces of powdered wood, can form an adequate opinion of the benefit conferred on our practice by the introduction of the sulphate; and this opinion should be further enhanced by the con- sideration that the ligneous matter of the bark is certainly a direct obstacle to the operation of the essential part of the mass, for the sulphate decid- edly exceeds the gross bark in febrifuge power, even though the latter be equally retained by the stomach. [It is proper, however, to remark, that in certain, but rare, cases the sulphate of quinia fails, and the powdered cinchona proves successful; a fact which would seem to show, either that cinchona may contain other active anti-periodic principles be- sides quinia, or that the ligneous matter, however objectionable it may occasionally prove, may still exert some influence by aiding in inducing the new nervous impression which arrests the inter- mittent. Ordinary doses of sulphate of quinia may, likewise, be associated with advantage with the cold infusion of bark.] Of the sulphate of quinine, which we shall consider as the representative of bark and all its preparations, two grains repeated every three hours, or four grains every six hours, are generally a sufficient dose in a case of either of the more lengthened forms of intermittent; but in one of quotidian it is preferable to give three or four grains every third hour. In a complicated and malignant disease, when a patient's life probabN 212 FEVER, (INTERMITTENT) depends upon the prevention of a paroxysm, it is frequently given in much larger doses, those of a scruple, for instance, repeated at short intervals ; and should those previously mentioned not sub- due the mild form of the disease, they should be increased; but doses of from two to four grains will generally accomplish all that is to be expected from the drug in the uncomplicated intermittent of temperate climates. The medicine may be given either in pills or in a draught in any agree- able cordial water, to which are added a few drops of diluted sulphuric acid, which very much aids the solution of the salt. The employment of the remedy should not cease with the suspension of the paroxysms, but should be continued some days as a security against relapse. It will be known to the reader that the propriety of promptly curing intermittents by means of bark was the subject of doubt and controversy from the first introduction of this drug, and that the two most distinguished writers on the subject, Syden- ham and Ramazzini, have taken different views of it, the latter attributing all the pernicious results of the disease to the remedy, the former vindicat- ing his favourite from similar charges brought against it by his British contemporaries, and as- cribing the evils to their more general cause, the long continuance of the intermittent. That the remedy is unjustly charged with the general ab- dominal obstructions and enlarged spleens which are so liberally attributed to it, is manifest from the circumstance that individuals so situated that they can procure neither bark nor any remedial assistance for their agues, and in whom conse- quently the disease follows its course unresisted, as happens to the peasants of the country border- ing on the Pontine marshes, have the spleen occa- sionally occupying almost the whole abdomen ; whilst those in whom the disease is promptly and judiciously treated, escape such complications. But it must be remarked that the employment of bark requires discrimination and judgment, and that much injury may be done by the routine practice of " pouring it in," as it is termed. The following circumstances should deter us from ad- ministering anti-periodic remedies, and particularly sulphate of quinine—the intermissions being im- perfect, and a recent local inflammation. In the former case, should we employ this class of medi- cines, we run great risk of converting the disease into a dangerous remittent or continued form; we ought therefore, by means of calomel purges, sa- line medicines, and occasionally topical bleeding, to endeavour to reduce the patient into an apyrec- tic state during the intermission, previously to commencing their employment. Should a recent topical inflammation of some degree of intensity exist, we should at once proceed to subdue it by bleeding general and local, mercurials, &c; and if the ague remain after its cure, then may the sulphate be administered; but the antiphlogistic means, with mercurials occasionally, remove both Cae local and general affection ; and if the anti- periodic be employed in this case, it is rather with a precautionary view than because it is rendered indispensable by the existing circumstances of the disease. It must be observed that the precautions here impressed on the reader against employing quinine during the persistence of topical inflam- mation do not apply to those chronic engorgements of the spleen and other abdominal viscera which so frequently exist in persons long subject to ague, and which are uniformly aggravated by every fresh attack of the disease. Were we to delay the cure of the intermittent till the splenic or he- patic engorgement were removed, months or years might be requisite for accomplishing the object; the anti-periodic, therefore, should be administered at once. It may be remarked, too, that occasion- ally circumstances exist which render it desirable that the tendency to periodical recurrence should be combated at the same time that measures are taking to subdue a pyrexial or inflammatory state, permanent but slight in degree; in which case arsenic, in the form of Fowler's solution, should be employed in preference to sulphate of quinine, as being less exciting: but should there be ob- served any increase of the general pyrexial state during its administration, it should at once be withdrawn, and the antiphlogistic remedies alone persevered in. Finally, by examining all the evi- dence on the subject, and observing the effect of remedies on ague, we shall reach the conclusion that the diseases which have been attributed to bark do not arise from its judicious employment, though they are occasionally owing to its abuse, but in such an immense majority of instances are to be ascribed to the severity and long continu- ance of a malady either imperfectly treated, or which our art was too feeble to subdue. [Should the condition of the stomach forbid the administration of the sulphate of quinia by the mouth, it may be administered in enemata, twice or thrice the ordinary dose being given. It if sometimes, also, used endermically, from four to eight grains being sprinkled, or applied in the form of ointment, on a blistered part, once or of- tener in the day. Cases of the successful treat- ment of intermittents by coating blistered surfaces with a strong ointment have been published; and others, in which the ointment has been rubbed successfully on the groins and armpits three or four times a day. Various preparations of quinia, besides the sul- phate, have been prescribed, — for example, the acetate, the citrate, the ferrocyanate, the muriatie, the nitrate, and the phosphate ; but they possess no advantages over it. (New Remedies, 4th edit., art. Quinix Sulphas.)] Arsenical solution is the anti-periodic medicine on which, next to quinine, the most reliance may be placed. An extensive experience leads the writer to give it a general preference over crude bark; but he thinks it inferior to quinine, though under certain circumstances it may supply the place of the latter valuable medicine advantage- ously. It has already been observed that it may be given in a more inflammatory state of the sys- tem than this medicine; and again, should an individual have been cured of ague by the sul- phate of quinine or any preparation of bark, and have a relapse, it will often be found that the same medicine will not restore him to health, it having lost its power over the system by familiar- ity, and some other anti-periodic must be resorted to, especially arsenic. This loss of power by long continuance takes place with respect to all the anti-periodic medicines ; and hence arises an FEVER, (INTERMITTENT) 213 advantage from having several, that one of these medicines may be substituted for another which has lost its influence. The one we are now con- sidering, arsenical solution, the writer has given in many hundreds of cases, and has never seen any permanently ill effect but a little nausea and griping, which a diminution of the dose, or the addition to each of a few drops of laudanum, speedily corrected. The dose in which it is gen- erally given is from five to twelve drops every four or six hours during the intermission. [In the winter of 1843-4, the writer presented to the clinical class of the Philadelphia Hospital several cases of quotidians and double quotidians, which were permanently cured by sulphate of quinia used simultaneously with arsenic, after they had resisted the former. (Med. Examiner, Feb. 10, 1844, p. 28.) The ferro-cyanuret of iron has been much extolled by many practitioners. Dr. Stokes (Lec- tures on the Theory and Practice of Physic, first Amer. edit., p. 349: Philad. 1837,) places quinia first, Fowler's solution second, and ferro- cyanuret of iron third in the scale of value. In the writer's experience, however, it is very far in- ferior to cinchona and the other vegetable anti-pe- riodics.] The sulphate of zinc stands next in the order of power among these medicines. The best mode of administering it is in pills composed of. the salt, powdered ginger, and conserve, each pill contain- ing three grains of the sulphate; and of these, two may be given three times a day during the intermission, the number being increased to three and subsequently to four, which are as many as the stomach can bear. It is advisable to avoid drinking immediately after them, as it is apt to induce vomiting. Various bitters, and combinations of them with aromatics, have been tried, and occasionally have proved successful. Quassia alone, or combined with some agreeable aromatic, is the most effica- cious of them; but all are inferior to the anti-pe- riodics previously mentioned. [The bark of Cor- nus Florida, C. sericea, and C. circinata; of Lirio- dendron tulipifera; of Aristolochia Serpentaria, and of yEsculus Hippocastanum, at one time much employed, have nearly gone out of use.] An extract of the bark of the olive-tree (Olea Euro- pea) has been employed lately in Spain and France, and M. Pallas (Reflexions sur l'lntcrmit- tence chez l'homme dans l'etat de sante et dans I'etat de maladie, Paris, 1830,) gives many cases of cures effected by its means. Salicina, the alka- loid of the willow-bark, has likewise been tried in France, and it is said with a success equal to that experienced from sulphate of quinine. We can- not give any opinion of the two last-mentioned remedies from observations of our own ; but the statements of others lead us to think favourably of their merits. [Piperin, obtained from the long and the black pepper; phloridzin, from the bark of the root of the apple-tree; and cetrarin, from cetraria Island- ica, have also been recommended, but they are rarely employed. (New Remedies, edit, cit.)] Treatment of the sequelx of the disease.—An important remedy for all forms of such affections, and one without which other means prove but too often unavailing, is a change from the contami- nated air in which the disease originated to a more healthy atmosphere; for it were to take a very partial and imperfect view of malaria to re- gard it merely as the cause of fever. It is a poi- son of the whole system generating various dis- eases, particularly of the abdominal viscera, and aggravating those which are existing, occasionally by the instrumentality of open attacks of inter- mittents, but not unfrequently by a slower and more insidious contamination of the frame. We have considered these sequela? under two forms, viz., the more complicated and dangerous one, in which the liver and other organs partici- pate, and the simpler, in which the spleen, an in- dolent and, so far as we know, comparatively un- important organ, is principally if not solely affect- ed ; and we shall observe the same order in our remarks on their treatment. In cases of the former description, topical bleed- ing, which may be occasionally repeated, from the epigastric and right hypochondriac regions by means of leeches, and subsequently blistering the same parts, will probably be found serviceable. One or two full doses of calomel should be given with some smart purgative, and then mercury in the milder form of hydrargyrum cum creta or blue pill, should be administered with or without ecco- protic laxatives according to the state of the bowels. After this course has been continued for some time, and been for some time suspended, the nitro-muriatic bath, or sponging the abdomen with the nitro-muriatic solution, may be resorted to. The waters of Cheltenham and Harrowgate are found beneficial after the inflammatory action has been very thoroughly subdued by topical bleeding and mercury. Should dysentery be coexistent with the liver affection, Dover's powder should be conjoined with the mild mercurials; and leeches may be applied along the course of the colon, whilst anodyne, emollient or gently laxative ene- mata should be administered. If dropsy exist, the mercurials should be combined with squill; but these are cases which too often mock the best efforts of our art. If the case be one in which the spleen only is affected, a general bleeding should be performed if the patient's strength admits it; and under all circumstances local bleeding from the left hypo- chondriac region should be employed and occa- sionally repeated; whilst counter-irritation from the same region by blisters, setons, or moxas, should be subsequently adopted. Purgatives which cause considerable exhalation from the mucous surface of the intestines, are valuable adjuvants to these measures; six or eight grains of compound extract of colocynth, with three or four of antimonial powder nightly, followed in the morning by a proportion of sulphate of mag- nesia, or other saline purgative, will answer the indication exceedingly well. The diet should be light and antiphlogistic. Should these means fail to subdue the disease, iodine will merit a trial. Mercury, so beneficial in most chronic inflamma tions, is rarely, if ever, of service in these cases. [It has lately been maintained, that in cases of splenic hypertrophy which follows long-protracted intermittents, the same plan of management is appropriate as is demanded for the cure of the 214 FEVER, (INTERMITTENT) intermittent. (MM. Bally, Nonat and Piorry, in La Lancette Francaise, cited in Med. Chir. Rev., July, 1840.) The sulphate of quinia, in ordinary doses, has been found highly efficacious, as well as the subcarbonate of iron, in full doses. Of late, strong testimony has been adduced in favour of very large doses of sulphate of quinia—from 12 to SO grains and more in the twenty-four hours— the most obstinate cases having yielded to a con- tinuance of this treatment for a few days. In most cases, the action of the quinia was aided by the previous abstraction of blood, by cupping or leeches, from the left hypochondrium. M. Levy, (Gazette Med. No. xxii.) has seen Iropsical effu- sions that not unfrequently supervene on neglect- ed cases of splenic enlargement, yield readily to the sulphate in large doses. (Bullet. General de Therap., Nov. 30, 1837.) The iodide of iron is a good preparation in such cases.] 2. Complicated or Malignant Intermit- tents.—It is not easy to present a methodical view of diseases so multifarious and variable as these. Their basis is an intermittent, which may be of any of the usual types ; but either from the very commencement, or shortly after the attack of ague, some important organ becomes affected with disease, generally of an inflammatory nature, which complicates the original disorder throughout its whole course, subsiding but not entirely ceasing during the intermission, and becoming dangerously aggravated during the paroxysm, when, and espe- cially towards its close, death occurs should the case prove fatal. These intermittents are distin- guished from those we have already considered by the complications in the latter being merely the re- sult of their long continuance ; whilst in the ma- lignant ague they are a part, and the most impor- tant and dangerous part, of the disease almost from its commencement. From the other division of these diseases, which we have subsequently to notice, they are distinguished by the circumstance, that in masked intermittents the character of ague is entirely immerged in that of some other disease, occasionally an inflammatory one, more frequently affecting the nervous system, occurring periodically, but without any other mark of ague, excepting perhaps a very slight chill, not at all resembling the full shivering of intermittent. Examples of dangerous complications of ague were once frequent in this country, when ague itself was a more common disease here than it now is, as we learn from the writings of Sydenham and Morton; and they are still occasionally met with, though very rarely in comparison with their former frequency, or their present prevalence in countries more marshy, and situated under warmer latitudes than our own. The Italian writers down to the present time are rich in observations illustrative of their prevalence and fatality, for many parts of that peninsula, particularly the vicinities of Rome and Sienna, are prolific of intermittents of the most pestilential character. The brain and its membranes, the viscera of the abdomen and those of the thorax, are the seat of these complications, and in this order we shall con- sider them, premising that it is so usual for the organs of the different cavities to be simultaneously affected that the line of demarcation will not be very precise; and when we speak of ague com- plicated with disease of a set of organs, it will be understood merely that the prominent and danger- ous symptoms are attributable to such disease, not that those viscera only are affected. Affections of the Brain and its Membranes__ The affection of these organs sometimes takes place suddenly, without there having been any thing in the previous symptoms of the intermit- tent to indicate to the patient or his attendants that any peculiar danger was impending. Werlhoff relates that one evening he met a widow-lady in the street, who entreated him to visit her on the following day, as she expected her third paroxysm. He went according to appointment, and found her not only in a severe fit of ague, but in a state of completeimmobility, and with the stertorous breath- ing of apoplexy. It was found impossible to arouse her; the pulse became more and more feeble, and she shortly expired. (Observationes de Febribus. Venet. 1764.) A similar case is related by Bailly, (Traite des Pievres Intermittentes Simples et Per- nicieuses.) Benoit Simonelli entered the hospital of Santo Spirito at Rome, on the 22d of July, 1822, labouring under tertian ; on the twenty-third he had a slight paroxysm and took after it two ounces of bark ; on the fourth, towards noon, he was walking in the ward and amusing himself with the other patients, when he was suddenly seized with a violent shivering, followed by high fever, during which he had convulsive contraction and flexion of the forearm on the arm, and complete coma, and in six hours he expired. These are examples of fatality supervening ra- pidly on the first symptoms of malignancy, but it is not unusual for patients to pass through a succes- sion of paroxysms, attended with convulsions and coma, alternating with intermissions, in which the convulsive movements disappear, and the patient is restored to comparative sensibility and intelli- gence ; yet may he ultimately sink under the dis- ease with all the symptoms of apoplexy, should the recurrence of the fits not be prevented. Indepen- dent of the complication, the paroxysms of malig- nant ague wear in all respects the ordinary cha racter, commencing with fully formed rigor suc- ceeded by intense heat, and this again, by sweat, in proportion to the copiousness of which is gene- rally the completeness of the apyrexia. But we often see that when intermittent assumes the com- plicated and malignant form, the cessation of fever at the close of the paroxysms is less perfect than in mild ague ; so that many cases which, from the mode in which the disease commenced and the periodical recurrence of rigors, are classed with intermittents, might, from the imperfection of the apyrexia, with equal propriety be referred to re- mittents. Indeed, it may be remarked of these two orders of diseases, that though the extreme points of the scale are readily distinguishable by the least practised eye, yet the intermediate degrees are so blended that it would be often difficult to say where intermission ceases and remission begins. It is usual too to find, that when the more intense symptoms of malignancy display themselves, the type vacillates ; a disease, for instance, which had occurred at the tertian period, assumes the quoti- dian form, whilst the paroxysms of one originally , quotidian are apt to be duplicated. FEVER, (INTERMITTENT) 215 The symptoms distinctly referrible to the brain and its membranes are of two orders, those of spasm or convulsion, and those of oppression or ,:o.'iia. Of the former there is not merely the ordi- nary subsultus of fever, but well-marked convul- sive movements, such as the rapid contraction of the flexor and extensor muscles of the forearm already mentioned, convulsive twitching of the fingers; occasionally tonic spasm of the same parts or of the lower extremities, so that the flexors and extensors being balanced, the members acquire a tetanic rigidity ; firm clenching of the lower jaw, and violent rolling or distortion of the eyes. Should both sets of symptoms occur in the same patient, it will generally be found that those of convulsion precede in point of time, though ere the close of the disease they are found coexisting. The signs of diminished sensibility are stupor, from which it is difficult or impossible to rouse the patient; im- mobility ; incapability of swallowing; eyelids wide open ; pupils occasionally dilated, sometimes mor- bidly contracted ; pulse sometimes strong and bounding, at others sinall and feeble, and sterto- rous breathing. M. Lallemand would consider the first set of symptoms, those of convulsion, to arise from in- flammation of the arachnoid membrane communi- cating irritation to a healthy brain, or, at least, to one retaining its functions to a certain extent; in the second he would suppose that inflammation of the cerebral substance itself existed. It is certain that convulsive movements are compatible and are indeed generally found co-existing with coma, more or less considerable ; but the opinion of M. Lallemand is supported by the facts, that in those cases of comatose intermittent in which there are convulsive movements, the patient is still capable of being roused to a degree of attention and to dis- play some share of sensibility ; and that in cases of coma without convulsion, the marks of cerebral inflammation are more considerable than in those in which convulsions existed. The appearances found in the dissection of these cases are—inflammation of the arachnoid coat, in- dicated by intense vascular congestion ; effusion of serum between the arachnoid and the pia mater ; adhesion between these tunics, so that they form but one thick membrane, into the tissue of which blood is effused, occasionally by granulations of the arachnoid, or by its being covered by a false membrane; inflammation of the brain, shown by the cortical substance being of a deep brown or reddish colour, of which the examiner becomes at once conscious if he have an opportunity of making a comparison with the brain of a patient who has died from some other disease, (Bailly, op. cit. p. 182); oozing of points of blood in great abundance from the medullary substance on its being incised, or softening of the organ, and effusion of serum in the ventricles and base of the skull. These changes may be found coexisting with extensive lesions of the liver, stomach, intestines, or spleen, such as are met with in the examination of those dead from ague with abdominal complica- tion, which we are now to consider. Malignant Ague, with Abdominal Complication. —The symptoms found in this complication are great pain of the abdomen increased by pressure; pain of the loins ; vomiting, sometimes uncontrol- lable, of matters generally bilious, frequently bloody ; discharges from the bowels of the same bilious or bloody appearance, or insurmountable obstruction ; great sense of internal heat; tongue dry, and of a yellow, brown, or bright red colour; urine scanty, high-coloured, and often jaundiced ; occasionally yellowness of the conjunctiva and skin; ardent thirst; frequently hiccup; pulse oc- casionally full, more frequently small, sharp, and contracted, and towards the close of the disease, feeble and sunk; the heat of skin often very great in the early part of the disease, but after it has continued some time the temperature is low, with lividity of the extremities, and cases are occasion- ally met with of which great coldness, not merely of the extreme parts, but of the trunk of the body, is a prominent symptom, not only during the rigor but the whole course of the disease : delirium fre- quently takes place during the paroxysm, and if the disease continue, it may be further complicated with coma or convulsions, the marks of lesion of the brain or its membranes. On examination after death, extensive lesions of the viscera of the abdomen are discovered, of which the following are of the most frequent occurrence. The mucous lining of the cesaphagus towards its lower part is occasionally inflamed, has a granu- lated appearance, or has a false membrane adhering to it. That of the stomach is thickened and in- flamed, being of a colour varying from rose to reddish brown, whilst its mucous follicles are in- flamed and so elevated as to resemble a miliary eruption, the follicles having a diameter varying from half a line to a line and a half, and being perfectly smooth, without central aperture. The mucous lining of the intestines presents in general the same deep shade of colour as that of the sto- mach ; the valvula? conniventes are red and swol- len, and there is occasionally, but not often, ulce- ration in the vicinity of the ileo-ca?cai valve. The sanguineous injection is not always confined to the lining of the canal, but occasionally affects the muscular and peritoneal coats. Occasionally, and especially in cases in which the alvine discharges have been sanguineous, we find the mucous coat not merely inflamed, but completely impregnated with what appears to be extravasated blood. The liver is found so gorged with blood, that its paren- chymatous structure is almost entirely lost, the whole organ being little more than a mass of ex- travasation, and so soft that when an attempt is made to raise it, it is torn in fragments by the hands. This softened state occasionally alternates in the same subject with a tuberculated and harder condition. The ductus choledochus is often thick- ened by inflammation, and the gall-bladder is oc- casionally inflamed and lined with fibro-albumi- nous concretion. The bile it contains is gene- rally as thick and black as tar. The spleen, occa- sionally weighing six or eight pounds, sometimes of its ordinary volume, resembles a capsule con- taining blood or a greyish pulp. When the peri- toneal surface of the intestines is inflamed, the omentum is generally dark and vascular. Ague with Tlioracic Complication.—This spe cies of complication is more rare than the abdo minal and cerebral affections ; but in the intermit- tents of temperate climates it often occurs, and in them probably rivals, if it does not exceed in fre- 210 quency, the disorders of the viscera of the other cavities. It may display itself in the form of bronchitis, of inflammation of the pulmonary tissue, or of pleuritis. It is probable that a con- gested state of the mucous lining of the bronchi, closely allied to inflammation, exists in very many cases, perhaps in all, during the cold fit and the short and anxious respiration which attends it; for the stethoscope has made manifest a strong sonorous rale in this stage, which has totally dis- appeared on the breaking out of perspiration. A similar remark may be made respecting the pul- monary tissue — the congested state of the lung which exists in the cold stage of ague is, as Dr. Stokes has intimated, (Edin. Med. and Surg. Journ. vol. xxxi.) closely allied to the first stage of pneumonia; but we should not consider ague to be complicated with either bronchitis or pneu- monia, unless the symptoms of one or the other of these affections were persistent through all the stages of the disease, and perceptible in the inter- misrion ; though it will be readily understood that these, like other inflammatory complications, must receive considerable increments during the vascu- lar disturbance which attends the paroxysm, and that their general intensity will be increased by each successive fit. We need not dwell on the phenomena which will be displayed by this complication, it being sufficient to remark that they are those of ague combined with the symptoms of pulmonary catarrh, pneumonia, or pleuritis. In cases of fatality, the lesions of tissue customary in the latter diseases will be discovered, with probably some marks of disease in the viscera of the abdomen, the affec- tions of which it is so usual to find associated with all the other complications of ague. Treatment.—The indications of cure are, to subdue the local affection, and to prevent the re- currence of the paroxysms, each of which, as has been explained, adds to its intensity. But we must not expect, in endeavouring to accomplish the first object, that the general system will bear those full depletory measures which are required by an idiopathic local inflammation. Rarely can we proceed beyond one general bleeding, and the topical detraction of blood by cupping or leeches, in our antiphlogistic treatment. The rule furnish- ed long ago by Sydenham for our guidance in the management of epidemics in general, admits of very important application to the treatment of malignant intermittent, that we should endeavour to seize the genius or character of the prevailing disorder, and regulate our measures accordingly ; for certain agues—those of some climates, and of different seasons of the same climate — are found to bear depletion better than others. It need scarcely be remarked that our local means should be directed to the head, thorax, or abdomen, ac- cording as the viscera of one or other of these cavities is the seat of topical lesion, and, conse- quently, the source of danger. Blisters to the nape in head-affections, and to the thorax and abdomen when they are the seats of disease, should not be neglected. Calomel should be freely administered, especially where the complication is situated in the head or the abdomen ; and in the latter case, should the irritability of the stomach 'iiduce vomiting, opium should be conjoined with FEVER, (INTERMITTENT) it. Emetics are rarely admissible, for they will tend to aggravate muco-gastritis, which is so fre- quent a complication, that perhaps no malignant form of the disease is free from a degree of it. Whilst these measures are proceeding, or after they have been employed for a short time, anti- periodics, especially the sulphate of quinine, should be administered. If the symptoms permitted delay, it might be advisable in every case to abate the local affection by bleeding, general and topical, and by blisters and mercurials, previously to their exhibition ; but in many cases we are under the necessity of deviating from this more scientific plan, and of endeavouring to prevent paroxysms, from which much danger is apprehended, by their early employment. An experienced French writer, M. Pallas, recommends that, in cases of gastro- intestinal irritation, each dose of quinine, the anti- periodic he recommends, should be conjoined with a grain of the watery extract of opium. If we succeed in stopping the recurrence of the pa- roxysms, the local affection, which owed much of its intensity to the increase that took place at every fit, frequently subsides easily without leaving any dangerous lesion of structure ; but in other cases it must be acknowledged, though the pa- roxysms are suspended, the disease proceeds in its fatal course under a complicated continued form. It will be readily understood, as we employ qui- nine or other anti-periodic medicines for the object of suspending the paroxysms, and not on account of their tonic powers, and as topical antiphlogistic remedies may with propriety accompany such an employment of them, that the diet and general regimen of the patient should, with the exception of those cases in which there is morbid coldness throughout the disease, be perfectly unstimu- lating. Proximate Cause or Nature of Ague.— We now reach the most difficult point, that of deciding upon the precise nature of those changes effected in the system by malaria, of which the symptoms of ague are the signs. Of these changes two views are taken, each by a different set of pathologists, similar to those entertained by them respectively of continued fevers. By the one party, the localists, a paroxysm of ague is deemed the sign of an intermitting local inflammation; whilst by the other it is thought to be a fever,— an abstraction if you will,—which is known by certain signs, but with the intimate nature of which we are not fully acquainted; and of which, though it is acknowledged that topical inflamma- tion may accompany or complicate it, such in- flammation is not thought to be the very essence and the cause of all its phenomena. We shall present the reader with a brief view of the facts which have furnished arms to the advocates of the respective opinions, with little more of com- mentary on our own part than is necessary to their being fully understood ; leaving him to form the conclusion in a matter, which, now that there is no dispute respecting the treatment of the dis- ease, may be considered rather speculative than practical. The opponents 6f the first opinion, that of the locahsts, remark, that though sanguineous conges- tions unquestionably exist during the paroxysm of intermittent, and cease at its close, yet it is not FEVER, (INT ERMITTENT) 217 easy to conceive actual inflammation, with its general thickening and lesion of tissue, as being thus fugacious. Sanguineous distention is an essential part of inflammation ; but if we consider it as constituting the whole of that state, the dis- tinction between congestion and inflammation is at an end, and it would perhaps not be very easy to draw the line between the latter and the occa- sional condition of the erectile tissue. Besides, if we regard the lesions which are discovered in fatal ague, of which so full an account has been given in the preceding pages, it will be impossible to conceive that such extensive disorganizations should have been produced during the last and fatal paroxysm. It will be evident that the in- flammation which operated such changes must have been existing in the parts for a considerable period, and consequently, that intermitting symp- toms ought not to be ascribed to this permanent cause. The localists appeal from the reasonings of their opponents on the necessary fixity or perma- nence of inflammation for a period longer than the duration of a fit of ague, to examples of ex- ternal inflammations, such as ophthalmias and cu- taneous affections, of which many are to be found in authors, and particularly in the work of M. Mongellaz. (Essai sur les Irritations Intermit- tentes.) If these cases are carefully examined, it will be acknowledged that almost all of them are rather examples of the aggravation of inflamma- tion during a paroxysm of ague, than of actual intermitting inflammations. But it must be al- lowed that all do not appear to be instances of the former description ; but that some cases are men- tioned which lead us at least to doubt of the ne- cessary permanence of inflammation during a considerable period. As good an example of this kind as is perhaps to be met with, is given in the lectures of Dr. Elliotson, published in the Medical Gazette, in which the bites of leeches which had been applied to the abdomen on account of a diarrhoea with some tenderness there, became itch- ing and tingling-, and red at a certain hour every evening, the patient, a boy, becoming at the same time excited and feverish. There was reason to think that he had been exposed to the influence of malaria, and he was cured by quinine. Allow- ing a certain degree of force to these cases, we may still be permitted to remark that it is one thing to prove that inflammation may be a fuga- cious and intermitting affection, and another to show that the phenomena of simple ague arise from an inflammation of this kind, existing we know not where, and disappearing and recurring at intervals ; though certain French pathologists, it is true, assure us, but on not very sufficient grounds, that it is seated in the gastro-enteric mu- cous lining; and it may, besides, be observed that these recurrent external inflammations, if there be no other disease existing in the system, do not produce the perfectly formed symptoms of a fit of ague. From the facts stated respecting the in- flammations which attend ague, it appears that the doctrine of the localists requires a more ample and impartial investigation than it has yet re- ceived, and the consideration how far a permanent inflammation may manifest its existence only at intervals and periodically, and by the phenomena Vol. II. — 28 t of a fit of ague, should form an important part of such investigation. The extreme feeling of de- bility, the pain and giddiness of the head, the aching of the loins, a certain degree of obscura- tion of the intellectual faculties, and the intense coldness of the surface, favour the opinion that the nervous system is the part primarily instru- mental in producing the general symptoms; but how far it is impressed by some local lesion lurk- ing in the frame, remains still to be proved. Intermittence is, so far as we yet know, an ul- timate or unexplained pathological fact. Specu- lative attempts at its explanation have been offered to the public, and we shall present the reader with that of M. Bailly, because it is founded in some degree on induction from facts, and possesses much more ingenuity than any other, though we acknowledge that it leaves unexplained pheno- mena, which, if it were successful, it ought to embrace, and reposes in part on an assumption which requires proof. M. Bailly first observes that in situations and seasons in which intermit- tents affect the human species epidemically, epi- zooties reign among the lower animals, of which he cites numerous examples; but, however their symptoms may vary in other respects, in one point they all agree, that of being strictly continued — intermittence being never observed in the diseases of brutes. M. Bailly then remarks that in the mode in which the actions of life are performed, we differ in one sole circumstance from domestic animals ; and in this he conceives that the expla- nation of the occurrence of intermittents in the human subject is to be found. Animals preserve, during the whole of their existence, sleeping or waking, in all the acts of life, the same horizontal position, and consequently the heart, abdominal viscera, and brain retain the same situation rela- tively to each other; but man, on the contrary, changes from the vertical to the horizontal posi- tion, and consequently in him each nycthemeron (period of one night and day) consists of a suc- cession of excitations or sanguineous congestions, which are felt according as he is in the erect or horizontal position, and according as these organs change their situation relatively to the heart, in the abdominal viscera or the brain. These vary- ing congestions of course constitute the physiolo- gical or healthful condition of the generality of persons; but (argues our author) every patholo gical or morbid state is but the exaggeration of a physiological or natural one. The sanguineous congestion of the digestive organs displays itself in a degree which may be considered morbid in females or other delicate persons, who are either sick on first assuming the erect posture in a morn- ing, or feel a total inaptitude for any occupation till they have taken food ; and is well illustrated by that febricula, first described by Roederer and Wagler, which may be said to constitute the habitual state of many literary and other sedentary persons. This slight disorder manifests itself simply by burning heat of the skin, with little acceleration of the pulse, and during it the patient pursues his accustomed avocations. At night he is either hot and sleepless, or is in a profound but painful and agitated sleep, and in either esse *eels unrefreshed in the morning; but if he remain in bed, the skin becomes soft, moisture is fe't on the 218 FEVER, (INT ERMITTENT) surface, in fact a sort of crisis takes place, and he feels tolerably well on the following day ; but if he rise before this light sweating stage may have occurred, he remains all that day with a hot and dry skin, his countenance wears an expression of fatigue, his mouth is dry, his limbs are feeble, he feels oppressed, and without having any decided indications of disease, feels equally incapable of thought and action. M. Bailly supposes that this disorder is gastro-enteritic irritation produced by the erect position acting on a delicate and sensi- tive frame ; that the horizontal posture diminishes it, and that if the patient remain so long in this posture as to bring this irritation to the lowest point, the functions of the skin are then restored, and the indisposition is removed temporarily by crisis. MM. Roederer and Wagler have observed that nothing tends so much to the production of intermittent fever in this delicate class of persons as the suppression of these morning perspirations. What has been described above, which is in some degree pathological, is but an excess of what exists in all individuals, and intermittent fever is but a further grade of such excess, or, as Bailly expresses it, is the exaggeration of that assemblage of organic acts which complete a nycthemeron, and which takes place in the following manner :— 1st, morning congestion of the stomach and intes- tines ; 2d, augmentation of the different nervous influences which it produces throughout the sys- tem, and which according to the particular dispo- sition of the individual gives rise to one set of nervous symptoms rather than another, or which excites that part of the nervous system which pene- trates all our organs accompanied by blood-vessels when intermittent, fever takes place; 3d, cessation of this congestion by the horizontal position. It would be unjust to deny the ingenuity of all this, which has received much more illustration from its author than we can transfer to our pages; but it must be remarked that it proceeds on the supposition that the cause of ague exists in the digestive canal, which in the present state of our knowledge of the subject can be considered as little more than a postulale, and whilst it provides an explanation for quotidian intermittent, leaves tertians and quartans unexplained, which are con- siderable lacuna? in the hypothesis. Other specu- lations have been offered to the world, one, for in- stance, by M. Roche, who says that intermitting fevers arise from intermitting causes. These pre- vail in spring and autumn, when there is a great difference between the temperature of day and night, and when in a few hours there are sudden alternations from great heat to comparative cold ; the malaria, too, which is generated is intermitting in its operation, for that which is produced in the middle of the day is so diffused by the rising of the heated air wmen is impregnated with it, that it uoes not act, but when concentrated in the con- densed and chill air near the surface of the earth, cooled by radiation during night, it is in a state fit to produce its effect on the system. Did each paroxysm require for its production the application of cold or malaria, and were it in the instantane- ous effect of such application, there might be some foundation for this hypothesis ; but when it is con- sidered, (even granting what is by no means proved that malaria acts only at night,) that a considerable period generally elapses between the first exposure to the action of the poison and the appearance of the disease, that indeed there must be such an interval if the poison is to act inter- mittingly or by a succession of nightly applica- tions, then it becomes manifest that to assume that the disease must imitate the preceding move- ments of its cause is the most entraordinary non sequitur that ever entered into the mind of man. This becomes still more manifest when we reflect that one single exposure to malaria will produce, days or weeks after, an attack of ague which shall last for weeks or months; as is often exemplified in the case of sailors steeping one night on shore; and happened to a friend of the writer from rest- ing, when travelling, for a few hours in a marshy situation where ague was prevailing. 3. Maskeh Intermittents. — These [often termed by the vulgar dumb agues,] may be suc- cinctly described to be certain diseases familiar in a continued form to medical men and our nosolo- gies, recurring at intervals in paroxysms of greater or less duration, when thus periodical apparently owing their origin to the influence of malaria, and remediable by the means employed to cure inter- mittent fever. It were no easy matter to give a detailed account of all the diseases which have been observed under this intermitting form ; to name those which have been remarked by authors to put on this charac- ter will he sufficient to make the profession aware that, whilst malaria is in operation, they must not expect all the diseases which are the result of it to assume the regular form of ague, but that such curious and anomalous disorders as those of which we are about to furnish them with little more than a list, will fall under their observation, and will require for their cure a treatment different from that of their continued type. These diseases are either inflammatory or nerv- ous. Of the first class tfcere have been mentioned examples of pneumonia, (Pallas, Reflexions sur lTntermittence); pleuritis, tertian, (Sauvages, Ar- loing)-, carditis, (Ibid, et Juncker); otitis, (Mon- gellaz and others); (peritonitis fell under the wri- ter's own observation); ophthalmia, frequent; co- ryza, frequent; tertian swelling of the head, (Mon- gellaz); quotidian and tertian urticaria, (Ibid.); quotidian scarlatina ; livid spots, probably of pur- pura, quotidian, (Storck); tertian erysipelas, (Mon- gellaz); rheumatism, quotidian, tertian, and quar- tan, (Ibid, and others); gout, first quotidian, then double quartan ; epistaxis, quotidian ; intermittent odontalgia and cephalagia, very frequent; quoti- dian inflammation of leech-bites, (Elliotson, Lec- tures published in the Medical Gazette); encepha- litis and meningitis, quotidian, tertian, and quartan, (Leucaire, Parent du Chatelet, Martinet, Des- landes and Audouard) -. gastro-enteritis, (Ha- vara7); diarrhcea, tertian (Pieque, Journal de Me- decine, 1774,) and quotidian, frequent (from the writer's observation); and dysentery has not un- frequently been found complicating the paroxysms of an intermittent; but it may be questioned whether it have itself been met with as an inde- pendent intermitting disease meriting the name of a masked intermittent. Other intermitting in- flammations are mentioned by authors, but on close scrutiny .' will be found that many of these FEVER, (INTERMITTENT) 219 diseases have been permanent, and that the ob- servers have not duly discriminated between a diminution of intensity and total intermittence. Of the nervous affections the following are the most remarkable: asthma, frequent, but many cases which have occurred in the practice of the writer, lead him to suspect that the periodical ex- acerbation of permanent bronchitis has been occa- sionally confounded with intermitting dyspnoea; periodical hysteria and epilepsy, frequent; inter- mitting deafness, type tertian, (Ephemerides Cu- rios. Natura?, 1704); tertian convulsions and blindness, (Ibid. 1694) ; quotidian dumbness,(Ibid. 1684); periodical sneezing, three paroxysms oc- curring every evening, and each paroxysm com- prising three hundred sneezes, (Ibid. 1672) ; ter- tian eructation, at the rate of three hundred eruc- tations per hour, (Ibid. 1672); periodical flow of leucorrhcea, with lypothymia, convulsions, and mutism; intermitting palsy is mentioned by many, and an excellent example of intermitting hemiple- gia of the left side is related in Dr. Elliotson's lec- tures published in the Medical Gazette. It was generally tertian or quartan, but once recurred at the interval of sixteen days. But neuralgia is by far the most common form of masked intermittent, exceeding in frequency of occurrence, so far as the writer has had opportu- nities of observation, all the other forms of this disease collectively; and it may be questioned whether many cases, supposed to have been exam- ples of the periodical recurrence of inflammatory disease, were any thing but a painful affection of the nerves of the part. The anterior tibial, occi- pital, and sciatic nerves have been observed to be the seats of quotidian, tertian, double tertian, or quartan neuralgia, (Stoll, Carron, Audouard). Many cases, commonly entitled spasmodic asthma, have been supposed by some to depend on the same disease situated in the pneumo-gastric nerves, and instances of intense periodical pain in the re- gion of the heart, extending thence to the middle of the left biceps, with small and fluttering pulse, deadly paleness, and inability of making the slight- est movement, which the writer strongly suspected to be the same affection seated in the cardiac nerves, and which were remedied by quinine and anodynes, have fallen under his observation. But the branches of the fifth pair of nerves are cer- tainly more frequently than any other the parts affected by periodical neuralgia, and we shall de- scribe the disease, when so situated, as the repre- sentative of all its forms. It prevails much in spring, particularly during the prevalence of strong easterly winds, affects most the quotidian or double tertian type, and the invasion of the paroxysm often takes place at ten or eleven in the morning, but occasionally at night, and sometimes as early as three in the morning. Its commencement is marked by a very slight chill, amounting perhaps to little more than some coldness of the hands and feet. Slight pain then begins to be felt either above the orbit only, or both in the forehead, over the cheek, and along the gums of the affected side. This speedily becomes agonizing, and is often at- tended with injection of the conjunctiva of the same side, lachrymation, abundant discharge from the corresponding nostril, and flushing of the cheek. This goes on for a period varying from four to six hours or longer, then subsides with slight moisture of the skin, and finally disappears totally, with the exception of a little soreness of the part which had been the seat of pain. During the paroxysm there is heat of surface, and the pulse becomes rapid and is increased in force. Throughout the disease the urine is high-coloured, and deposits a brickdust sediment; and the tongue is furred, till the state of the digestive organs is corrected by proper remedies. Treatment. — The principles of treatment so fully explained under the head of simple intermit- tent, apply to masked ague, the anti-periodic re- medies possessing the same power here as in the more usual forms of the disease, provided the in- termission be perfect and the paroxysms recur periodically. In treating the neuralgic forms, it will generally be advisable first to correct the state of the digestive canal by mercurial alteratives and purgatives, and then to endeavour to prevent the recurrence of the paroxysms by the sulphate of quinine or arsenical solution. It may be remark- ed that we shall often find the latter remedy suc- ceed where the former has failed, and inversely. Carbonate of iron, not accounted a remedy of common ague, has succeeded, when given in doses of a drachm every three hours, where both had been tried without effect, and a case fell under the writer's observation which yielded to powdered bark, after it had resisted the other means mention- ed. It is often advisable, especially in the case of females, who are more frequently the subjects of this disease than the other sex, to add some preparation of opium or hyoscyamus to the anti- periodics; and in all cases it is proper to give a full opiate at the commencement of the paroxysm. Covering the parts which are the seat of pain with a plaster of the extract of belladonna fre- quently diminishes its intensity. Any notice of those purely sympathetic inter- mitting paroxysms which are occasionally mei with in affections of the urinary organs and in certain chronic visceral diseases, not in their origin at all associated with ague, would be misplaced in this article. T ._ Joseph Brown. FEVER MILK. (See Lactation.) FEVER, REMITTENT. —This term is em- ployed to designate a fever of which the symp- toms undergo at intervals during its course a marked abatement or diminution, which is called a remission. Such a fever may ut considered as holding a middle rank, as to external character, between intermittent and continued fevers; but with respect to its nature, the localities in which it chiefly prevails, and the cause whence it princi- pally if not solely arises, it bears a closer affinity to the former than the latter. It may be regarded more properly as forming the mean degree in the scale of periodic or marsh fevers, of which inter- mittent and yellow fever constitute the extreme points. A more intense operation of the febrific cause than is required for the production of inter- mittent fever engenders remittent, and the more violent the latter the more remote is its character from that of intermittent; or, in other words, the less perceptible the remissions. That a more powerful action of the morbific cause is demanded for the production of remittent fever, is indicated 220 FEVER, (REMITTENT) by the circumstance that when periodic fevers are prevailing in certain countries, the permanent residents are often observed to have the disease in the form of ague only, and the mortality among them is small; but strangers unhabituated to the climate and its diseases, suffer from remittents, with a proportionably greater loss of life. In more sickly seasons remittents will be the prevailing form among both classes of persons, but strangers are more violently affected, and the mortality among them is greater. Its affinity to intermittent is shown, too, by the tendency which it has to pass into that form, and, inversely, by the pro- clivity of ague to assume the remitting type. (See Intermittent Fever.) Remittent is the endemial fever of warm cli- mates, especially of those of which the soil is marshy ; but it is to be met with in the more temperate regions of the earth, and is not unfre- quently observed in our own country, especially in seasons of unusual heat, and in those parts of it where under ordinary temperatures agues are prevalent. [The bilious fevers, as they are term- ed, belong to it.] In all countries which it invades, this disease is more generally observed in autumn than in other seasons of the year; but it is not unfrequent in summer, and is occasionally seen in spring. The writer has witnessed it in this country in winter, but, from the feeling of indisposition which had long preceded the manifest attack of fever, he had no doubt that the cause was applied the pre- ceding autumn. Symptoms. — The disease sometimes occurs suddenly, but more frequently it is preceded by unpleasant sensations at the stomach, listlessness, headach, and watchfulness of some days' duration. Its actual invasion is indicated by a feeling of coldness of the extremities and back, and some- times by general coldness and actual shivering. This sense of coldness speedily alternates with flushes of heat; the mouth at the same time is clammy or dry; there are considerable thirst, nausea, and occasionally vomiting; pains in the head, back, and limbs, with a hurried respiration; and frequent, small, and sometimes irregular pulse. To these symptoms succeeds a state of excite- ment, accompanied by a high degree of heat per- ceptible to the hand of the attendant as well as to the feelings of the patient; dry skin, violent and throbbing pain in the head, flushed countenance, a rapid, full, and forcible pulse, and sometimes delirium. The tongue is at the same time white and furred; there is generally some tenderness of the epigastrium, with nausea, and occasionally vomiting either of mere watery secretion or of bilious matter. The urine is high-coloured, the bowels are generally torpid, and the thirst is con- siderable. In about twelve or fourteen hours, though some- times not till nearly double this period has elapsed, there is a manifest remission of these symptoms; a moderate perspiration breaks out, the nausea and vomiting (if it has existed) cease, the pulse becomes softer and less frequent, the thirst abates, the heat of the surface is diminished, and the men- tal state becomes rational and tranquil ; but there is by no means a total cessation of fever, and after ». comparative calm of two or three hours' dura- tion, there is a renewal of the more intense symp. toms of excitement, occasionally preceded by chill or even rigor, but occasionally without such a precursor. After this the disease proceeds in its course, with remissions and exacerbations very variable in their degree and period of recurrence till about the seventh day, but in other cases til] the fourteenth, when all the symptoms cease with a general and copious perspiration, and frequently an abundant eruption of herpes labialis. The preceding sketch is drawn from examples of the mildest form of the disease, occurring in a warm climate, and in individuals of a vigorous constitution. It will be readily understood that the varieties arising from the different degrees of intensity in the usual cause, from circumstances which modify the action of this cause, and from peculiarities of individual constitution, must be so numerous, that the attempt to represent them all to the reader would be an insupportable tax on his attention and memory. We shall therefore present a picture taken from cases of the most ag- gravated form of the disease, leaving many inter- mediate degrees and varieties to be discerned clinically by the practitioner by the aid of some general observations on them, and the circum- stances to which they owe their peculiarity. This form, like the preceding, commences with a sense of coldness and sometimes with shivering, but in general the feeling of cold is rather long- continued than great in degree. It is followed by excruciating pain of the head, with a sense of tightness as if the skull, on a level with the upper part of the orbits, was firmly girt with a cord. The countenance becomes flushed, of a purple hue, agitated, and expressive of pain and anguish; the eyes are vascular and watery ; the tongue is white, clammy and moist, or rough, dry, and brown ; and pains are felt in the back and lower extremities, those in the latter resembling the sen- sations which attend the cramps of cholera. Nausea is an invariable symptom, and there is occasionally vomiting of viscid secretion ; the in- tellect is confused, with short bursts at intervals of outrageous delirium, and the pulse is frequent, small, and contracted, and occasionally irregular. The skin is either dry, or, if moist, the moisture is of a nature which indicates rather intensity of suffering than-energy of circulation ; the heat of the surface on the first application of the hand is not found to be great; but on longer or firmer pressure the fingers perceive a tingling sensation, the color mordax of writers; the bowels are either obstinately costive, or there are frequent, scanty, and loose stools; and the urinary secretion is either very much diminished or totally suspended. After this state has endured about twelve hours, a remission takes place, the patient remaining very ill and feverish, yet with less suffering than before ; but this tranquillity is of short duration, for in less than six hours in some cases, in twelve or fourteen in others, a slight chill is felt, and there is a renewal of the symptoms described in the last paragraph, with the additional circum- stances of a sense of pain in the epigastrium, much increased on pressure ; and irregular distribution of heat, the pra?cordia being excessively warm, whilst some other parts of the surface are cold; incessant restlessness and jactitation ; hurried or FEVER, (REMITTENT) 221 laborious breathing, and such insensibility of the skin that blisters sear but do not vesicate. In fatal cases these symptoms endure in varying degrees of intensity, but with very imperfect re- missions, from five to seven days. The approach of death is denoted by hiccup, distressing vomit- ing, hemorrhage from the intestinal canal, sinking of the pulse, muttering delirium, and coldness and lividity of the surface. Recovery may be expected if the pulse becomes more full and expansive, the heat more equalized over the surface, the pain of the head and epigas- trium less distressing, and if the countenance, though still flushed, loses the purple hue which it previously possessed. A favourable inference may be drawn, too, from the remissions becoming more distinct, the conjunctiva? being less vascular, the bowels more obedient to the action of purgatives, the restoration of a more abundant urinary secre- tion, and the appearance of bile in the matters vomited. These changes, which indicate relief from oppression, and restoration of natural secre- tion, with the continuance of open and safe vascu- lar excitement, are generally the result of medical treatment. The mean duration of this form of fever, in cases of recovery, is about fourteen days. The character of remittent fever is modified by the season in which it prevails. In spring, for ex- ample, it is more frequently associated with affec- tion of the organs seated in the thoracic cavity, than with prominent cerebral or abdominal com- plication. In summer, during which season, in the climates which are most frequently visited by it, determinations of blood to the head are frequent from insolation, and even from the high degree of heat independent of exposure to the direct rays of the sun, the brain is the organ which presents the most marked symptoms of affection. The opera- tion of this cause is frequently aided, especially among British troops in warm climates, by the abuse of fermented liquors and ardent spirits. In autumn an affection of the abdominal viscera con- stitutes the most prominent local affection, gene- rally associated, it is true, with marks of disorder in the brain and its membranes; but it is prior to such disorder in time, and exceeds it in degree. This disease, which is so rapid in its march under the ardent heat of tropical climates, when it appears in more temperate regions, for instance in our own country, runs a longer course than any fever, hectic excepted, with which we are acquainted; and its exacerbations and remissions are more distinct than in warmer climates, but exceedingly irregular in the period of their recur- rence. The former are not unfrequently ushered in by rigors nearly as severe as those of ague, or by a very well-marked chill; and occasionally so complete a remission occurs as to deceive the at- tendant by inducing him to suppose the patient convalescent: it has appeared to the writer that this very considerable abatement in the intensity of the disease is most apt to take place at one of the septenary periods from its commencement, especially about the fourteenth or twenty-first day. The whole course of the fever is frequently of forty or fifty days' and occasionally of nine or ten weeks' duration. Its great length is often attri- buted to relapses, but in the majority of such instances which have fallen under the writer's T * observation, he has had reason to think that re- mission had been mistaken for convalescence. This fever is not uncommon in this country and other temperate climates in autumns of unusual warmth ; and occasionally, too, it is observed in the beginning of winter, but the cause, it will be found, had been applied during the preceding season. A striking peculiarity frequently to be observed in the mental state of patients labouring under remittent fever has received little attention from authors, having been noticed only by the late Dr. Jackson, (Sketch of Febrile Diseases, by Robert Jackson, M. D. p. 123, et seq. London, 1817); and in a work published some time ago by the writer of this article. (Medical Essays, by Joseph Brown, M. D. p. 48, et seq. London, 1828.) Instead of the ordinary form of febrile delirium, in which the mind appears occupied with a crowd of uncon- nected ideas, and quite abstracted from surround- ing objects, it in this case retains all its acuteness of perception and vigour of reasoning; but there is one erroneous impression so firmly fixed in it that no argument can shake it, and it is frequently of so gloomy a cast as to impel its victim almost irresistibly to suicide. To accomplish this object, (and in too many cases which fell under the wri- ter's observation it was accomplished,) the patient will often display all the cunning of a monoma- niac. In many cases the impression was that of being causelessly abandoned to the scorn of the world ; and in others, of a disgraceful imputation having been fixed upon the character, of the false- hood of which no proof could be obtained. Dr. Jackson relates a case in which the patient, in the exacerbation of a remittent, believed he was to be hanged for stealing coals; during the remission the illusion ceased; but it recurred with the suc- ceeding paroxysm, and he then declared himself resigned to his fate, and thankful for the respite of the preceding day, that of the remission. It is scarcely necessary to remark that the crime for which he supposed he was to suffer was as imagi- nary as the punishment which awaited it. During this mental derangement, — an appropriate term, for it has the characters of derangement, not those of delirium, — the patient, so far from there being any general obscuration of the intellect, often dis- plays a self-possession and an acuteness of the mind above the ordinary level of his character. This peculiar state is not often observed in cases of the disease which are physically bad ones, nor is it confined to the advanced stage, ^hen the mental as well as the bodily powers might be supposed to be enfeebled ; but it exists from an early period, and is perfectly consistent with a considerable degree of general strength. It is more frequently observed among persons of the upper walks of life and of education, than among those of inferior station and attainments : the officers of the army in Spain, for instance, were more frequently the subjects of it than the soldiers, and it often fell to the writer's lot to see medical officers suffering under it. No decided peculiarity has been detected in tne symptoms during life, or the structural changes discoverable after death, to explain the striking discrepancy from the ordinary form of delirium which occurs in these cases. In all of them the) 222 FEVEK, (REMITTENT) has been evident derangement of the digestive canal, and its subsidiary viscera ; and this de- rangement, in general so apt to produce mental despondency, is acting on a sensorium enfeebled and irritated by fever; but the same circumstances exist in other cases in which there is either no aberration of mind, or in which, if it exists, it assumes the ordinary febrile form. We are there- fore compelled to suppose that some peculiarity of individual constitution co-operates with the dis- ease in engendering this unusual form of delirium; but there is considerable difficulty in discovering in what this individual peculiarity consists. A tendency to actual insanity will not explain it, for delirium has borne this appearance in individuals who have at no other period of their lives mani- fested any indications of that malady, and the mental illusions always cease on the subsidence of the fever. As it is more frequently observed in intellectual and educated persons than in those of a different class, perhaps mere sensitiveness will explain it; but the subject is involved in much obscurity. Another form of mental affection not uncom- mon in this fever, is an indelible impression on the mind of the patient of the necessary fatality of the disease, though there may be nothing in its physical symptoms to excite the apprehension of the attendant. We know not whether this can be considered as a mental illusion or not, for in every case which has fallen under our observation the patient's prediction has been fulfilled, and we feel in doubt whether the mental impression was instrumental in the accomplishment, or whether it did not r-self proceed from some deadly feeling of the patient which language could not express, and of which the cause did not display itself by manifest signs. Dissection has thrown no light on this point. Certain disorders are found to follow remittent fever. Of these, diarrhcea and dysentery are most frequently observed, and it may often be remarked that one or other of these disorders, especially the former, prevails simultaneously with it, and an attack of either of them appears to be equivalent to one of fever, those who suffer from the one es- caping the other. Occasionally, too, an attack of bowel-complaint, accompanied with constitutional disorder, precedes the invasion of remittent, and passes so insensibly into it, that the attendant is at a loss to say at what precise time the fever com- menced. Dropsy is a frequent sequel of this fever, especially of the cases complicated or followed by diarrhoea. In cases in which the head has been much affected by the disease, the mind, during convalescence, betrays a degree of feebleness al- most approaching to idiocy, from which recovery is very slow. Appearances on Dissection.—The changes of structure discovered in fatal cases of this dis- ease resemble so much, or rather are so identical with those observed in complicated and malignant intermittent, of which a full account is given in the preceding article, that a brief narration here, and a reference to that article, will furnish the reader with ample information on the subject. In the head are observed, vascularity of the membranes of the brain, and effusion of serum or gelatinous fluid between them; fluid in the ven- tricles in greater quantity than is ordinarily ob- served, and oozing of blood on cutting the hemi- spheres transversely ; but it must be remarked, that occasionally death, preceded by delirium or coma, takes place, and yet no morbid appearance of the brain or its membranes can be discovered; and we may go further, and state that cases have terminated fatally, and, on examination by acute and experienced observers, no structural change of any organ has been detected; though it must be acknowledged that such cases are so rare as to constitute the exception, not the rule. In the chest, adhesions and serous effusion are occasionally discovered between the pleura? and in the pericardium; the bronchial lining is frequently unusually vascular, and the parenchyma of the lungs is congested or inflamed. These changes are most discernible in vernal remittents. On ex- amining the abdomen there are found inflamma- tion and sometimes ulceration of the lining of the digestive canal, with occasionally an effusion of blood between the mucous and subjacent coat. The liver and spleen are often enlarged, and un- usually soft; and the urinary bladder is occasion- ally contracted in size, and has its mucous lining studded with clots of blood. The question of the nature of periodic fevor having been discussed at some length in the arti- cle on intermittent, to examine how far these pa- thological states are strictly essential to the dis- ease, or are to be regarded as mere concomitants or effects, would inevitably lead to a repetition of the arguments employed in that article, which we are desirous of avoiding. British writers on re- mittent fever have generally confined themselves to the relation of facts, and in their works it has generally been implied, if not positively stated, that this fever, like others, is a condition distinct from inflammation, but very generally associated , with it, and that this association should receive full attention in the treatment. The French writ- ers assume a more decided tone, and a numerous class of them, proceeding from the postulate that every fever commonly considered essential or pri- mary is but a symptom of a local inflammation. regard periodic fevers as mere indications of inter- mitting or remitting phlegmasia?. M. Rayer's doctrine is different from this. According to his views, intermittent fever is a cerebro-spinal neuro- sis, and remittent fever he degrades from the rank of a disease capable of nosological classification to that of "various complications of intermittent fever with other disorders." (Dictionnaire de MedecineA Treatment.—This, as in the case of most fevers, must vary so much according to the vari- ous circumstances of the disease, that it is impos- sible to lay down rules with respect to the employ- ment of any remedy which shall not admit nume- rous exceptions. General bloodletting, in attacks of the more ardent forms of remittent, may be employed freely at the commencement of the disease, and its repe- tition may be speedily required in such cases, if the force of the circulation is not diminished by the first bleeding, and especially if there are indl cations of cerebral affection ; and even in the more sunk and depressed forms, one bleeding at the commencement relieves the system, and, aided by FEVER, (REMITTENT) 223 the warm bath and other remedies, conduces ma- terially to the safety of the patient. Good effects are occasionally obtained in the latter description of cases, by drawing the blood whilst the patient is in the warm bath ; but we should be more spar- ing in quantity than in attacks of a more ardent disease. In the more protracted disease of tem- perate climates, it will rarely be advisable to per- form more than one general bleeding, and even this in delicate subjects may be frequently dis- pensed with. Free local bleeding, by cupping or leeches, from the vicinity of organs affected with inflammation, is always safe at the commencement of remittent, and may be often performed with advantage at a late stage. Purgatives, so administered as to unload the bowels without needlessly irritating them, are va- luable remedies. Pills of calomel, with a propor- tion of extract of colocynth, powdered rhubarb or jalap, followed by a solution of neutral salts, an- swer the purpose exceedingly well. In the more intense and excited variety of the disease, cold effusion may be employed during the exacerbation with great benefit; in milder cases, cold sponging at intervals during the same period will accomplish our object with less shock to the feelings of the patient. Cooling, acidulated drinks, and draughts with liquor ammonia? acetatis, or the ordinary saline draughts, tend to allay thirst, and, on the whole, to diminish the degree of excitement. There is so great a tendency to vomiting in this disease, and if excited it is so difficult to subdue it, that antimonials are not suitable remedies. The local affections which manifest themselves during the course of the disorder require attention. If there be much pain of the head, with or with- out delirium, besides bleeding by leeches from the temples, the scalp should be shaved and kept in- cessantly cool by sponging with cold water, or the constant application of wet cloths. Vomiting, which is a very distressing symptom, is most effectually relieved by the application of leeches and hot fomentations to the epigastrium, followed by a blister and the internal employment of some preparation of opium, for which the ordinary effervescing draught furnishes a convenient vehi- cle. Should diarrhcea exist, leeches, and subse- quently a blister to the umbilical region, unloading the bowels with castor oil, and afterwards the em- ployment of hydrargyrum cum creta with Dover's powder, will be found to be its most suitable re- medies. Independently of its effect in relieving vomiting or diarrhcea, opium is a valuable remedy in the advanced stage of the disease, to Ullay irritation and procure sleep. Mercury is of use as a purga- tive, and as a means of correcting the morbid secretions and condition of the intestinal canal, and the organs associated with it; but the attempt to supersede the febrile action in remittent by bringing on that of mercury we have never seen successful. It is true that on the subsidence of the fever, ptyalism takes place, and is often exceed- ingly injurious to the patient; but there is never reason to think it instrumental in producing con- valescence. We are recommended by some writers to at- tempt to cut short the disease by the administra- tion of bark, arsenic, or other anti-periodic reme- dies as in intermittent; but the remission must be so perfect as to amount to an actual apyrexia, and the disease must, therefore, become identified with intermittent, before such a plan can be attempted with propriety; for we have almost uniformly ob- served that the employment of any anti-periodic in actual remittent not only failed in its object, but has invested the disease with a more continued and dangerous character. The diet at the commencement of the disease should consist of the lightest and most cooling diluents, such as tea, tamarind-water, lemonade, &c.; but in the advanced stage more nutritious matters, sago, arrow-root, panado, chicken-broth, and even a little wine may be allowed. In some of the more sunk and oppressed forms, it may be advisable to give wine or other stimulants cau- tiously at an early period. As soon as the patient's state will admit of his being removed, it is advisable that he should, if possible, quit the district in which the disease has been generated. . JosEpH Br()wn [FEVER, MALIGNANT REMITTENT.— Remittent fever appears in certain localities and seasons with a more malignant aspect,—most, if not all, of the cases presenting phenomena char- acterized by marked adynamia and ataxia. In many parts of this country, and in the most un- healthy regions of the torrid zone, remittents are often extremely violent and malignant from the outset. The cold stage is generally of brief dura- tion, the succeeding fever very violent, and accom- panied by excruciating headach, pain in the back and limbs, anxiely, dyspnoea, and a distressing feeling of weight and oppression at the epigas- trium ; these symptoms usually continuing for about twenty-four hours, when a remission, often amounting almost to an intermission, occurs, which is not, however, of long duration. A second pa- roxysm supervenes of greater severity than the first, which terminates sooner or later with a clammy perspiration—great oppression at the epi- gastrium being present. The paroxysm recurs, if the disease be left to itself; but not uncommonly death takes place in the third paroxysm. If the disease continues, however, great prostration fre- quently occurs with all the symptoms that are characteristic of highly adynamic fever. The more malignant forms are often congestive, and hence the name given to them in many parts of the United States, where they occasionally prevail most destructively. In these varieties, the accession of symptoms of debility; oppressed re- spiration; small, weak pulse; anxiety; prolonged perspirations ; faintness ; cold, livid extremities, &c, set in early; and the disease is often alarm- ingly fatal, so as to have acquired, in the southern parts of the Union, the name of cold plague — a name, which has also been given to the worst forms of typhus. Malignant remittent is very apt to be compb cated with organic mischief in the alimentarv canal, liver or brain, which is announced by the phenomena denoting subacute gastritis, hepatitis, or encephalitis. Occasionally, too, the bronchial tubes participate in the morbid condition. Fate' 224 cases arise from these local lesions, but death may occur, as in other febrile affections, in consequence of the patient being worn out by irritation. The lesions, met with in those who have died from remittent fever, are various. At times there are evidences of hyperemia, and inflammation of the lining membrane of the stomach and intes- tines, and of the follicles there situate. An accu- rate observer, Dr. Stewardson, of Philadelphia, found on the examination of those who died under his charge at the Pennsylvania Hospital, during the years 1838, 1839, and 1842, lesions of the spleen and liver in every case, and development of the glands of Brunner in the duodenum ; and he considers, that the frequent enlargement and uniform distinctness of these constituted a striking peculiarity of the disease. The stomach, likewise, was very frequently inflamed. In the cases ob- served by him, the essential anatomical character- istic of the disease appeared to be the morbid con- dition of the liver, which was found to be flabby, of a bronze colour, with the two substances that enter into the constitution of the organ so blended together as to be scarcely distinguishable. The spleen was much enlarged and softened. (Amer. Journal of the Medical Sciences, April, 1841, and April, 1842 ; and Stewardson's edit, of Elliotson's Principles and Practice of Medicine, p. 338 : Philad. 1844.) In the remittent fevers of India, according to Mr. Twining, (Clinical Illustrations of the more important Diseases of Bengal, &c. Calcutta, 1832,) the brain and stomach seem, at times, to be almost exclusively affected; in other cases, the spleen, intestines and lungs; and in others the liver. In the fatal African remlUent fever of 1841-2, described by Drs. M'William and Pritchett, (re- viewed in Amer. Journ. of the Medical Sciences, for April, 1844,) the morbid appearances were not uniform. The colour of the liver is stated to have been grey or pale—certainly ana?mic. As elsewhere remarked, (Practice of Medicine, 2d edit. ii. 451,) the appearances, presented on the examination of those who have died of remittent fever, must differ almost ad infinitum. In dis- eases attended with so much irregularity of the functions of innervation and circulation, and im- plicating the whole system, there is scarcely an organ which may not give evidences of hypere- mia, if not of active inflammation. Treatment.—In the severe remittents of the southern parts of this country, the gastric compli- cation is usually so urgent, that emetics or cathar- tics would be inadmissible, should they seem, from other considerations, to be indicated. Bloodlet- ting, practised early, has been found to check the excessive irritability of the stomach at once.— When employed, however, it must be done early. Afterwards, should the irritability continue, sina- pisms may be applied to the epigastrium; with the internal use of ice, ice-cold soda-water, and the othe. means that are usually found to check vomiting. In the malignant forms of intermit- tents, bloodletting, if proper at all, can only be so at the veiy onset; but where doubts exist as to the propriety of practising it, there may be none as regards the application of leeches to the sp.gastrium, or to the temples if the head be INT MALIGNANT] much affected. Both in this country and in India, calomel is generally administered freely, to induce a new action in the system, and thus to break in upon the morbid chain already existing. Twenty grains are often given every three or four hours, and repeated until either the gums exhibit its influence, or the evacuations become manifestly bilious; and, along with this, the ordinary refri- gerants recommended in fever are prescribed. In all cases, it is important to take advantage of the earliest remissions ; and to administer the sulphate of quinia freely. This course has been found highly successful in malignant remittent as it has prevailed in the southern and western parts of this country. In the congestive fever of the western states, after re-action has been established, the sulphate of quinia is considered by one writer as " the remedy," —" the master-article of the materia medica:" (Dr. C. Parry, in Amer. Journ. of the Medical Sciences, 1843.) The dietetic treatment throughout the disease must be that of febrile diseases in general; and when adynamia is considerable, it must be met in the same manner as where it supervenes in other febrile diseases—always bearing in mind the great tendency of malignant intermittent to induce hy- peremia and serious mischief in some internal and important organ. Robley Dunglison.] FEVER, INFANTILE REMITTENT.- By infantile remittent is now commonly under- stood a species of fever to which children, from one year old up to ten or twelve, are very subject, characterized by one or more daily exacerbations and remissions, by pain of the belly and some- times also of the head, and by an unnatural state of the alvine discharges. This, in the language of the older writers, from its supposed but imagi- nary cause, was usually denominated a worm fever. In the last century, indeed, many epidemics, even of adults, were thought to receive their pe- culiar type or character from the presence of worms, and were distinguished from other fevers by the name of febres vcrminosx. The existence of worms in fevers, is now universally considered by all but the vulgar, amongst whom the exploded doctrines of antiquity so often and so obstinately linger, as a mere accidental complication, which may present itself in epidemics of the most differ- ent characters, and which exercises little influence either over their progress or their appropriate me- thods of cure. During the greater part of the eighteenth cen- tury, however, the opposite opinion maintained its ground. Thus Baglivi says, let the diseases of children be"what they may, we ought always to suspect worms; and some later writers, amongst whom Van den Bosch rendered himself conspi- cuous, attributed almost all diseases to the genera- tion of worms in the intestines. Sauvages gives a list of upwards of twenty disorders which he supposed occasionally to have a similar source. Hoffmann endeavours, but very unsatisfactorily, to account for the frequent non-appearance of worms where he had expected to meet with them, in the following passage: » Plerumque tamen vermes non excernuntur si febris juncta, quia a?stu febrili dissolvuntur in putridum magna." The FEVER, [REMITT FEVER, (REMITT morbid intestinal secretions were thus evidently mistaken by him for the remains of dead and corrupted worms, and it exemplifies a fact of which unfortunately instances are not wanting even in our own day, namely, that preconceived and theoretical notions may go a great way to counteract and pervert even the testimony of our senses. The importance of worms continued long to be overrated even after Pringle and Sarcone had re- marked that their presence in fevers scarcely re- quired any peculiar modification in the treatment of these disorders ; and after Bianchini in Italy, and De Haen in Germany had pointed out how exaggerated was the influence attributed to them by some other writers. Yet even De Haen him- self did not rise altogether above the prejudices of his age on this matter, as he admitted the oc- casional existence of verminose epidemics, pleu- risies, &c. To British writers much of the credit of ex- posing and refuting this antiquated opinion is due. St. Clair, of Edinburgh, about one hundred years ago, proved that worms were not always disco- vered in the so-called worm fever, and pointed out the uncertain nature of most of the symptoms sup- posed to indicate their existence. Dr. Hunter de- clared that he had searched for them in vain in those who were said to have died of such disorders; and Musgrave proved that those affections were attributable less to the presence of these parasitic animals than to suburrae in the prima? via?. Dr. Clark of Newcastle, in his work on fever, remarks on the impropriety of the term worm fever, and dwells upon the fact which he had ascertained by experience, that anthelmintics will rarely if ever cure it. In the year 1782, Dr. Butter's work on the Infantile Remittent Fever appeared, and it has continued ever since to be the chief authority on this subject. In this treatise he has approximated still more nearly to the truth than any of his pre- decessors, attrihuting the symptoms of the above named fever almost exclusively to a weak state of the digestive organs, to morbid accumulations in the prima? via?, and to that peculiar irritability of habit and proneness to fever which distinguish the period of infancy. There is not, he asserts, the least ground for regarding worms in the treatment of the infantile remittent. He thinks, indeed, that they are deserving of little attention in the treat- ment of any of the diseases of children, except so far as is absolutely necessary for the satisfaction of friends; for though their existence may be a proof of disease, they are neither a cause nor a necessary symptom of such disease. He supports the singular opinion that they are nature's resource for consuming the superabundant morbid humours, and for stimulating the intestines by their move- ments, and thus assisting the peristaltic motion to carry off" the remains of the offending load. This startling proposition, as to the positive utility of worms, which is sometimes attributed to Dr. But- ter, and sometimes to Rush, does not appear to have originated with either of them, as we find the following passage in Roederer and Wagler's valu- able treatise " De Morbo Mucoso," of which the first edition appeared in 1762.— « Infantibus ca?te- rum plethoricis pauciores hospites intestinales re "era emolumento sunt, modesta consumptione su- Vol. II. —29 3NT INFANTILE) 225 perfluum nutrimentum corpora noxium subtrac- turi." Dr. Rush, from the frequency with which worms occur both in the young of the human species and of the lower animals without appearing to produce any disease, inclines to the opinion that they must serve some useful and necessary pur- pose in the animal economy, such as consuming the superfluous aliment which all young animals are disposed to take, and even suggests the proba- bility of children sometimes being disordered for the want of them, asserting that it is in the gross- est and most vigorous children that they are most frequently found. Worms are often discharged in small-pox and measles from children who never had any symptoms of them before, and are fre- quently discharged in swarms during fevers of all kinds. In the existence of such a disease as the idiopathic worm fever Rush has no belief, coin- ciding in opinion with the Indians of America, who ascribe the occasional discharge of worms to the fever, and not the fever to the worms. He admits, however, that they may sometimes give rise to anomalous symptoms in the course of a fever, and justify the blending of anthelmintics with the ordinary treatment. The symptoms said to indicate their existence are most deceptive, and none more so than that which is usually so much depended on, the picking of the nose. The actual discharging of worms from the bowels is, perhaps. the only symptom that is truly pathognomonic of their presence. Gardien, on the other hand, ridi- cules the idea of worms answering any beneficial purpose in the intestinal canal, and asserts that they occasionally give rise to a species of hectic fever. In support of this he states that he had himself met with one example of this, and refers to Morton and Trnka for others. He supposes them to be injurious, both by absorbing the chyle, and by the irritation they produce. Sydenham is thought to have alluded cursorily to the infantile remittent, describing it as a kind of hectic, which holds children a long time, during which they languish with little heat, a loss of ap- petite, and a wasting of the whole body ; and from this description Sauvages has established his spe- cies hcctica infantilis, which is not, however, very well characterized, and might apply to the symp- tomatic fever accompanying mesenteric and other scrofulous diseases, as well, or perhaps better, than to the one in question, with which it has, not- withstanding, been considered as synonymous by most subsequent writers. An equal degree of doubt attaches to the febris lenta infantum of Hoffmann, usually given as another synonym of the disease. The probability indeed is, that several very dissimilar affections were crowded together under these titles, at a period when diagnosis was so much more imperfect than at present. The infantile remittent, according to Dr. But- ter, is distinguished by drowsy exacerbations, wake- ful remissions, pain of the head and belly, total loss of appetite, little thirst, and slimy stools. Ho admits three varieties of the disease, viz. the acute, the slow, and the low infantile remittent. The acute infantile remittent may begin sud denly, but is more commonly preceded for several days by symptoms of indisposition: the chiiu looks unwell, and his colour is changed ; he frc- FEVER, (REMITTENT INFANTILE) 226 quently picks his nose and lips, and has an of- fensive breath, short dry cough, anarexia, and flatulence, pain in the head and belly, with occa- sional enlargement of the latter. He starts, grates his teeth, and moans in his sleep; the urine ap- pears milky soon after it is passed, and quickly deposits a whitish sediment. The belly is in ex- tremes, either costive or loose. Fever soon super- venes, and is ushered in by a cold fit. The child is hot and restless at night, and diurnal exacerba- tions soon succeed. Of these there are often three in the twenty-four hours, one in the forenoon, one in the afternoon, and a third in the night, which is the longest and the most intense. When the fever is very severe, the remissions become very short and almost imperceptible. During the exacerbations all the symptoms become aggra- vated ; the child is drowsy and sleeps, but not soundly, for he starts, moans, talks incoherently, and even screams in his sleep ; there is a trouble- some flatulence, more frequent cough, and accele- rated respiration. Nausea and vomiting occasion- ally occur. The pulse varies from 140 to 160. In the remissions, all the symptoms abate; the child is wakeful and attentive to things around him, occasionally playful and disposed to leave his bed. If he chance to steep, he now rests com- posedly, and the pulse is reduced to 120 or 130 in the minute. The skin is usually dry, both in the exacerbations and in the remissions; and if any sweats occur, they are partial, being limited to the head, breast, or palms of the hand. The abdomen and palms are always warmer than the rest of the body. There is complete loss of appe- tite and hardly any thirst, so that the patient in some cases can scarcely be got to take either food or drink, and often rejects them by vomiting as soon as swallowed. The urine is of a transpa- rent orange colour, and the stools are always un- natural, either as to their colour, consistence, or smell; thus they are either paler or darker than in a state of health, more offensive, consisting often almost entirely of slime, and occasionally frothing and fermenting like barm. Worms are in some cases thrown off by vomiting or stool, and some- times crawl spontaneously out of the body either by the mouth or anus. As the fever declines, the exacerbations become milder and shorter, the ap- petite returns, long and refreshing sleep and a general moisture of the skin takes place, the pulse fails, and the urine deposits a copious sediment, leaving the supernatant fluid of a straw colour; this sediment gradually diminishes, and the stools assume a healthy appearance. The pulse, how- ever, occasionally continues quick long after all the other symptoms have disappeared, and till the patient has nearly regained his flesh and strength. The ordinary duration of the complaint is from one to three weeks or longer. The slow variety of infantile remittent comes on with the same symptoms, but more gradually and imperceptibly than the acute, the flesh and strength slowly declining, the appetite being un- equal, the belly often enlarged, and the breath offensive. There is but one well-marked exacer- bation, which, taking place in the evening, lasts till morning, and is succeeded by a profuse sweat. Throughout the day the skin is dry and harsh, »nd hectic flushings art frequent. The pulse sel- dom exceeds 140 in the exacerbations, and is about 100 in the remissions. The patient is weak, indo- lent, listless, and disinclined to move, as any at- tempts at walking makes the limbs ache. Yet he is rarely so ill as to be confined to bed. The day as well as the night is passed mostly in dozing, and in his sleep he often starts and moans, and pi. ks his nose and fingers till they become sore and scabby. The tongue is white and moist; there is no appetite, and little thirst; the urine is of a deep orange colour; that passed in the morning deposits a sediment—that during the day contains only a cloud. The stools are of the same unnatu- ral character as in the acuter form. When the fever is about to decline, the nocturnal exacerba- tions and succeeding sweats abate; the flushings become less frequent, whilst all the other morbid symptoms gradually disappear, and the patient re- covers his flesh, strength, colour and cheerfulness. This variety may last for two or three months or more. The low infantile remittent fever begins sud- denly, and for the first week perfectly resembles the acute, save that the head is more affected, and delirium sometimes occurs. After this the low state succeeds, the child becoming quiet, indifferent to surrounding objects, and indisposed to answer ques- tions. He rarely asks for any thing, but takes his food or drink when it is offered to him ; the trunk and lower extremities generally remain fixed in one posture, but the arms and hands are almost always in motion when he is awake : sometimes he flings them about, and at other times picks not only his nose and lips, but even his tongue, eyes, and other parts of his face till they become sore. At the height of the disease the difficulty of re- plying to questions, arising from debility, termi- nates in a temporary loss of speech and voice, and the jaws are occasionally locked together. He slum- bers much during the exacerbations, and in there- missions performs with his hand the gesticulations above described. When the low stage sets in, the eyes are reddish, dull, and inattentive ; the counte- nance is expressive of distress, and the tongue, teeth, and lips, are covered with a blackish fur.— The patient is particularly uneasy before stools, or the escape of flatulence. The urine and stools, which are of unnatural appearance, are involun- tary, yet he is quite sensible. The pulse, which is about 100 in the remissions, rises to 120 in the exacerbations. When the disease takes a favour- able turn, the exacerbations become shorter, the child is less drowsy, the eyes are clearer and more observant, the countenance is placid, and the tongue cleaner, the pulse is calmer, and the appetite re- turns. The voice is regained, and, though weak at first, soon becomes stronger, and is frequently exercised, as he cries whenever he is disturbed or wants any thing, or if he feels himself unable to reply to questions, or to put out his tongue when desired. The strength, flesh, and colour are gra- dually recovered, and he yawns, sneezes or coughs, which he was previously unable to do. The urine, which is of a straw colour, is still for a consider- able time passed involuntarily. The crying and fretfulness long continue. The stools at length become natural, and there is no complaint made but of weakness. The pulse occasionally con- tinues accelerated till the recovery is complete. FEVER, (REMITT The duration of this fever is from a month to six weeks, or even longer. Perhaps the preceding account might be sim- plified with advantage in a practical point of view, and a nearer approach to the truth made, by con- sidering the infantile remittent in the first place as a disease of indeterminate duration; by this the first and second subdivisions would be got rid of; and in the second place, as liable to be con- siderably modified by the habit and health of the individual, and the epidemic constitution of the season, which would enable us to discard the third variety. According to Dr. Pemberton, who has given a simpler description of this disorder, the fever is merely symptomatic of derangement in the intes- tines. The affection comes on very gradually, and first manifests itself by irregularity in the bowels, which more frequently are costive, though sometimes they are too much relaxed. In the course of the day there are several slight acces- sions of fever, which are marked by drowsiness, the child in the intervals appearing perfectly well, though always peevish. The appetite is variable, and the pulse ranges from 100 to 130. This state of things lasts for eight or ten days, when all at once a more violent paroxysm preceded by rigor and vomiting takes place, the pulse rises in fre- quency, the drowsiness is increased, and the cheeks are flushed but there is not the least pain com- plained of in any part, except, now and then slight pains shooting through the abdomen. Incessant picking of the skin of the nose, lips, and angles of the eyes, is a symptom which is almost inva- riably present. The function of digestion seems to be almost totally at a stand, for if any food be taken it is brought up a considerable time after unaltered. " The intestines also seem to be in a manner paralysed ; they exert no action on the food, for it passes off like a mass of putrid animal and vegetable matter which had been sometime subjected to heat and moisture, without its having the smallest resemblance either in appearance or smell to those fa?ces where the powers of digestion have been exerted.'' The appetite is quite lost, and delirium occasionally occurs for two or three days together, but does not indicate that the case will be peculiarly severe or contracted. There is a symptom which we have met with in this disease, which has been omitted in most of the descriptions of it, viz., a stiffness in the neck, and an intolerance of pressure in the upper part of the spine; with this a general increase of the sensibility of the whole surface of the body seems sometimes to coexist, so that the child can scarcely bear to be touched in any part. The first of these symptoms has not, however, escaped the notice of Heberden. "In the fevers of chil- dren," says this accurate observer, " the face is sometimes drawn to one shoulder. I have often seen this, but never knew it continue long after the fever was cured." He alludes to it in an- other part of his work under the name of " the wry neck of children." Underwood has also noticed it. A similar stiffness about the nape of the neck occasionally occurs in cases of dyspepsia in adults. The infantile remittent fever, according to Dr. Butler, may be cilher sporadic or epidemic, and INT INFANTILE) 227 in the latter case it appeared to him to be occa- sionally contagious. Dr. Sims gives the follow- ing description of an epidemic infantile remittent, which occurred simultaneously with the preva- lence of a low nervous fever amongst adults. " It was called," says he, " by some a worm fever, though I believe worms were seldom the cause; yet, as that lay apparently in the stomach and intestines, the error did not materially affect the practice." The leading symptoms were heat, thirst, quick pulse, vomiting, coma, and sometimes slight convulsions, an universal soreness to the touch, troublesome cough, and extreme peevish- ness. The fever was constantly of the remittent kind, the cheeks often appearing highly-flushed, at other times very pale; it lasted for several days, but seldom beyond a week, and the fatality, though greater than in the fever existing at the same time among adults, was not very considerable. Many of those who were seized by it had been subject for a length of time to those symptoms which are thought to point out the existence of worms in the prima? via?; such as picking the nose, grind- ing the teeth, and starting out of the sleep, swell- ing of the belly, white urine, short dry cough, &c; yet worms scarcely ever appeared. From what we have seen of this affection, as well as from a careful consideration of the best descriptions which have been given of it, we are disposed to consider it merely as a variety of gas- tric fever, modified by the irritable constitution of infancy, and closely allied to, if not identical with, the febris pituitosa of Frank. Feverish affec- tions in all feeble and nervous subjects, as well as in infants, manifest a tendency to nightly exacer- bations. Richter conceived that every fever which presents remissions partakes more or less of the gastric character; and Selle recog'nised no other kind of remittent fevers except the gastric and the hectic. In France this affection is, like most other fe- vers, considered to be and treated as a species of gastro-enteritis. That a depraved state of the se- cretion of the mucous membrane exists is evident, but that this necessarily depends in all cases on inflammation has not been satisfactorily made out; and we believe that medicines which slightly in- crease and modify the secretions of this surface will generally be found to conduct the disease to a favourable termination more speedily than. the sole employment of directly antiphlogistic mea- sures. The irritation which exists about the nostrils and angles of the mouth, and the scabby erup tions which frequently appear in the latter of these situations, together with the state of the tongue, the total loss of appetite, the faint sickly smell of the breath, the morbid condition of the alvine secretions and of the urine, the swelling of the belly, the good effects of purgatives, and the fact that the gradual subsidence of the fever keeps pace with the improvement in thp stools,— all taken conjointly, seem to point in a manne. which cannot be mistaken i the chylopoietic vis- cera as the original seat of the disvase. The premonitory symptoms, especially the ob stinacy and irregularity of the bow< Is, fetid breath and gradual failure of the appetite, together with the causes of the disease, which seem to Oous'^ 228 FEVER, (RE MITT! chiefly in the use of improper food and neglect of the bowels, (circumstances which, like the fe- ver itself, are of much more frequent occurrence amongst the children of the poor than of the rich,) all tend to confirm the above view of the nature of this affection. The prognosis under proper treatment and ex- act compliance with directions on the part of the attendants, is mostly favourable. A return of appetite, an improvement in the character of the evacuations, and the remissions becoming length- ened, are signs of approaching health. If, on the other hand, the exacerbations increase in frequency, and the fever becomes almost incessant, and the abdomen swollen, the case is not without danger. In a fatal case of this kind, recorded by Pember- ton, the intestines on dissection were found enor- mously distended, and the mesenteric glands slightly enlarged. No inflammation, however, was detected either in the bowels, peritoneum, or any of the viscera, nor was there any effusion into the abdominal cavity. This inflation of the intestines and occasional enlargement of the me- senteric glanda is also mentioned by Hoffman. The infantile remittent sometimes passes into hy- drocephalus, especially when it is neglected or mismanaged. The possibility of such a termina- tion should never be forgotten, else the moment for active treatment will be lost irretrievably. Dr. Cheyne believes that such a transition would be much less frequent if it were more the practice to bleed children in those febrile attacks which com- mence with sickness, vomiting, and fullness of the hypochondria. Besides, cathartic medicines would then be found to act more readily, and the crisis would occur on an earlier day. The diagnosis of infantile remittent from hydro- cephalus often presents great difficulty. Sims believed that the distinction in children under five or six years of age was often impracticable until within a day or two of the fatal period, when the dilatation of the pupils, and insensibility of the eyes to light, point out the latter disease too strongly to be mistaken. Pemberton, however, thinks that hydrocephalus may almost always be recognised by the screaming in the sleep, tossing of the hands over the head, and the continual effort to thrust the head backwards; by the intol- erance of light, strabismus, interruption of the intellectual faculties, and by food being taken without discrimination or reluctance. In infantile remittent, on the contiary, there is seldom scream- ing or intolerance of light, there is no strabismus, the intellectual faculties can be roused, the appe- tite is so totally destroyed that the child can scarcely be persuaded to take either food or medi- cine. The discharges from the bowels are very unnatural, often black, and smelling like putrid meat, sometimes curdled, with shreds of coagulable lymph floating in a dark greenish fluid. In very young children the irritation may cause convul- sions, and during the fit it is totally impossible to determine whether the head or the intestines be iheir source. If, however, after the fit is over the faculties be completely restored, this, taken con- jointly with the preceding symptoms of the case, f the uterine veins, in consequence of the sepa- ration of the placenta, must be favourable to the production of inflammation, and inflammation once excited is seldom limited to these orifices, but extends with greater or less rapidity along the continuous membrane of the uterine veins to the spermatic or hypogastric veins, and from thence to the vena cava and its principal branches, which return the blood from the lower extremities.* The effects of inflammation in the uterine veins are the formation of adventitious membranes on »heir inner surface, and the deposition of coagula * A paper by the writer of this article on the structure of the human placenta and its connection with the ute- rus, was recently published in the Philosophical Trans- actions, with.the object of proving that no vessels pass from the uterus to cells in the placenta, as the Hunters supposed,, and consequently that no great blood-vessels are lacerated in labour. of lymph, or of purulent matter within their ca. vities. Coagula of the fibrine of the blood, which often extend a considerable distance into the uterine veins, are formed in the orifices of these vessels after every labour, and are the principal means employed by nature for the permanent suppression of uterine hemorrhage. These may be distinctly perceived for a long period after delivery, and they have a form and colour different from the coagula produced by inflammation. In opening the body of a patient four weeks after confinement, we ob- served distinct traces of these coagula, partially absorbed, in the muscular substance of the uterus at the part where the placenta had adhered. The inflammation may be limited to the veins, but not unfrequently the muscular tissue conti- guous to them participates in the inflammation and becomes of a dark red, or blackish-brown co- lour, and of an unusually soft consistence. The peritoneal covering may also be affected, and the usual consequences of puerperal peritonitis then ensue. The veins which return the blood from the uterus and its appendages may be either wholly or in part inflamed : generally, however, (and this is a circumstance in the history of uterine phlebitis deserving particular attention,) the inflammation attacks the spermatic veins alone, and for the most part the one only on that side of the uterus to which the placenta has been attached ; and it may either confine itself to a small portion of the vessel, or extend throughout its whole course from the uterus to the vena cava. The usual consequences of inflammation of veins are then apparent, viz. injection and condensation of the cellular mem- brane in which they are imbedded, thickening, induration, and contraction of their coats, and the deposition of lymph mixed with pus and coagula of blood within their cavities. The same is the case with regard to the hypo- gastric veins, one only being generally affected. These are, however, more rarely affected than the spermatic veins; and this would seem to depend on the latter veins being invariably employed to return the blood from that part of the uterus to which the placenta had been attached. But inflammation having once begun, it is liable to spread continuously to the veins of the whole uterine system, to those of the ovaria, of the fallo- pian tubes and broad ligaments. The vena cava itself does not always escape, the inflammation spreading to it from the iliac or from the spermatic veins. This occurrence seldom takes place to a great extent through the medium of the spermatic, the inflammation usually terminating abruptly at the opening of the spermatic into it on the right side, or of the renal on the left. If it pursue, as it sometimes does, the direction of the kidneys, the substance of these organs, as well as their veins, may be involved in the disease. When the inflammation affects the hypogastric veins, it may extend from these to the iliac and femoral veins, and thus give rise to all the pheno- mena observed in phlegmasia dolens. (See the article Phlegmasia Dolens.) Uterine phlebitis would appear to result either from the mechanical injury inflicted by protracted labour, from the force required for the extraction FEVER, (P of the placenta in uterine hemorrhage, from re- tained portions of placenta undergoing decompo- sition in the uterus, and from any of the causes which produce the other varieties of uterine in- flammation. Though a most dangerous disease, uterine phle- bitis is not invariably fatal. That it often occurs in puerperal women where it is not suspected to exist during life, is demonstrated by the fact that in the spermatic and hypogastric veins of females advanced in life, calcareous concretions and various kinds of disorganizations have frequently been observed, which must have been the consequence of attacks of acute inflammation at some remote period. Causes of Puerperal Fever.—The causes of inflammation in the uterine organs in puerperal women are often involved in great obscurity. In some cases the inflammation is distinctly referable to the injury inflicted upon the uterus by severe, protracted, and instrumental labour, the forcible introduction of the hand into the uterus to rectify the position of the child, exposure to cold and moisture, and various irregularities of diet soon after delivery. But frequently it arises in the most malignant form where none of these causes have been applied, and where we are compelled to refer it to some peculiar noxious constitution of the atmosphere, or to the communication of contagious miasmata. It is a point of great practical importance to determine how far contagion is to be considered as a cause of the disease. Dr. Hulme maintained that it was not more contagious than pleuritis, nephritis, or any other inflammatory disease. M. Tonelle, who has recorded the history of the most fatal epidemic which has ever occurred in Paris, asserts that the idea of contagion was clearly out of the question there, for in the Maternite the women who were newly delivered had each a separate apartment, and yet were attacked with the disease, while in the sick ward of the hospital no instance of the propagation of puerperal fever ever occurred. The evidence of M. Duges against the doctrine of contagion is not less strong, for he states that in numerous instances pregnant women have been placed in the Infirmary, where they were sur- rounds] by cases of peritonitis without imbibing the perm of the disease, and that still more fre- quently he has seen women newly delivered brought with some other complaint into the in- firmaries, who did not contract the reigning ma- lady, notwithstanding the miasmata which sur- rounded them. In no instance has he observed a midwife charged with the care of two women at the same time communicate peritonitis from a sick to a healthy individual, as is reported to have happen- ed in London; and never has this inflammation been propagated from patient to patient in the wards set apart for the reception of healthy wo- men. (Baudelocque, sur la peritonite puerperale : Bvo. Paris, 1830.) In the earlier descriptions, however, of uterine inflammation, it is referred not only to the cor- rupted atmosphere of hospitals, but also to con- tagion. In the Dublin Lying-in Hospital, the Edinburgh Infirmary, the General Lying-in Hos- Vol. II.—-31 v JERPERAL) 241 pital at Vienna, and in most of those in this metropolis, it has raged as an epidemic at different periods with great violence, and has appeared to be propagated by contagion. Dr. Gordon of Aber- deen states that he had unquestionable proof that the cause of the disease was a specific contagion,. and not owing to any noxious constitution of the atmosphere. The disease seized such women only as were visited or delivered by a physician, or taken care of by a nurse, who had previously at- tended patients affected with the disease. " I had abundant proofs," he observes, " that every person who had been with a patient in the puerperal fever, became charged with an atmosphere of in- fection, which was communicated to every preg- nant woman who happened to come within its sphere." (A Treatise on the Epidemic Puerperal Fever, by A. Gordon, M. D. London, 1795, p. 64.) Mr. Hey observes, " If the puerperal fever of Leeds was infectious, which by many it was thought to be, it was so in a very inferior degree to that at Aberdeen ; for I have known instances of free communication, by the intervention of others, between women in iabour or child-bed and those affected with the disease, without any bad consequence. And, on the contrary, in many cases of puerperal fever, no channel whatever was discoverable whereby the disease could have been conveyed." (A Treatise on the Puerperal Fever, by William Hey, jun. London, 1815, p. 19S.) Dr. Armstrong observed that most of the cases at Sunderland (forty out of forty-three) occurred in the practice of one surgeon and his assistant. " Tt is hardly possible to prove," says Dr. J. Clarke, " that it is not infectious, but it has also arisen, as far as we can judge, as an original disease win re there had been no communication with infected persons." (Dr. J. Clarke on the Epidemic Dis- ease of Lying-in Women, 1787 and 1788.) It is difficult to reconcile this conflicting evi- dence and the facts we have observed : though they have ted us to adopt the opinion that the dis- ease is sometimes communicable by contagion, yet they have not, perhaps, been sufficiently nu- merous and of so decisive a character as to dispel every doubt on the subject of its contagious or non-contagious nature. It is but proper to state that it has occurred in many cases in the most destructive form where the idea of contagion could not possibly be entertained. In the last two weeks of September, 1827, five fatal cases of uterine inflammation came under our observation. All the individuals so attacked had been attended in labour by the same midwife, and no example of a febrile or inflammatory disease of a serious nature occurred during that period among the other patients of the Westminster General Dispensary, who had been attended by the othej midwives belonging to the institution. On the 16th of March, 1831, a medical practi tioner, who resides in a populous parish in the outskirts of London, examined the body of a wo- man who had died a few days after delivery from inflammation of the peritoneal coat of the uterus. On the morning of the 17th of March, he was called to attend a private patient in labour, who was safely delivered on the same day. On tho 19th she was attacked with the worst symptom* 242 of uterine phlebitis, severe rigors, great disturb- ance of the cerebral functions, rapid feeble pulse, with acute pain of the hypogastrium, and peculiar sallow colour of the whole surface of the body. She died on the fourth day after the attack, the 22d of March, and between this period and the 6th of April this practitioner attended two other patients, both of whom were attacked with the same disease in a malignant form, and fell victims to it. On the 30th of March it happened that the same gentleman was summoned to a patient, a robust young woman, seventeen years of age, affected with pleuritis, for which venesection was resorted to with immediate relief. On the 5th of April there was no appearance of inflammation *round the puncture, which had been made in the median basilic vein, but there had been pain in the wound during the two preceding days. The inner surface of the arm from the elbow, nearly to the axilla, was now affected with erysipelatous inflammation. Alarming constitutional symptoms had manifested themselves. The pulse 160, the tongue dry ; delirium had been observed in the night. On the evening of this day the inflamma- tion had spread into the axilla. The arm was exquisitely painful; but in the vicinity of the wound, which had a healthy appearance, the co- lour of the skin was natural, and no hardness or pain was felt in the vein above the puncture. On the 6th patches of erysipelatous inflammation had appeared in various parts of the body ; on the upper and inner surface of the left arm and in the sole of the left foot, all of which were acutely painful on pressure. The inflammation of the right arm had somewhat subsided. The pulse was 160, the tongue brown, dry, and furred. Restlessness, constant dozing, and incoherence. When roused, she was conscious. The counte- nance cold ; heat of the surface irregular. On the 7th, pulse rapid ; countenance anxious; teeth and lips covered with sordes; somnolence and deli- rium. The left arm above the elbow was acutely painful, and very much swollen. The right was but little painful, and the erysipelas had made no further progress. The patches of erysipelas on the forehead and sole of the foot had disappeared, but there was a slight blush of inflammation on the inner side of the calf of the left leg. The symptoms became aggravated, and she died on Saturday, the 9th of April. The author of this article examined the body with Mr. Prout on the 11th, and the following morbid appearances were observed. The wound in the median basilic vein was >.pen, and its cavity was filled with purulent fluid. The coats of this vessel and of the basilic vein were thickened so as to resemble the coats of an artery. The inner surface of these veins was tedder than natural, and at the upper part had lost its usual smoothness, but there was no lymph deposited upon it. The mouths of the veins en- tering the basilic were all closed up with firm coagula of blood or lymph. The cellular membrane klong the inner surface of the arm was unusually vascular, and infiltrated with serum. This infil- tration was to a much greater extent along the situation of the erysipelatous inflammation of the ERPERAL) left arm; but the veins of this arm were perfectly healthy. In the autumn of 1829 a physician was present at the examination of the body of a woman who died soon after delivery from inflammation of the peritoneal and muscular tissues of the uterus. He dissected out the uterine organs, and after inspect- ing them carefully, assisted in sewing up the body. He had scarcely reached home when he was hastily summoned to attend a young lady in her first labour, who was safely delivered. In sixteen hours she was attacked with violent pain in the region of the uterus ; unequivocal symp- toms of uterine phlebitis soon after showed them- selves, and she narrowly escaped with her life. In December, 1830, two patients in the British Lying-in Hospital, who had been attended by the same midwife, were both attacked with the same disease on the same day, and both died from inflammation of the absorbents and deep-seated tissues of the uterus. Another patient was ad- mitted into the hospital two days after the death of the last of these women, and was examined by the same midwife to ascertain if labour had com- menced. The pains were false pains, but she remained from Saturday till the Monday in the expectation that labour would come on. The pains having left her, she returned home, and on the following day was suddenly taken in labour and safely delivered before she could set out for the hospital. She went on favourably for two days, and was then attacked with the worst symp- toms of inflammation of the veins of the uterus, and died in thirty-six hours. The following statement has lately been pub- lished by Mr. Robertson, of Manchester, in Num- ber 214 of the Medical Gazette, and it goes to support the opinion that puerperal fever is a con- tagious disease. From December 3d, 1830, to January 4th, 1831, a midwife attended thiny patients for a public charity ; sixteen of these were attacked with puerperal fever, and they all ultimately died. In the same month three hundred and eighty women were delivered by midwives for the institution, but none of the other patients suffered in the slightest degree. Mr. Robertson states that these sixteen were all cases of inflam- mation of the peritoneal surface of the uterus, and that in no instance did he meet with inflammation of the veins of the uterus. These facts point out the necessity of adopting every precaution to prevent the extension of the disease, by careful and repeated ablution, and changing the clothes after attending patients who are affected with it. They show also, whether they be considered perfectly conclusive or not as to the communicability of the affection from person to person, that we ought not to expose ourselves beyond what is absolutely necessary in examining the bodies of those who have been cut off by the complaint. When post-mortem examinations are required, they should be conducted by those who are not engaged in the practice of midwifery. We certainly owe it as a duty to our patients to act as if the contagion always existed. [According to many observers, the miasm, pre- sumed to arise from an individual labouring under puerperal fever, is more virulent than that of almost FEVER, (P FEVER, (PUERPERAL) 243 any disorder Teputed to be contagious; and exam- ples have occurred of all the patients of one part- ner in a medical firm having been successively at- tacked after delivery, when those of another part- ner had entirely escaped. In an epidemic puerpe- peral fever, which prevailed in Philadelphia in 1842, the disease in one district was confined exclusively to the practice of a single physician extensively engaged in obstetrics; whilst not an instance of the disease had occurred under the care of any other accoucheur practising within the same district. Scarcely a female that had been delivered by this gentleman for weeks previously, had escaped an attack. (Dr. Condie, in Trans- actions of the College of Physicians of Philadel- phia for 1842.) The arguments and the ex- amples of apparent communication of the disease brought forward by Dr. Oliver W. Holmes, of Boston, in a recent paper on the contagiousness of puerperal fever, (iVeiy England Quarterly Jour- nal of Medicine and Surgery, 1842,) taken along with other evidence, (Amer. Journ. of the Med. Sciences. Jan. 1843, p. 224; July 1843, p. 260; Jan. 1844, p. 19; and April 1844, p. 487,) ap- pear, indeed, to compel us irresistibly to the be- lief in its contagious nature.] Whatever conclusion we may arrive at as to the contagious or non-contagious character of the disease usually termed puerperal fever, it cannot affect the view which has now been taken of its proximate cause or essential nature, for the symp- toms, morbid appearances, and influence of reme- dies, all incontrovertibly prove, whatever the na- ture of the remote cause may be, that it acts by exciting inflammation of the uterine organs. With regard to the nature of this inflammation, it is difficult to determine whether it be of a com- mon or specific kind. It certainly arises where individuals are not exposed to the ordinary causes of inflammation, and it often reigns as an epidemic, particularly in hospitals; and in this respect it resembles erysipelas, hospital gangrene, and other specific inflammatory diseases, which are generally supposed to depend on a vitiated state of the atmosphere. Like these diseases, too, it ceases without any assignable cause, perhaps for several years, and then re-appears in the same establish- ments, and is attended with the same destructive consequences. Sporadic cases of puerperal fever are met with in all seasons of the year and in all the different ranks of life, and the disease is sometimes not less destructive when occurring in this form than in hospital during the prevalence of an epidemic. Pouteau supposed the inflammation of the uterus to be of an erysipelatous nature, and the same opinion was maintained by Dr. Lowder and Drs. Home and Young of Edinburgh, who saw the disease in the lying-in wards of the Royal Infir- mary. Dr. Gordon observed erysipelas to prevail extensively at Aberdeen in 1795, but he has not inferred from this circumstance that the peritoneal inflammation which he has so accurately describ- ed was of an erysipelatous kind, or different from common abdominal inflammation. Dr. Abcrcrombie has lately described several cases of peritonitis which he considered to be allied to erysipelas. The principal pathological character of this affection noticed by him is, that it terminates chiefly by effusion of fluid, without much and often without any of that inflammatory and adhesive character of the disease in its more common form. Pinel, Bayle, Gasc, and Laennec, to whom we are so much indebted for the know- ledge we possess of the anatomical characters of inflammation of the peritoneum, have traced no resemblance between the phenomena of puerperal peritonitis and erysipelatous inflammation, and it is still extremely doubtful if serous membranes are liable to attacks of erysipelas. Dr. Hodgkin has stated to us that the appearances after death in puerperal peritonitis do not differ from those observed in ordinary peritonitis in the male sex. Dr. Whiting maintains, in his lectures, that the uterine inflammation of puerperal women is essen- tially different from common inflammation, and that it is of an erysipelatous nature. To establish this doctrine, it is requisite that some decided dif- ference should be perceptible in the products of the inflammation subsequent to delivery, in the changes of structure, in the progress of the symp- toms, and the effects of the remedies employed. Of the numerous dissections which we have made of the bodies of those who have died from puer- peral fever, we have not discovered in the morbid appearances any thing to justify this distinction. Instead of running a definite course in spite of the application of remedies, as erysipelas does when it appears on the external surface of the body% the inflammation of the peritoneum in puerperal women is in most cases completely cut short at the commencement, if the appropriate treatment be vigorously adopted. Erysipelas in other parts of the body cannot be cut short in this manner. The following coincidence may seem, however, to prove that there is some connection between erysipelas and puerperal fever. In the autumn of 1829, a short time before the epidemic broke out in the British Lying-in-Hospital, which led to its being closed for several months, two children died of erysipelas. Another fatal case occurred in the course of the epidemic, and on examining the ab- domen we found the peritoneum extensively in- flamed, with a copious effusion of sero-purulent fluid. A few days before the re-appearance of the disease in the hospital, in December, 1830, an infant died of erysipelas of the internal organs of generation and abdomen, and the same diseased state of the abdomen was observed. Another in- fant was attacked with gangrenous erysipelas of the extremity of the right fore-finger on the 28th of December, whose mother had been cut off on the 24th by uterine phlebitis. Mr. Blagden has related a similar case which occurred in his practice. A midwife of the hos- pital had a severe attack of erysipelas of the face a few days after attending in labour a fatal case of inflammation of the absorbents and uterine ap- pendages. During the prevalence of the disease in the win ter of 1831 and 1832, two children died from in- flammation and suppuration of the umbilical vein, and in both there were patches of erysipelatous inflammation on different parts of the body. In none of the hospital attendants has erysipelas shown itself at any of the above periods, and cases of infantile erysipelas have repeatedly occurred at peri ods when there were no examples of puerperal fevp- 244 Treatment. — Like inflammation of other or- gans of the body, that of the uterus varies greatly in severity in different cases. At some particular periods we have remarked the existence of a dis- position to the disease in certain puerperal women, evinced by tenderness of the uterus on pressure, and by acceleration of the pulse, where inflamma- tion has not been actually developed, or where it has taken place in so slight a degree as to yield readily to the exhibition of opiates, and the appli- cation of hot fomentations and cataplasms to the hypogastrium. Some physicians, and more par- ticularly the late Professor Chaussier, have been so convinced of the advantages and necessity of employing these remedies, with the view of pre- venting attacks of the disease, that they have caused all their patients recently delivered to take from time to time, and at intervals more or less distant, small doses of Dover's powder, and have applied emollient cataplasms to the region of the uterus. In cases of intestinal irritation, after-pains, and various spasmodic affections of the uterus and ab- dominal viscera, this plan of treatment will prove successful. In slight inflammatory affections of other organs it is not unusual for the symptoms to subside without the employment of active reme- dies ; and from what we have observed in many cases, it does not admit of a doubt that, in the milder varieties of inflammation of the uterus, a spontaneous solution of the disease not unfre- quently takes place. But where inflammation of the peritoneal coat of the uterus is fully developed, and where the affection occurs in a severe sporadic or epidemic form, the soothing plan of treatment will prove wholly insufficient to arrest its course, and unless bloodletting general and local, and other antiphlo- gistic remedies be early and vigorously employed, it will in most cases proceed to a fatal termina- tion. In the treatment of puerperal fever, the great objects we are constantly to have in view are the following: first, to subdue the local in- flammation of the uterine organs; and, secondly, to moderate the constitutional disturbance which it invariably produces. In fulfilling these indica- tions no exclusive plan of treatment should be adopted, but we ought, according to the peculiari- ties of each case and stage of the disease, to em- ploy bloodletting, mercury, opium, cathartics, dia- phoretics, blisters, and whatever other means we can discover to possess an influence in controlling the disease. In no inflammatory affection of the internal or- gans are the good effects of bloodletting, general and local, more strikingly displayed than in the first variety of uterine inflammation — peritonitis; but the results of our experience do not confirm the accuracy of the conclusions of some authors, that in all cases by the early employment of these means we can succeed in curing the disease. It is always an affection atterded with great danger, and it not unfrequently runs 'ts course rapidly to a fatal termination, in spite of the most prompt application of remedies. When the symptoms of puerperal peritonitis manifest themselves as before described and in a violent form, twenty or twenty-four ounces of blood should be immediately abstracted from the ERPERAL) arm by a large orifice, and while the patient has the shoulders and trunk considerably elevated in bed. We should not be deterred from employing the lancet because the pulse is sinall and con- tracted, provided it does not exceed 110 or 115 pulsations in the minute; for in many cases the pulse has become fuller and stronger during the time the blood has been flowing or soon after, and there has been a marked relief from suffering. In all cases, if possible, a decided impression should be made upon the system, and where syncope or faintness follows the venesection, it increases the salutary effect. In no case of inflammation of the peritoneal surface of the uterus have we observed any bad consequence to result from depletion car- ried to this extent; and in many, from its early use, the force of the disease has at once been com- pletely broken. [See Prof. C. D. Meigs, in intro- ductory essay to a reprint of Gordon, Hey, Arm- strong, and R. Lee, on Puerperal Fever, p. 18, Philad. 1842.] When the attack of inflammation is violent, and when the pain is but slightly relieved, the venesection should be followed without loss of time by the application of one, two, or three dozen of leeches to the hypogastrium, proportioning their number to the urgency of the symptoms. When the leeches have fallen off, the bleeding from their bites should be encouraged by warm fomentations or by a thin warm linseed-meal poul- tice applied to the hypogastrium. We have never observed poultices occasion uneasiness or an ag- gravation of the symptoms by their weight. Care should be taken to have them frequently renewed. At the same time ten grains of calomel should be administered in combination with five grains of antimonial powder and gr. iss or gr. ii. of opi- um, or with ten grains of Dover's powder; and this medicine should be repeated every three or four hours, until the symptoms begin to subside. Upwards of fifty grains of calomel have been given in many cases in this manner with decided benefit, and in two only out of one hundred and fifty-six patients has the mouth been severely af- fected. We have never seen the mercury in such large doses produce those symptoms of alarming weakness, and that tympanitic state of the abdo- men with vomiting and great irritability of stomach, which some have represented. After the second dose of the calomel we have often exhibited with advantage a strong purgative enema, or a cathar- tic draught of senna and salts, repeating it also according to its effect. After the operation of the medicine in some cases, the pain of the ute- rus, which had been only relieved, has completely subsided. There are few cases in which it is necessary to have recourse to a second bleeding from the arm; and where the propriety of this is indicated by a renewal of the acute pain, the quantity of blood taken away should not exceed gxii. or ^xiv. However much the patient may complain of the uterine pain, if the pulse be above 120 and feeble, and if the powers of the constitution have been much reduced by the previous treatment, blood should not be drawn a second time from the arm. Should the pain continue undiminished in vio- lence six or eight hours after the first bleeding, or still later, and the pulse be full and not very rapid, FEVER, (PI FEVER, (PU E R P E R A L ) 245 md the strength of the patient but little impaired, a second venesection, to the extent above stated, may be ordered, not only with safety but with decided benefit. It ought, however, to be remem- bered that much greater caution is required in pre- scribing the second than the first bleeding in puer- peral peritonitis; and where we are not fully con- vinced that it is absolutely necessary, it is better to repeat the leeching than to abstract blood again from the arm. In no case of peritonitis which has fallen under our care has it appeared neces- sary or safe to bleed from the arm a third time, and in a very large proportion of cases one bleed- ing only has been had recourse to. After the violence of the attack has been sub- dued, it is proper to continue the use of the calo- mel, but in diminished doses. Five grains of calo- mel, combined with the same quantity of Dover's powder, should be given every six hours, and this should be continued until the mouth becomes af- fected, or until the uterine tenderness be relieved. The great object in the administration of mercury is to remove the congested and inflamed state of the vessels of the peritoneum, and to prevent the termination of the complaint by effusion of fluid, when all remedies are generally unavailing. In the epidemic which prevailed in the Maternite at Paris in 1829, mercury was not employed until the last, stage of the disease; and it is to this neglect, and to the almost exclusive use of local bleeding and emetics in the first stage, when ac- tive antiphlogistic treatment only could have avail- ed, that we are disposed to attribute in a consider- able degree the frightful mortality which ensued. Where the symptoms do not indicate an attack of a formidable nature, we ought not to carry de- pletion so far, or to employ mercury and opium in the doses we have now recommended. In many of the cases which we have treated, one general bleeding has proved sufficient to overcome the disease, and in many the application of leeches alone, with five grains of subrnuriate of mercury and an equal quantity of antimonial powder, or Dover's powder, with cathartics, have subdued the complaint. [Large quantities of mercurials have been given and extolled by some. A patient of Dr. Collins took, in the course of treatment, an ounce of calo- mel ! and twenty grains every four hours has not been an uncommon quantity ; but large doses of calomel have not proved so successful in the hands of Dr. Locock and others. (Locock, in Tweedie's Library of Medicine, 2d Amer. edit., p. 379 : Philad. 1842.)] Other means, besides those now described, have been recommended by different authors in the treatment of puerperal fever, such as oleum tere- binthina?, ipecacuan, digitalis, colchicum, and camphor. Since the oil of turpentine was introduced into practice by Dr. Brenan, the most contradictory statements have been published respecting its effects. In a paper published in the Dublin Hos- pital Reports, Dr. Douglas observes that in the epidemical and contagious puerperal fever, giii. of the ol. terebinth., with an equal quantity of syrup and gvi. of water, should be given three or four hours after the exhibition of the first dose of the calomel; and that after the lapse of an- v* other hour this should be followed by an ounce of castor oil, or some other briskly purgative medi- cine. In some instances the oil of turpentine and castor oil may be combined in one draught. The internal use of turpentine is not to be repeated more than twice in any case whatever. " In sev- eral cases," Dr. Douglas adds, « where the debil- ity is very considerable, the local bleeding may also be omitted ; and in this case a flannel cloth, steeped in oil of turpentine, should be applied to the abdomen, and allowed to remain on for the space of fifteen minutes. This external applica- tion of turpentine, without either its internal use or the aid of bloodletting, I have frequently expe- rienced to be entirely efficacious in curing puer- peral attacks ; and although I have hitherto omit- ted to speak of turpentine for the cure of the other varieties of this disease, yet I would not feel as if I were doing justice to the community if I did not distinctly state that I consider it, when judi- ciously administered, more generally suitable and more effectually remedial than any other medicine yet proposed. I can safely aver I have seen wo- men recover apparently by its influence from an almost hopeless condition, certainly after every hope of recovery under ordinary treatment had been relinquished." We have not ventured to prescribe in many instances the internal use of ol. terebinth., either in the superficial or deep-seated inflammatory af- fections of the uterus ; but whenever this has been done, it has not only produced a renewal of the pain, but has excited the most distressing nausea and sickness. The results of our own observa- tions and those of the most accurate observers in this country coincide very nearly with those which are described as having taken place in the practice of Dr. Joseph Clarke: " In addition to the usual routine of practice," he observes in his letter to Dr. Armstrong, " numerous trials were made of the rectified oil of turpentine, in doses of from six to eight drachms, sometimes in plain water, some- times combined with an equal quantity of castor oil. The first few doses were generally agreeable to the patient, and seemed to alleviate pain. By a few repetitions it became extremely nauseous, and several patients declared ' they would rather die than repeat the dose.' In more than twenty trials of this kind not a single patient recovered." In favour of the use of digitalis, and colchicum in puerperal fever, little evidence that is satisfac- tory has hitherto been adduced. Emetics.—Willis, White, and other physicians employed emetics, and more particularly ipeca- cuan, in the treatment of puerperal 'fever, before the year 1782, when Doulcet recommended the exclusive use of these remedies at the Hotel Dieu. Most exaggerated reports of the success of his method of treatment were speedily propagated throughout Europe, and many were disposed to consider the results at the Hotel Dieu as affording unequivocal proofs of the power of emetics to ar- rest the progress of the disease when occurring in the most malignant forms. Two hundred women were represented as having been saved to society in the course of one epidemic in Paiis, by tne ad- ministration of ipecacuan at the onset of the at- tack. It appears, however, from the statement of Alphonse le Roi, that the recovery of so many 246 FEVER, (PUERPERAL) em acco individuals was attributed, without any just ground, to the peculiar treatment adopted : for the ployment of ipecacuan and Kermes mineral, rding to him, was commenced by Doulcet in the lying-in wards of the Hotel Dieu when the epidemic was ceasing, but these means were found wholly inefficacious in the months of November and December, and at the beginning of the follow- ing year, when the mortality was greater than in 1780, before the remedy of Doulcet was known. M. Tenon affirms that in 1786 the complicated puerperal fever was curable by no means then discovered. From the intense pain of the abdomen, aggra- vated by the slightest pressure of the hand or by compression of the abdominal muscles, and from the early occurrence of nausea and vomiting in the worst cases of the disease, emetics obviously appear to be little calculated for the relief of the symptoms, and few enlightened practitioners have employed them in this country for the last forty years. Some have gone so far indeed as to de- clare that they are sufficient to produce inflamma- tion where it does not already exist, and that their employment is not only useless, but dangerous and absurd. Several distinguished continental physicians, as Hufeland, Osiander, and Desormeaux, have, how- ever, continued to employ emetics in the treatment of puerperal fever, and have supposed that they derived benefit from their use. M. Tonelle states that M. Desormeaux first made trial of them about the end of 1828, and that great advantage resulted from it. During the greater part of the following year they were again employed, but they succeeded in only a few isolated cases, and most frequently they entirely failed; they never, however, appeared to produce any aggravation of the pain or other symptoms. A new trial was made of them after this, and they were again followed by the most happy results. At the commencement of Septem- ber, 1829, in the course of a fatal epidemic, and during a cold and moist season, emetics were again had recourse to; and for the two months during which this treatment was pursued, all the sick were not relieved, but a great number were delivered from their sufferings as by enchantment, and for an instant there seemed to be a renewal of that brilliant success which had followed the adoption of this method by Doulcet and the phy- sicians of the. Hotel Dieu. But at the end of Oc- tober emetics gradually lost their influence; and towards the middle of November no advantage whatever was derived from them. In some of the successful cases related by M. Tonelle it ought to be observed, that forty leeches, and warm cata- plasms, had been applied to the hypogastrium be- fore the emetic was given, and in those where the relief was most decided the ipecacuan either pro- duced a profuse perspiration, or acted freely upon the bowels, causing numerous, copious, and bilious alvine evacutions. It is highly probable, from the histories of the successful cases, that the effects of the treatment were referable rather to the action of the ipecacuan on the skin and intestines than on the stomach, for the relief experienced did not immediately follow the vomiting. M. Tonelle admits tnai where effusion or suppuration had akei place, emetics were of no avail; and he also relates a number of cases in which the application of leeches to the hypogastrium and the employ. ment of other antiphlogistic remedies were followed by speedy and complete relief where emetics had entirely failed to procure this. In the milder forms of uterine inflammation, (and many of the cases related by Tonelle were of this description,) it is highly probable that an emetic, which would produce a sudden determi- nation to the skin and a free action of the intesti- nal canal, would relieve the congested and in- flamed state of the uterus, and thus cut short the disease. We have met with no case, however, in which we have considered it safe to administer emetics in any stage of the complaint, and we cannot conceive it possible for a case to occur in which the treatment should chiefly or exclusively be conducted upon the plan of Doulcet. The application of blisters to the hypogas- trium and inside of the thighs and legs, has often been found advantageous where the pain of the hypogastrium has continued severe after the gen- eral and local bleeding. The external use of the oleum terebinthina? has also in some cases un- questionably been followed by considerable relief of the pain; and its effect is more sudden than that of a blister. Both general and local warm baths have been highly recommended by foreign practitioners. Where the skin was hot, the pain moderate, the strength of the patient not much depressed, the immersion of the whole body in warm water was often followed by a general perspiration and relief of all the symptoms. On the other hand they state, that when the pains were excessive, when there was great anxiety, a profuse general or par- tial perspiration, the strength much reduced, the respiration hurried and anxious, and the face red with intense headach, the patient could not sup- port the warm bath, and derived no benefit what- ever from it. The hip-bath was found more gene- rally useful, and was employed almost indiscrimi- nately by M. Desormeaux in all the different varieties of the disease. Recolin, Dance, and Tonelle highly recommend the injection of warm water into the vagina and cavity of the uterus, by means of an elastic gum canula. These injections were repeated three oi four times in the course of the day, and they not only washed away the putrid matters adhering to the internal surface of the organ, but they ap peared to relieve the irritation and inflammation of the organ itself. In many cases of puerperal fever severe irrita- tion of the stomach supervenes in the progress of the disease, and this symptom seems occasionally to be aggravated by anodynes and saline efferves- cing draughts. A drachm of sub-carbonate of pot- ash should be added to gv. of aqua? menth. virid. and an ounce of this mixture given every two or three hours. The effect of this medicine in al- laying the irritability of the stomach has been very remarkable indeed in some cases related to us. Should diarrhcea take place spontaneously, or result from the use of the mercury, it must be moderated by opium. The starch and laudanum glyster is by far the best mode of administering the anodyne. During the active stage of the complaint, cii)- FEVER, (PUERPERAL) 247 chona, camphor, and stimulants are inapplicable ; but when the inflammatory symptoms have been subdued, and the patient is left in a state of great exhaustion, quinine, ammonia, wine, and other stimulants sometimes produce the happiest effects in rousing the powers of the system. We cannot too strongly urge the necessity of continuing to employ these remedies, and whatever else is judged useful, whilst the slightest hope of recovery can be entertained. Some women have been re- stored to health where the pulse had risen to 160, and had become so feeble as scarcely to be felt at the wrist, where there has been constant delirium for many hours, and the most alarming prostra- tion of strength. Recovery has even taken place in some cases where the abdomen has become tym- panitic, and effusion to a considerable extent has taken place into the abdominal cavity. In no acute disease is it of greater consequence than in this now under consideration, that the patient should be visited by the medical attendant at short intervals, and that the effects of the reme- dies he prescribes should be narrowly watched. With regard to the treatment of inflammation of the uterine appendages and of the deeper-seated lissues of the uterus itself, whether of the absor- bents, veins, or of the muscular structure, the symptoms from the commencement are generally those which contra-indicate the use of general bloodletting. In cases where the re-action at the invasion of the disease has been violent, and vene- section has been employed, the relief obtained has only been temporary, if at all experienced, and in some instances the abstraction of only a few ounces of blood from the arm has produced alarm- ing syncope. Where the local pain is severe, leeches and warm fomentations seem to be the appropriate remedies ; but as far as our own ob- servations go, we are in possession of no remedial means which effectually control those varieties of inflammation of the deeper-seated structures of the uterus which we have attempted to describe. The French physicians are, however, of a con- trary opinion, and are satisfied that we possess a powerful remedy, even in the worst cases, in mer- cury employed so as to excite salivation. In seve- ral cases of uterine phlebitis we have pushed this remedy by inunction to a great extent, and brought the system under the influence of mer- cury in less than twenty-four hours ; yet the pro- gress of the symptoms was not arrested, and the patients died, as others had done where the re- medy had not been administered. In other cases we have employed mercury to a great extent in- ternally, without the slightest benefit; and it may justly be doubted, from the results of M. Desor- meaux's practice, whether or not it possesses the influence M. Tonelle supposes, for of forty-three cases where mercury was used as the chief remedy, only fourteen recovered. In the latter stages of inflammation of the deep-seated structures of the uterus, the great depression of the powers of the system renders the liberal administration of stimu- lants absolutely necessary, and in several cases of phlebitis the life of the patient appeared to be pre- served by them. The importance of the prophylactic treatment is rendered obvious by the preceding observations. A puerperal woman ought to be as careful of her- self for ten days after delivery as an individual who is recovering from an attack of continued fever or inflammation of some important viscus. While the uterus can be felt above the brim of the pelvis, and the lochial discharge continues to flow, the most fatal consequences may result from ex- posure to fatigue or cold, and the slightest impru- dence in diet. The administration of acrid cathar- tics soon after delivery should always be avoided, and no unnecessary pressure of the abdomen should be made. The greatest care should also be taken by the practitioner, in performing the operations of midwifery, to avoid inflicting an in- jury on the soft parts of the mother. The hand ought not to be passed into the cavity of the ute- rus but with the utmost gentleness, when the in- troduction of it is required to alter the position of the foetus, or to withdraw the placenta; and por- tions of placenta should be prevented from re- maining and undergoing decomposition in the uterus. It is impossible too strongly to condemn the practice recently recommended, in cases of flooding after the expulsion of the placenta, of passing the hand into the uterus for the purpose of compressing the orifices of the uterine sinuses where the placenta had adhered. We cannot conclude this subject, which is un questionably the most important in obstetrical medicine, without pointing out the necessity which there exists for a full investigation of the means best calculated to prevent the occurrence of ute- rine inflammation in lying-in hospitals, where its dreadful fatality has been recorded by all writers since the foundation of these institutions. From the registers of the British Lying-in Hospital, the Maternite of Paris, the Dublin Lying-in Hospital, and the tables of M. De Chateauneuf, it is proved that the average rate of mortality greatly exceeds that of establishments where individuals are at- tended at their habitations; and if it should ulti- mately appear that all precautions are unavailing in.diminishing the numbers attacked by the dis- ease, it will become a subject deserving of the most serious consideration on the ground of hu- manity, whether lying-in hospitals should not be considered rather injurious than beneficial to so- ciety. From what has fallen under our observa- tion in the British Lying-in Hospital and other similar institutions in the metropolis, where the utmost attention is paid to ventilation and cleanli- ness, and where the wards are not overcrowded with patients, we cannot hesitate to express our decided conviction that by no means hitherto dis- covered can the frequent and fatal recurrence of the disease be prevented, and that the loss of human life thereby occasioned completely defeats the objects of their benevolent founders and sup- Porters- Robert Lee. YELLOW FEVER; Kendall fever,- Bilious remitting yellow fevei, Bulam fever,- Coup de barre,- Mai de Siam ,- luvre Matelote,- Fievrc Amaril,- Vomito prieto ; Yomito negro; Fiebrc Amurilla; Novo pest is,- Typhus icterodes; Ty- phus cum flavedine cutis, &c. &c. The anomalies which this disease has been ob- served to present,—the absence, under the obser- vation of one medical man, of some of the symp- toms which during another epidemic ' ad bee.v 24S FEVER, (YELLOW) well marked, —the fact of practitioners having observed that certain symptoms, prominent during one period of an epidemic, have at another period been totally absent; — the fact, too, of patients in the very same ward of an hospital being frequently found to labour under symptoms so variously grouped as to lead an inexperienced practitioner to believe that he had before him three or four diseases bearing little affinity to each other ;—all these circumstances have thrown difficulties in the way of this disease having had a place assigned to it in nosological arrangements free from ob- jections. By some, accordingly, the yellow fever has been classed with continued fevers, the symptoms not having appeared to them to correspond with those laid down by nosologists as characterizing remit- tents ; while, according to the statements of others, of whose accuracy of observation there cannot be a doubt, the disease has assumed the most unequi- vocal remittent form : indeed, as will hereafter be shown, there is very respectable evidence in proof of its having, en some rare occasions, assumed even the character of intermittents. This is not the place to attempt defining what constitutes, rigorously, remittent fever: it is plain that in most countries the opinions of medical men are at variance upon the subject. The re- marks of close observers go to prove how fre- quently remittents may be masked so as to mislead us, if not very much on our guard, as to their true character. Those therefore cannot, with justice, be accused of much inaccuracy, who, confining themselves probably to their own field of observation, have looked upon yellow fever as belonging to the class of continued fevers; but it is important to show whether those are right who maintain that the disease bears no affinity whatever to remittents, and that it never assumes any other than the con- tinued form. On this point it cannot be necessary to quote more than a few authorities of respecta- bility. Dr. Rush, from his extensive experience at Philadelphia towards the close of the last cen- tury, may be considered as entitled to the first place; and in his account of the epidemics of 1793 and 1794, he distinctly notices remissions in several pages:—" The remissions were more ?vident in this than in the common bilious fever. They generally occurred in the afternoon." (Ac- count of Epid. of 1793, p. 79.) "It," speaking if delirium, " alternated in some cases with the exacerbations and remissions of the fever." (Op. cit. p. 62.) Speaking of the second class of this iever, he says that it was attended " with obvious emissions." (Ibid. p. 82.) At p. 45 of his ac- :ount of the epidemic of 1794, he says that the disease " appeared most frequently in the form of a remittent. The exacerbations occurred most commonly in the evening." In another passage, often quoted, " Never has the unity of our au- tumnal fever been more clearly demonstrated than in our present epidemic. Its principal grades, viz. the intermittent, the mild remittent, the inflamma- tory bilious fever, and the malignant yellow fever, nave all run into each other in many instances. A tertian has ended in death with black vomiting, and a fever, with the face and eyes suffused with hlood. has ended in a quotidian which has yielded to a few doses of bark." (Letter to Dr. Millar, New York Med. Repos. vol. vi. p. 249.) In an official report from Mr. Campbell, of the army medical department, dated from Montserrat, in 1825, he gives as his reasons for thinking that the remittents, &c. of the West Indies are grades of the same disease, that during a yellow fever epi- demic at Barbadoes in 1821, he observed "the most marked difference in the type and symptoms of cases of patients from the same barrack or hut, where not the slightest doubt could be entertained of the disease being produced in both instances by one and the same morbid cause, yet so modi- fied by physical causes, connected with the patient, as to appear quite different diseases, and certainly requiring different modes of treatment." The frequent occurrence of yellow fever in certain parts of Spain, entitles the statements of the me- dical men of that country to great consideration on the point in question. To begin with the late Dr. Arejula, who was so familiar with yellow fever as it appeared in most of the epidemics which have occurred in Spain within the last half century,— the writer of this article has been repeatedly in- formed by him that the disease frequently assumed the most marked remittent form. In his descrip- tion of the Malaga epidemic of 1803, (see his work on Yellow Fever, p. 25,) he tells us that the bark was found useful during the remissions. At p. 71 he is clear on the subject of remissions; and at p. 139, informs us that the disease " with- out doubt deserves the name of remittent fever:" (" Merece sin duda el nombre de calentura remit- ente.") He even says, when describing a black vomit epidemic, " the termination of our remittent in intermittent, which also occurred in some in- stances at the close of the epidemic, was an indi- cation that the disease was about to be extin- guished." The recorded opinions of Dr. Velasquez of Seville are fully in corroboration of the state- ments of Arejula. The following physicians were contemporaries of the latter gentleman, and had witnessed some of the yellow fever epidemics of Spain : Dr. Balmis,'who called the disease, as it presented itself during the Cadiz epidemic of 1800, "a putrid malignant remittent;" Dr. Flores Moreno, who describes in his work " accessions and remissions ;" Dr. Alfonso de Maria of Cadiz, who is a state pensioner in consideration of his services during some of the epidemics of Spain, says, " when the yellow fever degenerated into in- termittent." In the third volume of Hurtado's Decadas, published at Madrid, may be found a memoir relative to one of the Seville epidemics, with the signatures attached of Drs. Gabriel Rod- riguez, Serafin, Adame, Velasquez, and Chichon, to the effect that " sometimes, though rarely, the fever presented itself following the type of an in- termittent :" (" Alguna vez, aunque rara, se pre- senta la calentura, siguiendo el tipo de intermit- ente.") In the Trozos ineditos of Dr. Saiva, professor of medicine at Barcelona, evidence is to be found of the disease having been observed to assume the remittent form. In conclusion of this part of the subject it may be stated that the re- cords of the Gibraltar yellow fever epidemics fur- nish the following names in support of the fact that remissions not unfrequently take place in this disease, —Drs. M'Mullin and Browne, Messrs. FEVER, (i Sproule, Wild, Martindale, Amiel, Daw, Donnett, Humphries, Lee, and Hugh Fraser. History of the Disease. — Previous to en- tering into details, it may once for all be stated that a disease is here understood in which, along with other symptoms hereafter to be referred to, yellowness of the skin, partial or general, and to- wards the fatal termination, vomiting of a black or dark-brown fluid, are frequent, though by no means constant, occurrences. As it will be ne- cessary to refer frequently to the yellow-fever epi- demics of Spain, and as, notwithstanding all that has been written upon the subject, the identity of yellow fever, as it has appeared in that country, with the black-vomit fever of the West Indies and North America, has been denied, so late as 1828, by a French physician (Dr. Rocheaux), who went to investigate the Barcelona epidemic of 1821, it may be proper here to premise that the perfect identity of the disease has been admitted to have been established beyond all doubt, at Gibraltar in 1828, as will be shown further on. Among writers on yellow fever of different na- tions, the names of respectable men will be found who maintain the doctrine that this disease has only made its appearance in modern times on the continent of America, in the West India islands, and certain parts of Europe. In opposition to this it has been shown by others, that though in for- mer ages, as in modern times, this disease may not have been observed to prevail epidemically in that part of the neighbourhood of the Mediterra- nean in which Hippocrates practised, it is not the less true that this close observer had been familiar with a fever in which the two symptoms considered by most writers as characterizing the disease (yel- lowness of skin, and black vomit) were some- times present. Respecting black vomit, held as being so peculiarly diagnostic, Hippocrates says, in the twelfth section of his prognostics, that if the matter vomited, in the form of fever which he is describing, be of a black colour, it betokens ill. In the first section of his prognostics, vomiting of a black fluid is mentioned as one of the most fatal symptoms; and in the fourth section of the same book this is pointed out by him as indicative of a high degree of malignancy. We are reminded by Humboldt that the period of the first description of a disease furnishes no evidence of its having only then for the first time appeared; and the ensemble of the symptoms of yellow fever being perhaps only to be found fully and accurately detailed by writers of the last cen- tury, will scarce be considered as furnishing con- clusive evidence of the non-existence of similar epidemics at periods more remote. Owing to the state of medicine in former ages, and to the fact of practitioners having been so few that the sick were not unfrequently wholly destitute of aid, the exact nature of many epidemics which reigned from time to time, under the names of pest, pes- tilential disease, black death, yellow death, &c. has not been handed down to us. We have a re- markable proof of this in epidemics which from time to time prevailed in this country formerly, under the name of sweating sickness; for the ac- counts of that disease are quite unsatisfactory as to its nature. To admit that all epidemics of for- mer ages, within certain parallels of latitude, and Vol. II___32 FELLOW) 249 termed pests or plagues, were of the charactei of true plague, while all the epidemic fevers of mo- dern times, which have so frequently afflicted the inhabitants of the same latitudes, have not pos- sessed the characters of plague, but those of yellow fever, would be admitting what is but little con- formable to the usual course of nature. Pere Dutertre, one of the oldest writers on the yellow fever of the West Indies, employs the term peste, when detailing symptoms not corresponding with those of plague, but such as peculiarly belong to yellow fever. To give here even but a partial view of the ar- guments employed by various British writers in support of and against the statement of the yellow fever having been imported into the West India islands for the first time in 1793, would occupy more space than could with any propriety be de- voted to the point. Its importation to the island of Grenada in the year in question rested chiefly on the authority of the late Dr. Chisholm, whrn mnro m-rMini-li> K«l----:___.. _ .* .. f ..... much more commonly its seat. A simple test of true black vomit has been proposed, which is dipping into it white paper, which it does not tinge. FEVER, (YELLOW) 257 live to two cases, ultimately terminating favoura- bly, where the fluid ejected possessed the most unequivocal characters. Recovery may be hoped for, even where he- morrhage the most profuse takes place from one or more of the natural orifices, if the number of patients be not so overwhelming as to prevent the possibility of allotting to those who are in such a state incessant care and good nursing. Reason- able hopes may be entertained, when in the ordi- nary forms of the disease, the pulse is not found to give way remarkably about the end of the third day. Distinct remissions have been remarked as favourable. Surgeon Callow says, " if a distinct remission occurs, it generally proves a favourable indication." If the skin, during the first forty- eight hours, maintain an equable temperature and softness, there is great probability that symptoms of a very severe character will not set in. Se- renity of countenance and a facility in moving the eyes are favourable indications ; but, with respect to the first of these, it is especially to be remarked that traits, often so light as to escape inexperienced observers, are of high moment; and on this ac- count additional advice should be resorted to whenever practicable, even in what may seem a very mild case. The miliary eruption noticed by certain Spanish writers is to be regarded as fa- vourable ; so, in a high degree, are some hours of sleep not broken in upon by vomiting ; and so are, as perhaps need scarcely be mentioned, dejections of a proper colour. The restoration of the moisture and bulk of the tongue from the remarkable dry and withered state often occur- ring in the protracted forms, is one of the most promising signs. Whatever be the colour of the urine, its secretion in due quantity is always a favourable point, though not to be considered as one of the most prominent indications of a favour- able issue. On the whole, the yellow fever is considered the most insidious of all fevers ; for it is known that in persons sitting up in bed amusing them- selves, and apparently in a favourable state, the black vomit has suddenly appeared, quickly fol- lowed by death, to the utter astonishment of the medical attendants. Morbid Appearances.—1. In cases of ex- treme malignity, and terminating rapidly (con- centrated form,—congestive form). The party- coloured appearance remarked as existing during the attack in this form, more strongly marked, the lividity being more prominent, especially in the most dependent parts; and a pale yellow line, mingling with the other colours, can be observed from about the nose to the pubis. The ears, hands, and arms quickly become of a brown- black; the palms being equally dark with the backs of the hands. The penis and scrotum also become particularly dark. This appearance of the body has sometimes given rise to a hasty con- clusion that rapid decomposition had taken place ; but it does not appear, from observations made during a long time in dissecting-rooms, that the odour of putrefaction takes place sooner after death from yellow fever than in other cases. Cellular tissue, unhealthy in appearance, but having no yellow tinge. Muscles, dusky, and softer than natural; so that they may usually be Vol. II. —33 w* broken down by pressure between the fingers. The heart, same appearance as other muscles. Liver, change of colour seldom very remarkable; but light olive patches are sometimes observable, which would seem to indicate that a change simi- lar to what is common in the more protracted forms of the disease had commenced in this viscus. No trace of inflammation, by adhesions, abscesses, &c. Congestion, though not always present in a remarkable degree, has been observed. The gall- bladder, remarkably diminished in size, (some- times shrunk, and in other instances greatly at- tenuated); altogether empty, or only containing a minute quantity of bile of a deep orange-red colour, or of green bile, or of serum, or, more rarely, of pus ; its mucous lining in some in- stances highly injected with blood of a bright red colour.* The cystic duct, in a few instances so completely closed that a probe could not be passed through it.-f- Peritoneal surface, free from adhe- sions or other evidence of inflammation. Stomach, free from what, in the present clay, is admitted by the best authorities to be evidence of inflamma- tion ; mere redness, whether in streaks in various directions, or in stellated patches of various sizes, has been on several occasions remarked in the mucous membrane, in the same degree as it is observed to occur in chronic or other diseases, or in cases of accidental death, where there is not the remotest suspicion of gastritis. Spots of a purple colour are much more common than those of a bright red. A perfectly pale state of the membrane is far from being of rare occurrence. Dark streaks or patches in the mucous membrane are not uncommon, and would give an impression of their being occasioned by blood, changed in the capillaries to black vomit, in its progress to the surface. This appearance no doubt it is which has given rise to the opinion that gangrene of the stomach occurs in yellow fever ; but the most careful examinations at Gibraltar, in 1828, fully bear out those observers in America, the West Indies, and Spain, who deny not only that gan- grene does take place in the disease under con- sideration, but also that any lesion whatever of the stomach is to be traced. As the same may be said, very confidently, with respect to the other parts of the body, it would be unprofitable to enter more into details upon this part of the subject; and it need only be observed further that here the contraction of the bladder has appeared to be constant. 2. Where death takes place after the more or- dinary forms of the disease.—Little lividity of the skin, ex^-ept in dependent parts. Where no yellowness has appeared during life, a little may now be observed about the eyes, at the sides of the nose and mouth, along the course of the large vessels of the neck, and about the chest. Where yellowness had existed during the attack, it now becomes more intense and general, and extends to the fat and cellular tissue; but it is proper to state * It is to be remembered that, though these appear ances were so constant in the examinations made on an extensive scale at Gibraltar in 1828, they have also been occasionally found by pathologists in other fevers, and even in phthisis. ■f This, as is well known, occurs in other diseases : if the peculiar valvular as well as spiral structure of the duct be not kept in view, we shall often be misled in supposing that actual occlusion exists. FEVER, (YELLOW) 258 that the assertion as to the pericardiac fluid and that contained within the ventricles of the brain being sometimes tinged yellow, has not been veri- fied under the observation of many who have had ample experience in this disease. Muscles, their natural colour and firmness little altered. Peri- toneal surface, free from adhesions or other evi- dence of inflammation. Liver, presenting remark- able changes of colour. Sometimes (as during the greater part of the Gibraltar epidemic of 1828) the colour has been a pate olive, or mixture of green and yellow, usually taking place uniformly throughout the whole substance of the organ, in some rare instances alternating with dark green, in regular strata, and occasionally taking place in the left lobe only ; the liver observed, at the same time, to be studded, or punctuated, very thickly, with minute spots of bright red, being, perhaps, the granulated structure retaining its colour. The colour of the liver is, in some cases, especially in women and children, lighter than here described. In children it has been observed, after having been merely put into water for a moment, to be as pale as box-wood. Another change of colour is to reddish brown, compared by some (Arejula, &c.) to that of red Peruvian bark, and by others to the leaves of an autumnal scene: this was almost the only change of colour which presented itself during the latter part of the epidemic season of 1828 at Gibraltar. Portions of the liver washed, pressed, or bruised in a mortar, did not give out colouring matter, whatever the shade might have been ; and portions of the light olive coloured have remained un- changed by long immersion in spirits of wine. Little or no blood exuded from this viscus when deep incisions were made; and when broken up between the fingers, the impression given was what is termed friability of texture. No trace of bile has been observed in the pores on the occa- sion just referred to, nor had the hepatic or common duct been ever found obstructed, like the cystic; no traces of inflammation discoverable, and, from the whole of what has appeared upon this subject, the morbid change may be considered as being connected with derangement of function. [The inferences of M. Louis (op. cit.) from the same Gibraltar epidemic were,—that the liver is the only organ constantly, and more or less uni- formly, altered; and that as such alteration is not found in persons dying of other diseases, it must necessarily be regarded as the anatomical charac- ter of yellow fever. The alteration of the liver consisted in a discoloration, — the organ being sometimes of the colour of fresh butter; at times, of a straw colour ; at others, of that of coffee and milk; at others, of a yellowish green or mustard ; and at others, of an orange or pistachio. In the yellow fever of Martinique, M. Catel ob- served these appearances in the whole of 150 cases examined in the hospital there ; and in a single case that presented itself in the Pennsylva- nia Hospital, the appearances were found by Dr. Stewardson to be the same as those observed by M. Louis. (Amer. Journ. of the Med. Sciences, Jan. 1842.) On the other hand, M. Rufz, (Me- dical Examiner, vol. iii. p 54,) observed these in Martinique in only two of three cases. Dr. Ashbel Smith, in the yellow fever of Texas, (An Account of the Yellow Fever which appeared in the City of Galveston, See, in 1839, Galveston, 1839,) saw the ana?mic condition and light colour of the organ in three cases only out of seven ; and in the yellow Fever of 1820, Professor Jackson (American Journal of the Medical Sciences) found the liver usually gorged with blood. Professor Physic states that he rarely found it diseased.] The gall-bladder, usually containing bile, of a highly inspissated and sometimes dark tar-like ap- pearance. Stomach, not unfrequently found to contain the black vomit strictly so called, and, though infinitely more rarely, may be smeared over with the dark adhesive and jelly-like substance spoken of under another head ; containing some- times an obvious proportion of blood mixed wilh other fluids ; often the ingesta only, or mucus. Ruga?, the " etat mamelonne," together with ap- pearances adverted to under another head, as they are admitted to present themselves very frequently in dissections after diseases of any kind, or, in- deed, where (as in the case of accidental death) no disease had existed, need not be particularly entered upon on this occasion. Those who have asserted that ulceration of the stomach takes place in any form of yellow fever, are quite unsupported in the statement by observations made with the greatest attention, and on a scale of sufficient ex- tent : that mistakes have here, as on other occa- sions, often arisen from the facility with which the mucous membrane gives way on handling, there seems little reason to doubt. As to mere " ramolissemenl" of this membrane furnishing a proof of inflammation, this will not be now con- tended for, it is presumed; and it may be here stated that, on an examination in the case of a death by accident at Gibraltar in 1829, where the man had been in perfect health previously, the whole of this membrane, in the intestines as well as stomach, was in the hands of experienced per- sons from Paris, found to be so soft that, with the utmost care, not more than two or three lines of it could be raised at any point, but for the most part not even that quantity. The ccsophagus pre- sents an appearance, in some of the cases where black vomit takes place, of this being thrown out from its surface as well as from that of the sto- mach, especially at its lower portion ; an abrasion of its epithelion throughout its whole course has been sometimes observed, as in examinations after other diseases. The idea suggested itself at Gib- raltar that this denuded state of the tube might give rise to the peculiar burning sensation no- ticed ; but as the same sensation has been observed to occur frequently in cholera, a wider field is open on the point. Duodenum,—much of what has been observed regarding the stomach will apply here. Small intestines, — even in cases where no black vomit had been ejected before death, or where, on inspection after death, it had not been found either in the stomach or duodenum, the black jelly-like substance was sometimes found in the jejunum, but oftener in the ileum; and in some cases where it has been found both in the stomach and ileum, the whole intervening jeju- num has not presented a trace of it. In the me- moir by the writer of this article, from which im- perfect extracts were some time ago printed in Paris, the remarkable fact was noticed that the ulceration so liable to take place during the pro- FEVER, (YELLOW) 259 rress of typhus, as well as other fevers mali moris, n that part of the ileum more especially occupied )y the glands of Peyer, are not found to take place in yellow fever. The most trifling lesion ias not been discovered in those parts of the in- testine, on very careful examinations. The colon, its mucous surface sometimes covered with the adhesive black substance ; in a few instances con- taining a quantity of a pale red fluid, approaching to blood in its character ; is occasionally contracted at different parts. Whether we speak of the stomach or intestines, the mucous surface is usu- ally found quite pate on removal of the particular substance described as being black and jelly-like. In the colon especially, but also in the small in- testines, another substance has been occasionally found adhering in great quantity to the mucous substance; this has been compared by French writers to a mixture of linseed-meal and water ; but it has been found of a lighter colour, so as to resemble the substance found sometimes adhering to the intestines of persons who have died of cho- lera spasmodica. Regarding red points or patches found not unfrequently in different parts of the intestinal canal, little need be added to what has been said, when speaking of the mucous mem- brane of the stomach, as to their not furnishing evidence of inflammation. If, as is the opinion of some of the most eminent pathologists of Europe, before inflammation of this surface be admitted it must be shown to be thickened as well as being red and so soft as not to admit of being torn off in portions of several lines in length, then may it, as we conceive, be with much certainty stated that the phenomena of yellow fever cannot, as has been supposed, be referred to gastritis, or gastro- enteritis. The bladder, in those cases where sup- pression of urine* took place, found contracted very remarkably, but without lesion. Mr. Lin- ton, of the Naval Hospital, Jamaica, has noticed in one of his official reports, that he considered "the pancreas in some cases as being friable in texture ;" but this has not been remarked by others who have paid the closest attention in their ex- aminations ; and regarding the alterations or le- sions alleged from time to time to have been ob- served in other parts contained within the abdo- minal cavity, they do not seem to be verified in subsequent examinations conducted on a larger scale. Within the cavity of the thorax no appreciable lesion of organs seems to be admitted in the more ordinary forms of yellow fever; the change of co- lour and friable texture of the heart, in the highly concentrated form, has been referred to. False polypi in the cavities of the heart have perhaps been more common in this form of yellow fever than is usually found to be the case after death from other diseases. In a limited number of cases, towards the close of the epidemic of 1828 at Gibraltar, the attention of the medical officers of 'he garrison was directed by some of the members of the French medical commission to those dark, well-defined circular patches in the lungs, having * In some cases, especially children, retention of urine has taken place in this disease and been mistaken for suppression; so that, on a po>t-mortem examination, the bladder has been found distended above the pubis: the "ccurreiice of this at Gibraltar in 1828 led to the practice of careful examination of the region of the bladder. very much the colour and consistence of the spleen, which have been noticed in other diseases, and the appearance of which was perhaps merely adventitious on the occasion in question. In the examinations made in the year just mentioned, the blood was not observed of the particularly dark colour attributed to it in this disease by a few writers. The question, however, as to the changes in the chemical properties of this fluid remains open. Contents of the cranium.- In the course of the last Gibraltar epidemic, as well as on other occasions in the West Indies and elsewhere, extensive observations, carefully conducted, have quite negatived any assertions made from time to time as to morbid changes in the substance of the brain; as an inordinate quantity of fluid in its cavities, or under its coverings; remarkable con- gestions ; extravasation of blood ; the effusion of lymph, &c.: even where profound coma had taken place in the Gibraltar cases, morbid states by which this might be explained were not discover- ed ; and the deviations from perfectly natural states observed in any cases, were considered, by those who had most opportunities of making the examinations, as nothing more than the fortuitous appearances which present themselves in a pro- portion of instances, no matter from what disease death is produced, and which, as is now generally admitted, may arise from stasis, or the longer duration of the last agonies in particular instances: cadaveric changes, too, have, no doubt, given rise to mistakes, particularly as to great vascularity or congestion in the posterior and more dependent parts of the membranes of the brain, as it has re- garding the most dependent folds of the intestines. Contents of the vertebral column, found to be equally free from lesion as those of the cranium. In examinations conducted on a small scale by a French medical commission sent to Barcelona during the epidemic of 1821, erroneous views had been hastily adopted as to the spine being the fons et origo mali in yellow fever; but those opinions were, wholly or in part, subsequently admitted to have been erroneous. Magendie having shown that a certain quantity of fluid within the theca belongs to a natural state of the parts, errors on the part of future observers are less likely to occur. Before quitting the subject of morbid appear- ances, it may be stated that a very remarkable occurrence presented itself in a few instances during the last Gibraltar epidemic, — the infiltra- tion of venous blood, in the most uniform manner possible, into the cellular tissue of the minutest fibres of muscles. The whole substance of the muscles, which appeared almost black, seemed one soft mass, which yielded to pressure between the fingers as readily as the spleen. The biood thrown out became grumous, so that incisions caused but little exudation from the parts ; no putrid odour or appearance of sloughing. In one man this infiltration took place into the whole of the muscles of the right thigh, the abductors ex- cepted, from their origin to their insertion ; in another the parts involved were the gastrocnemii of the left leg and flexors of the right arm. This man had suffered a good deal of pain in those parts, and the process was very rapid. In a third case precisely half the diaphragm (right side) was 260 FEVER, (YELLOW) found in this state; and the infiltration, bound down by all the foldings of the peritoneum, ex- tended in a most singular manner in one con- tinuous sheet, from the diaphragm, posteriorly, down the right side to the bottom of the pelvis, keeping with great precision a line corresponding to the axis of the vertebral column, and covering every organ, or part of intestine, &c, which lay on that side. The muscles, except in the portion of the diaphragm referred to, were healthy. In this case the disease had run a rapid course, and some of the symptoms were well marked, as yel- lowness of the eyes and skin, violent jactitation, delirium, singultus, and dark stools, but no black vomit; a remarkable tremulous motion of the hands, not common during the epidemic, also took place in this case, near the close of the attack. We were not in those cases able to discover the rupture of any considerable vein. Although Arejula notices in his work the occurrence of large and painful tumours during some of the epidemics of Spain, which, had examinations after death taken place, would probably have been found of the nature just referred to, nothing as to the occur- rence, in the yellow fever of parts of Europe, of the precise morbid states here referred to appeared till the publication, at Paris, in one of the num- bers for 1829 of the Bulletin of Sciences, of an abridgment of notes, made by the writer of this, of the autopsies at Gibraltar, in 1828. Up to so late a period as 1828, the identity of the yellow fever of Spain with that of the West Indies had been denied by Dr. Rocheaux, who was at Barce- lona in the epidemic season of 1821; but the editors of the Bulletin consider all doubt now at an end, " identite parfaite" being established by the account of those infiltrations in the cellular tissue in some of the Gibraltar cases. In America and the West Indies those appearances had been particularly noticed by Dr. Ghervin of Paris, so celebrated for his researches in yellow fever for many years; they are particularly noticed in a communication to the Academy of Medicine, in 1827, by Dr. Keraudren, from one of the French West India Islands. Mortality.— As has been frequently observed regarding other diseases, the malignity of the cases, and consequently the mortality, is usually much greater in the first than in subsequent periods of yellow fever epidemics; the violence of the dis- ease has, however, been known to receive, in some rare instances, a fresh impulse, as at New York in 1822.* In Hurtado's Decadas it is stated that, of the first 134 cases treated at Murcia in 1804, not more than three or four recovered. Dr. Ro- cheaux, one of the French physicians at Barcelona during the epidemic of 1821, states, in his book on yellow fever, printed in 1828, that in the early part of the epidemic the mortality was in the pro- portion of 19 out of 20 ; that towards the middle it became much less, and at the close was only two-thirds. (Vide p. 464.) In the early part of the Gibraltar epidemic of 1828, very few recove- ries took place in the Civil Hospital; of the first * About the middle of October " the disease became again as fatal, or indeed more so, than at its commence- ment ; the proportion of deaths being to the proportion of sick as three to four!" — Townsend, Yellow Fever of 1S22 at JVew York, p. 197. thirty-five Jews received into the establishment, it is stated that all but one were swept away. On the same occasion, two corps in particular, as officially stated to the authorities by the late Dr. Hennen, then medical chief, were early attacked by the disease in a peculiarly malignant form, and suffered a loss of about one-half of the cases. On some occasions the form of the disease has been so mild that very few deaths have been recorded in proportion to the numbers attacked: even dur- ing the same epidemic, from a difference in the localities, or from other circumstances not ad- mitting of easy explanation, there has been less mortality, in proportion, in one regiment,-)- class of persons, or family, without an essential differ- ence in the mode of treatment, and solely arising from the disease having been milder. A full con- sideration of the subject must prove that the ex- pectante system, or any system of " mild popular remedies," cannot be admitted (as has been at- tempted to be shown) to be followed by less mor- tality than what our French neighbours call " les moyens perturbateurs." It does not appear that in their colonies, where trifling means only have been so often resorted to by the French, any good has followed. At Barcelona, in 1821, scarcely a patient survived in the wards given up to the dis- tinguished members of the French commission. (O'Halloran on the yellow fever of Spain.) At the period in question, the mortality, under Spanish and French medical men, in the establishment called Seminario, was 1265, out of 1739 cases treated. Under the mild, or what has been called the French and Spanish treatment, the mortality at Malaga in 1803 was 11,486, out of a popula- tion of 36,054. In the epidemic of the preceding year at the same place, 6,684 deaths occurred out of 16,517 attacked. In an epidemic at Xeres a few years ago, one-third of the whole population was swept off, under circumstances when, in the bulk of the patients, a few domestic remedies only could have been employed. Many other similar instances might be cited in proof of our being warranted in employing potent means likely to induce a favourable change in the form of the dis- ease on its first invasion. From the wide range which the symptoms take, — so wide that, but for the black vomit being liable to occur, as a con- necting link in the various forms during the pre- valence of an epidemic, we should, from the symptoms, as well as post-mortem appearances, often have reason to suppose that different remote causes were giving rise to different impressions,— it is obvious that in no disease is it more difficult to lay down rules of practice, and in none can the medical man's tact and attention be more needed. [In the Gibraltar fever of 1828, according to a calculation made by the medical commission, from 600 cases, short histories of which had been taken, the mortality was in the proportion of one to six and a half. It varied, however, according to age and sex; — of children attacked, a seventh part only died ; of women one in five and a half, and t At Gibraltar, in the epidemic of 1813, the mortality was so much less in the Military Hospital under Mr. Brown, that medical gentlemen were induced to inquire into his practice, which they found did not differ from their own FEVER, (YELLOW) 261 of men one in four and a-half. M. Louis ob- serves (Op. cit. p. 261,) that the same symptoms had not the same value in prognosis at all periods of life; for instance, the black vomit, which in men was the most certain harbinger of death, took place in a great many children who reco- vered.] Nature of the Disease. — It has been at- tempted, on various occasions, to explain the phe- nomena of the disease by the inflammation of certain organs or parts; and by the majority of those who. have adopted this view of the matter, the gastro-intestinal mucous membrane is the part to which the morbid action has been assigned.* As might have been anticipated, we find this doc- trine supported by all the ingenuity of Broussais and his followers; but by nobody has it been more strenuously advocated than by M. Boisseau, in his " Pyretologie" (fourth, edition). Among the medical men out of Europe who have advocated this last opinion, the statements of Dr. Bone, of the British army, who has been resident for many years in the West Indies, are perhaps worthy of most attention ; they are to be found among the many valuable manuscript documents in the ar- chives of the Army Medical Department in Lon- don. What has been shown, however, under the head of morbid appearances, will probably estab- lish, to the satisfaction of our readers, that there are sufficient grounds for believing that the pri- mary morbid action is not the alleged inflamma- tion of parts. The inhalation of a specific poison has, as on other occasions, been considered by some as directly productive of changes in the chemical properties of the blood sufficient to ac- count for the derangement of various functions which occur in this disease; but, without denying the probability of this, there is as yet nothing be- fore the public to establish the point satisfactorily. Dr. Guyon, who practised for some years at Mar- tinique, has spoken of this " lesion" of the blood as probable ; and Dr. de Fermon, of Paris, well known for his acumen in all matters relating to medical science, seems to favour this view of an alteration of the blood, "primitivement," in yel- low fever. In the most concentrated and rapidly fatal form of the disease, there is evidence, as has been shown, in proof of congestion in the liver. By others, the nervous system is considered as primarily affected, and some observations lately made on this subject by Dr. Wilson, of the navy, in his very ingenious book on yellow fever, seem particularly worthy of notice; especially with re- spect to the different train of symptoms to be looked for — on the one hand by the abstraction, and, on the other, by the obstruction of the ner- vous power in different individuals. The uniform integrity of the cerebral functions in the first stages of this malady, as observed at Gibraltar in 1828, and as noticed on other occasions by many authors—the extremely frequent integrity of those functions to almost the last moment of existence, in its "congestive" or most intense and fearful form,— together with the remarkable manner in which (in the last mentioned form especially) the secretions are suspended, — induced the writer of * Toniassmi, strangely enough, considers not only the castro-intestinal mucous membrane as the seat of in- flammation in yellow fever, but also the liver. this, when drawing up a review of the last Gib- raltar epidemic (1828), to state his belief that the ganglionic system was involved very prominently. in the series of morbid actions. That this should in any case be the first link of the chain can never perhaps be satisfactorily demonstrated; but on many occasions it appears highly probable from the manner in which several fatal signs concur with the suppression of the secretions, as if some powerful agent had been directly applied to that system of nerves which so specially presides over the secreting organs. But to enlarge on points necessarily speculative would be unfitting an oc- casion like the present. Cause of the Disease.—The more fully this subject is examined, the more evident it must ap- pear that in the present state of our knowledge nothing satisfactory can be arrived at; for al- though, as will be shown when speaking of con- tagion, reasonable causes have been sometimes assigned for the appearance of the disease on board ship as well as in certain localities, it has been impossible to assign appreciable causes in many other instances. What can be stated in this respect with regard to Gibraltar, will apply to other places. By ample tables in our possession, it does not appear that either before the appear- ance of the epidemic of 1828 in that garrison, or during its progress, any atmospheric changes took place differing materially from other years in which epidemics did not occur. The average heat was not greater)- than that of the preceding year. The quantity of rain which had fallen up to the appearance of the epidemic was within a fraction of that which fell in 1827. The influ- ence of a prevalent easterly wind had been much dwelt upon in the explanations offered respecting the epidemic at that place in 1804; but in 1828 no unusual prevalence of that wind took place. In fairness, we think that, like many other places which may be mentioned where yellow fever is known from time to time to appear, it cannot be admitted that Gibraltar furnishes sources from which malaria, in the usual sense of that word, arises, sufficient to account for the appearance of a malignant fever; neither can we concede to au- thorities of great respectability, that either there or in various other places the solution of the ques- tion is to be found in a crowded population, the filth of the town, or the state of the sewers ; though the last may have been an auxiliary. Compared with Gibraltar, places might be men- tioned where, as we know, yellow fever does not appear, in which those circumstances obtain in a much greater degree. It may be urged against the salubrity of Gibraltar, that the habitations are for the most part deprived of free ventilation, being backed by a rock of from twelve to fourteen hundred feet high ; and that the impinging of the sun's rays, for so many hours daily, on the sloping and inhabited part of the rock, should be admitted to a share in the consideration: but the great mystery is, that with these and other circumstances in operation every year, the disease should omy prevail epidemically in particular years. Though a certain degree of heat seems so essential, it by no means appears that epidemics have usually f Average at noon, in the autumnal quarter, ... 7CJ " " in the last quarter,.........63| 262 occurred in years most remarkable for heat. If we consider soil and elevation, it must be admitted that here too no satisfactory conclusion can be drawn ; for if we find evidence, especially in the West Indies and on the American continent, of the influence of a marshy soil, on several occa- sions, this does not hold good in other instances ; and in those countries, as well as in Spain, many places might be mentioned where elevation, soil, &c. would seem to guaranty immunity, but where, nevertheless, the disease occasionally prevails to a devastating extent. Notwithstanding what has been here said, we do not apprehend that, in the present day, epi- demic or catastatic influences in determining the irruption of diseases will be denied, though not cognizable by our senses, or appreciable perhaps by chemical tests. Influence of temperature, Sec. — There is no- thing connected with yellow fever which seems so invariable as the decline of the epidemic on the setting in of cool weather. At a temperature of about 50° Fahr., fresh cases soon cease to appear, and in Spain and North America the disappear- ance of the disease at a particular period is usu- ally calculated upon with precision. In some epidemics females have remained won- derfully exempt : this'was the case during a ter- rific epidemic at Dominique and Martinique in 1801, as the writer of this witnessed; for while two battalions of the 68th regiment, composed of fine young men, suffered so much from the dis- ease as not to be able latterly to furnish any men for duty, and had lost forty-six officers within six months, not a single woman was attacked; and it may be observed that, in those days, more fe- males were allowed to embark with regiments from home than at present. Children were also exempt on the occasion in question. In some epi- demics in Spain the disease has been observed to attack women in a milder form ; while in others, as that of Xeres in 1811, they suffered in a par- ticular manner. During the early part of the epidemic at Gibraltar in 1828, the women were attacked with great severity, but subsequently in a milder form. On that occasion, too, children under twelve months had well-marked symptoms. Particular classes will sometimes suffer more than others ; thus, according to a memoir by Mr. Hugh Frazer, lately surgeon to the Gibraltar Civil Hospital, of the first thirty-five Jews who pre- sented themselves to him during the epidemic there of 1828, scarcely a single person recovered. Bakers and cooks have been said to suffer in a greater proportion than common; but perhaps the nature of their occupations permits fewer of these people, in proportion, from leaving a city or town when an epidemic prevails. Negroes are considered as being usually insusceptible of attacks; but even in them a susceptibility has been created, as on certain occasions in America, by a residence for some time in a different climate from that to which they had been long accustomed: indeed, without change of climate, they have, as instanced by Dr. O'Halloran in his report of the Jamaica epidemic of 1825-6, been attacked in considera- ble numbers, though not with equal severity as the white population. At Gibraltar in 1828, a negro, the servant of a hotel-keeper, had two at- iELLOW) tacks, one of which was particularly well marked, Circumstances connected with localities being equal, the upper classes of society seem, on all occasions, to suffer from attacks in a full propor- tion. Persons of regular habits do not seem less exempt from attacks during epidemics; but it may be admitted that their chance of recovery is greater than in the case of free livers. Those born or long resident in places where the disease is liable to prevail, will escape from attacks during the prevalence of some epidemics, while in others (as in that at Barbadoes in 1816, and Jamaica in 1825-6) the old inhabitants will suffer in propor- tion. A well-marked attack on one occasion gives a great degree of security from attacks during sub- sequent epidemics: this was stated, some fifty years ago, by Lining, reiterated by Sauvages, and known so well among Spanish medical men, that the late Dr. Arejula placarded the fact on the corners of the streets in Medina Sidonia in 1801, with the view of insuring better attendance to the sick : the claims, therefore, of some persons of late years to any discovery on this point, are ut- terly groundless, as are the statements which would go to the denial of the fact, regarding the occa- sional occurrence of two distinct attacks at remote periods; and, were this a place for minute details upon every point connected with yellow fever, a list could be furnished of the names and dates of several which took place at Gibraltar. Relapses are very common : at Gibraltar, in 1828, one hundred and two cases of relapse occurred among the mili- tary alone ; and their names have been registered in the medical office of that place. The occupiers of upper floors have, in many instances, especially at the commencement of epidemics, been attacked in fewer numbers than those on ground floors; and in the West Indies and Gibraltar, families occupying low huts have frequently furnished the first cases. The manner in which the disease has sometimes been confined to a particular extremity of a building, or even to a particular side of a ship, is well illustrated by surgeon Callow, 84th regi- ment, at Fort Augusta, Jamaica, in his official report for 1827 ; and by surgeon Wilson, Royal Navy, in his work on yellow fever. [The attention of the Gibraltar commission was directed to two points. First. Whether an indi- vidual, who had had yellow fever in Europe, was susceptible of a second attack in Europe. And secondly. Whether one who had had the disease in Europe could have it a second time in America, and conversely ? Their inferences were, that se- cond attacks are more rare in the case of yellow fever than of small-pox,—that a person once at- tacked, even in the slightest degree, is, with very rare exceptions, for ever exempt from future at- tacks; and that this is true, not only where the first attack and second exposure have taken place in Europe, but where the attack and exposure have been in different continents. It was remark- ed, that the preservative influence of a first attack is not destroyed after a considerable lapse of time, —24 years for example,—since the inhabitants of Gibraltar, who had passed through the yellow fever in 1804, were preserved from it in 1828 as effectually as those who had been attacked by it in 1815. (Louis, op. cit. p. 312.)] Treatment. — It is painful to be oblige*? » FEVER, ( FEVER, (YELLOW) 263 admit that our advancement, within the last half century, towards any thing like a satisfactory treat- ment of this disease, in its formidable shape, has been sadly disproportionate to the degree of intel- lect brought to bear upon the subject within that time by professional men of different countries. Even with respect to those forms in which the symptoms, though formidable, are comparatively less intense, it seems very difficult to draw, from a review of what has been done by many, fixed rules for our guidance on certain points of practice. The discrepancy in the statements of respectable autho- rities regarding the efficacy of a particular line of practice can indeed be no otherwise explained than by the admission that in some epidemics very re- markable peculiarities occur. Venesection may be particularly referred to in illustration ; for though it has over and over again, after trials in the hands of men who are not to be set down as injudicious, been decried in our West India colonies as well as America; and though it has been generally aban- doned long since by the experienced practitioners of Spain, we find it, nevertheless, lauded on certain occasions, especially very lately at Trinidad, jointly with the warm bath and other means, by persons of unquestionable judgment. On our first acquaint- ance with this disease, nothing would seem more plainly indicated than this remedy, when the ex- citement runs high ; but it has been too frequently found that after its employment, even but to a limited extent, the true character of the disease had been masked, and, as the Spanish practitioners express it, that the patient is speedily found to require all the strength which had been taken away. Frequently as we have witnessed blood taken from the arm in this disease, under a strong impression that a highly inflammatory action was going on, never has the blood, in a single instance, presented a buffy surface with a firm coagulum; it has on the contrary always formed a loose mass, yielding readily to the pressure of a finger, the serum sepa- rating very imperfectly or not at all. It may here be mentioned that our experience by no means bears out the assertion of some, as to the remark- ably dark colour of the blood drawn from yellow fever patients. Without any intention to impugn the statements respecting the advantages derived from liberal venesection on particular occasions in die West Indies, it must be declared that the weight of evidence is against its general adoption in yellow fever, even where, prima facie, it would seem to be indicated. The valuable naval medical retards at Somerset-house being rendered accessible for reterence by the liberality of Sir W. Burnett, some highly interesting observations on the point in question will be found in the reports from Mr. Linton, who has been long resident in the West Indies, and for some time in charge of the Naval Hospital at Jamaica. Quite in accordance with our ample experience of the disease, as it has ap- peared in the West Indies and Gibraltar, this gentleman describes the disease as " decidedly not inflammatory," though "inflammatory symptoms may concurrently or adventitiously take place:"— would adopt the expression " inflammatio simu- lata," as expressive of " irritation or vascular sensi- bility :"—states that in the records, extending back for many years, the mortality was very great from the depleting system, which, from the seeming inflammatory nature of the disease, had been acted upon ; and that the "post-mortem examinations which have occurred within the last twelve months [referring to a particular sickly season] presented no appearances which could be legitimately ascribed to this state [inflammation]." As in other fevers, circumstances will arise where the application of leeches to the temples, or of leeches and cupping- glasses to the epigastrium, may be strongly indi- cated ; but the experience of others bears out the last-quoted gentleman in a remark that there is great risk of mischief from opening the temporal artery, collapse being very liable to be induced. Having mentioned cupping, it suggests itself (though perhaps not as a very promising specula- tion) that in the hope of affording some palliation of the incessant vomiting often so very distressing in yellow fever, we may give a trial to dry cupping on the epigastrium, as practised by ancient physi- cians in their endeavours to relieve the vomiting in malignant cholera. Blisters, with this object, are frequently applied at an early stage to the same part; but to Mr. Linton of the Royal Navy the profession is indebted for a suggestion as to their application in another manner with the same view. He states in a report from Jamaica, dated Septem- ber, 1830, that having placed a blister the whole length of the spine in a certain number of cases, the irritability of the stomach was relieved in all except one. Their application to the head is some- times found beneficial in protracted cases accom- panied by cerebral affection. The warm bath, where we have not morbid heat of the surface with high vascular action, holds its place as a fJseful auxiliary in the early stage ; and where these symp- toms predominate, the tepid bath, occasionally repeated, is employed by many ; or, by some, the cold bath, or sponging with cold water, or with vinegar and water. Assiduous friction of the whole surface, after the bath in any form, has been considered beneficial. The promised advantages from Dr. Jackson's suggestion of a cold bath with frictions, immediately after a warm bath, have not been realized. The application of cold by means of wet cloths to the forehead has been found useful in relieving the severe frontal pains liable to occur in persons in the full vigour of life. Regarding internal remedies, they cannot in truth be spoken of in this as in almost all other diseases, for in the generality of cases the irrita- bility of the stomach is so great that hour after hour, at the period when medicines might be hoped to make some impression on the disease, drinks of the mildest kind and medicines of every description, even in the smallest quantity, are-in- stantly rejected; and, driven to total despair of anything being retained, we are often obliged to leave nature to her own resources, in expectation of an interval of repose. In a disease of this kin<' it seems quite impossible to explain how, up to the time of his death, large doses of the bark should have merited the special favour of Dr. La- fuente, one of the principal physicians connected with the epidemics of Andalusia during some of the first years of the present century. Where remissions take place, as noticed by several au thors, as well during convalescence, the advantages! from the exhibition of quinine seem to be generally admitted; but the doses must be regulated with 264 caution, for given in large quantities, it has not only produced great irritability of the stomach, but much mischief in the head. [Within the last few years, much attention has been paid in Louisiana to the effect of large doses of sulphate of quinia in this disease,—not given during a period of remission, but in the very incipiency, whilst the morbid action is forming, and before any local lesions have occurred. It was prescribed in one very large dose of from 20 to 50 or 80 grains, and is said to have acted like a charm. When taken under such circum- stances, its effects are said to be, a very slight increase of the febrile symptoms ; the pulse is perhaps quickened ; the respiration more hurried, and the usual signs of excitement are present. This condition is, however, but transient, and it is promptly followed by corresponding depression. All the more violent symptoms subside; the tem- perature of the surface is lowered; pain is dimin- ished ; the pulse is gentle and subdued, and the skin covered with a healthy moisture :—in short, the chain of morbid associations is broken, sleep is induced, from which the patient awakes refreshed, and substantially better; and within 24 or 36 hours, he is considered to be in a state of conva- lescence. (Medical Examiner, Oct. 19 and Oct. 26, 1839.)] Among a very limited number of practitioners have emetics been at any time in favour. Arejula, the great authority on the epidemics of Andalusia, informs us that in pregnant women he found their exhibition prevent abortion and its usual conse- quence, death ; this, to the extent of a few cases, seemed to have been corroborated in the practice of a Spanish medical man at Gibraltar, in the epi- demic there of 1828. In a report drawn up by a commission of Seville physicians, relative to an epidemic which prevailed in the quarter of Santa Cruz, in that city, in 1819, it is stated that much reliance had been placed on the exhibition of anti- monial emetics in the early stage. (Decadas de Hurtado, vol. iii. p. 120.) In No. 16 of the Ga- zette of Health, there is a paper by Dr. Hacket, surgeon to the forces, in which, referring to a late period of sickness at Trinidad, he states that his " practice commenced in almost every case by an emetic of sulphate of zinc ;" and it would seem that in the employment of this, in addition to his other means, he found sufficient reason for being satisfied as to its utility. This may be the place to refer to the exhibition of the nitrate of silver, given by Dr. O'Halloran, surgeon to the 77th regiment, at Jamaica, in 1827, in doses of from four to six grains, so as to act as an emetic; and from which this gentleman at one time conceived that he had received considerable advantages in his practice ; but it is proper to state that, how- ever further trials of this particular form of medi- cine may be warranted, he has not, in a conversa- tion which we have had lately with him on the Bubject, expressed himself very confidently as to its efficacy. In regard to purgative medicines, there seems, among the mass of experienced prac- titioners, an admission as to the propriety of their emplovment in those forms where the excitement runs high, although the practice is not without opponents from the modern school, which refers iie train of symptoms in this as in so manv other rELLOW) diseases to inflammation of the gastro-intestinal mucous membrane. It is not an easy matter to conceive how, in this disease, bulky doses of drastic purgatives, as jalap, &c. could have merit- ed the estimation in which they were at one time held, their immediate rejection from the stomach being always so exceedingly probable. This un- quiet state of the stomach has led to a very general practice, especially (but by no means exclusively) among British medical men, of administering, in as small a form as possible, doses of calomel with the view of clearing out the bowels as a first step; and whether in the form of small pills, or the powder in half a tea-spoonful or so of gruel cautiously swallowed, there is always a greater chance of its being retained than perhaps any other form of purgative. It would seem, however, that the proposed object may with more certainty be obtained by the application of the croton oil to the tongue, as particularly recommended in the number for August, 1825, of the Medical and Physical Journal, by Mr. Tegart, formerly chief of the medical department of our West India islands. A drop or two on the tongue has not only excited the immediate action of the bowels, without increasing the irritability of the stomach, but has also been observed to favour the secretion from the kidneys, a point perhaps of no small importance. In the paper by Mr. Hacket who has been referred to, written this year (1832) no small share of success in the treatment of yellow fever at Trinidad is attributed to the croton oil, which it would appear this gentleman gave in large doses, as well as exhibiting it in the form of enemata ; for after mentioning the emetics of sul- phate of zinc, bleeding in the warm bath, the shower bath, and enemata of salts and castor oil, where there was much excitement, he states that " croton oil was invariably given to the extent of three or four drops. I have known this repeated thrice through the night; and it is most worthy of remark, the more irritable and distressed the stomach, — though, prima facie, to those unac- quainted with the great febrifuge virtues and extraordinary powers of croton oil in restoring the peristaltic motion of the intestines, which seems in other diseases to be inverted altogether, this irritability, hitherto our bane, (I may almost say the very leading feature and peculiarity of tropical fevers,) would be to them a cogent reason for not administering the oil, — yet in almost all such cases it was found invariably to be triumphant, so that in the morning we generally found our patient thus treated with a perfect or nearly per- fect remission." He says, a little further on, " the power of croton oil in allaying gastric irritability and general nervous excitement, as well as restor- ing the circulation to the surface, and thus reliev- ing the congestive state of the internal and deep- seated central vessels, is really extraordinary; and though it may seem for the moment, when first given, to increase that irritability, yet after a little time I have hardly ever seen it fail in producing the desired end." Much as we are taught by ex- perience not to be too confident in our expectations of the efficacy of medicines, from the advantages which may seem to result from their employment in particular instances, there is enough here, from a gentleman who has had ample field of observa- FEVER, ( FEVER, ( tion, to draw special attention. According to an official report referring to the events of the epi- demic of 1821 at Barbadoes, Dr. Bone, deputy- inspector-general of hospitals, wno had a very important charge at the time, relied chiefly on the exhibition of opening medicines of the saline class; during the first twenty-four hours, for instance, four ounces of Rochelle salts, with or without two grains of tartarised antimony, given in small doses. But if what he considers as obstruction of the gall-duct took place (shown by the absence of bile from the dejections), he continued this solution, with perhaps small doses of the extr. cathart. for three or four days, or until bile appear- ed. He varied his saline medicines to Seidlitz powders, Cheltenham salts, soda tartar., or potass. tartar.; or he gave the cassia fistula ; and this, with the occasional use of the warm bath, seems to have been his widest range of practice. That on the occasion in question Dr. Bone should have displayed sound judgment cannot be doubted, from his extensive experience for many years in the West Indies, and from the remarkable degree of tact which he has displayed on many practical points connected with yellow fever. How far any of the alleged advantages derived from this practice may be attributable to the views lately promulgated by Dr. Stevens, it is impossible to say, as the question of the advantages of the ex- hibition of neutral salts in yellow fever, on the principle of their immediate action on the blood, is involved in controversy. But whether in re- ference to the exhibition of small doses of neutral salts as here spoken of, or to the popular remedies long in use in Spain, of large doses of the super- tart, potassa?, or of olive oil, or of castor oil, the difficulty always presents itself as to those means being generally applicable in a disease where the excessive irritability of the stomach forms so pro- minent a character. Enemata are very generally had recourse to as useful auxiliaries; one consist- ing of sea-water only was preferred by the late Arejula of Spain. In the West Indies and other places a' proportion of the ol. terebinth, has been sometimes used with the other materials. At Gibraltar, in 1828, the employment of enemata of every kind was not unfrequently found impracti- cable from distressing excoriations which took place about the anus. Mercury. — On a review of the different modes of practice adopted in this proteiform disease, within the last forty-two years, by practitioners in the British West India islands, the United States, and Gibraltar, this remedy seems to have best maintained its ground ; for though it be quite true that it has from time to time fallen into discredit from persons having, in the course of an epidemic, frequently found, that, like all other human means, it made no impression on the most aggravated forms of the disease, it nevertheless has stronger testimony in its favour than any other practice which can be named. The late venerable Chis- holm said, after a consideration of the subject du- ring thirty years, " Are we then, from any vain or unfounded apprehension, from reasoning drawn from false premises, or from uninformed or preju- diced minds, to yield up the result of our own fre- quently reiterated experience ? — to relinquish the best aid [i.e. mercury] which we can bring to the Vol. II___34 x ELLOW) 265 support and relief of our fellow creatures suffering under so direful a malady 1 — Forbid it humanity ' — forbid it heaven !" Since the history of the American epidemics of 1793 and 1794, by Rush, numberless have been the publications in which the practice, either by inunction or otherwise, has been recommended, and the medical archives of our army and navy contain very strong evidence of the great advan- tage to be expected from the remedy in one shape or other (though not to the exclusion of other means) in those cases where a hope from the em- ployment of any remedies can be entertained. Among the latest authorities in its favour is Mr. Linton, of the Naval Hospital, Jamaica, the gentle- man before quoted as having had long experience in the West Indies. He states in his official re- port of December, 1829, that in his practice, after purging, the bath, and blisters, he gave calomel every two hours, in doses of from five to ten grains, and that, where the symptoms made rapid strides, he commenced mercurial frictions at an early pe- riod. He states in a previous report that, where he had been tempted, after the first calm from va- rious remedies, not to push the mercury, he " had frequent reason to regret this misplaced confi- dence." He says, " In every instance, as soon as the mouth became affected by the mercury, so that ptyalism was unequivocally established, the patient might confidently be pronounced conva- lescent." He remarks, with great judgment, and in doing so he is perfectly borne out by the expe- rience of others, that, " there is, however, a condi- dition of the gums, which are only to a certain degree affected by mercury, which is often con- founded with ptyalism, and which has frequently induced some medical writers, unacquainted with or prejudiced against the use of mercury, to affirm that several patients die in a state of ptyalism. A strong mercurial halitus may be perceived; the gums are swelled, spongy, and livid, and a clammy, thick secretion of mucus, not saliva, takes place; but under these critical circumstances farther pro- gress of ptyalism is arrested." Under these cir- cumstances, and the symptoms not yielding, Mr. Linton recommends that the internal use of the remedy should be suspended; that generous nou- rishment, warm baths, and stimulants should be had recourse to, and frictions then continued in the hope of obtaining the desired end. In one of his reports he alludes to trials of the medicine in a particular form : " in three cases which recovered under similar circumstances, I have latterly em- ployed a solution of oxymiiriate of mercury with decided good effect; but when the stomach is very irritable, this form of medicine is inadmissible." Another gentleman of long experience in the West Indies, (Dr. John Arthur,) states in an offi- cial report from Barbadoes, of the 17th of March, 1821, "I believe far the most recoveries have been after the use of this medicine in one shape or other." It is stated in a report of the same year by staff-surgeon Hughes of Berbice, that calomel was given with "great advantage, and one satis- factory conclusion to be deduced from its opera- tion, when it affects the mouth, was that of the patients being on the side of safety." In a report from surgeon Callow of the 84th regiment, relative to the Jamaica epidemic of 1827, he states that 266 FEVER, (YELLOW) he " relied considerably upon the specific action of mercury for ultimate cure ;" that he employed the blue-pill " certainly with advantage," and in- unction as' an invariable adjuvant. It has been stated by Dr. Francis, when referring to the treat- ment adopted in the epidemic of 1822 at New- York, that " mercury was considered by some phy- sicians as conspicuous among the curative means." The history of the Gibraltar epidemics furnishes the names of many experienced men who have seen good reasons for relying much on the use of mercury in this disease; among these, Mr. Amiel, now surgeon to the 12th regiment, should, per- haps, stand first. This gentleman having wit- nessed epidemics in that garrison at three different periods, and closely observed the effects of treat- ment the most varied, considered mercury, up to the last case in 1828, as his " sheet-anchor." It is scarcely possible to name a British author on yellow fever whose views do not accord more or less with those expressed in the extracts here given. Mr. Wilson of the Royal Navy, the au- thor of a work of great merit in many respects, published in 1827, when referring to the treat- ment even of those aggravated forms " where the nervous torpor and vascular atony are great, and where re-action is tardy, irregular, and imperfect; where the patient, without complaint of pain, lies prostrate, letting the head fall from the pillow, or pushing the pillow away, the countenance being ghastly, pale, or livid in colour, and fatuous in expression, the iris scarcely influenced by light," —informs us that " calomel ought to be adminis- tered in most cases from the beginning ; it should not be delayed beyond the operation of the purga- tive medicine. The quantity of this most valuable remedy and its manner of combination with others, must of course be varied according to circumstances; but the dose must on the whole be large and often repeated. If the character of the disease be not changed at an early period, its end will generally be in death." He adds, " with the other reme- dies recommended, I have given, and would give, ten, fifteen, or twenty grains of calomel twice or thrice daily, with a grain or a grain and a half of opium to each dose, according to the state of the digestive organs." The other means to which he here alludes are warm baths of high temperature, (" above that which a person in health could bear,") and continued for some time, and assidu- ous friction after their employment; warm pur- gatives, combined with aromatics ; warm drinks ; warm stimulating injections ; occasionally a little brandy, oil of terebinth in small doses ; blisters over the epigastrium, between the shoulders, and to the head. He says that he was not deterred from this practice, ia the forms alluded to, by the nausea and vomiting so characteristic of this fever. Like what occurs sometimes in the stage of re-action in cholera, he found it useful to ab- stract blood cautiously in the period of re-action following the low state of the animal energies here referred to. The rationale of Mr. Wilson's practice is extremely ingenious and well worthy of attention. He admits, as all must, " that in many cases the resources of our art have little in- fluence on the disease, and that in its worst forms it is utterly beyond control." Indeed, it is not per- mitted us to be too sanguine as to the efficacy of any remedy in even a seemingly mild case of this "perfidious" disease; and the specific action of mercury, even after baths and aperients, will often fail to take place, the torpor of the absorbents being quite insurmountable ; but as in an infinity of cases we can have no right to assume that this is the case, it must rest with the judgment of practitioners to decide how far they may he war- ranted in withholding a remedy standing so re- commended as this does from various quarters.* Of one thing we have ourselves been convinced by ample experience, that though patients may often do well under other treatment, the medical attendant will be infinitely less likely to be taken by surprise, when ptyalism once sets in, by the sudden invasion of those symptoms which, within a couple of hours perhaps, are known to cut off a patient who seems to be in a state of convales- cence, or nearly so. An objection is often made that, in the employment of these means, "we lost time ;" and a very excellent objection it must be considered to be when it can be shown that in the average of epidemics (for it is quite a delusion to speak of what takes place on particular occasions) other plans are found more useful. Previous to dismissing the subject of the exhi- bition of mercury in yellow fever, it may be well to quote an observation from a gentleman in the West Indies, which goes to meet another objec- tion sometimes made : " calomel does not, that I can perceive, produce any better effect in doses of twenty grains than in those of five ; but even in very large doses I have never known it to cause hypercatharsis or any other bad symptom."-)- The foregoing extracts are selected from a great mass to the same effect, as they complete the evidence that, up to the latest epidemics, mercury has been considered as holding a prominent place among the remedial means from which most hopes are entertained in yellow fever. In the cases of profuse hemorrhage which fre- quently occur, the stomach is usually more reten- tive, and a bitter infusion, with a proportion of sulphuric acid, is found beneficial. The bleeding from the mouth is so excessive sometimes as to excite great apprehensions, but a strong solution of arg. nitr., applied very freely over the gums or other parts from whence blood is chiefly observed * The remedy was adopted by Palloni, in the yellow- fever epidemic of 180-1, at Leghorn. Among the Spanish practitioners who have adopted it are Dr. Flores Moreno, of Cadiz, Dr. Ardevol, of Gibraltar, and Dr. Bobadilla, also of the latter place, who had experience in epidemics of Andalusia duriiig thirty years, and who was so con- fident of the remedy (chiefly in the form of inunction) that, on the invasion of the epidemic of li-.'H, he memo- rialized the governor of Gibraltar to be mile red to treat some of the military exclusively on his plan. The ex- hibition of mercury of late years by some of the best practical men in Great Britain ami Ireland, not only in fevers mali moris, hut in diseases purely inflammatory, including arachnitis will probably tend to dissipate the prejudices of the French against the remedy. They have, indeed, already, by the admission of Messrs. Louis and Trousseau at Gibraltar, gained advantages from the adoption of mercurial frictions at Paris in puerperal peritonitis, a case of which seldom recovered under former practice there. Perhaps, loo, as, according to the same gentlemen, two of every three cases ol typhus die at the Paris hospitals, advantages might be looked forward to there by the adoption of the more energetic system of those British practitioners who find the exhibition of mercury diminish the mortality in this last disease. f Surgeon Macdermot, 4th regiment. Officinl report to the Army Medical Board, December 20, 1821. FEVER, (YELLOW) 267 to flow, will often check it. In this stage of the disease every thing may be expected if circum- stances admit of incessant good nursing, with the frequent supply, in small quantities, of nourishing articles of diet, as sago, arrow-root, broths, panado, &c, and wine or porter. This may be the place to refer to the hemorrhage from leech-wounds, formerly stated as likely to occur, and which it is extremely difficult to suppress when in soft parts, as the epigastrium ; here minute bits of lint, dip- ped in the tinct. ferri mur., and pressed on each bleeding point by means of a probe, will be found more effectual than even the application of caustic in substance. The occasional employment of other remedies, as saline draughts, sudorifics, opiates, ether, vari- ous cordials and aromatics, call for no particular remark. Where the remarkable " burning sensa- tion" take places, extending sometimes as high as the pharynx, from about the cardiac orifice of the stomach, calcined magnesia and prepared ehalk have each afforded occasional relief; but these cases must be considered as utterly hope- less. When in the advanced stages great ex- haustion has been produced by the incessant vomiting and want of sleep, a moderate dose of opium and capsicum, in minutely-divided pills, has sometimes produced a better effect than other medicines. The most grateful drinks are spruce or ginger- beer, or a mixture of the white of egg, sugar, water, and some aromatic. As no small consid- eration in the management of patients, the tempe- rature of the hospitals or apartments demands great attention. From what they have seen use- ful in other fevers, those unacquainted with the peculiarities of this disease are very apt to err on the side of over-ventilation, whereby, in some of its forms and stages, the vital energies are liable to lie lowered perhaps to an irretrievable degree in an inconceivably short space of time ; hence tents, or slightly constructed huts, or temporary build- ings are always objectionable. During the epi- demic of 1828 at Gibraltar, a visit was made to one of the hospitals by Dr. Broadfoot, Mr. Amiel, and the writer of this article, when it was observed that in two of the wards an extraordinary propor- tion of the patients were doing well, and that in almost all these the specific action of mercury on the salivary glands had taken place. On inquiry it was established that, from an accidental circum- stance, these wards were what might be called, very badly ventilated; and the circumstances altogether struck Mr. Amiel so forcibly that he instantly returned to his own hospital (12th regi- ment) and altered the plan of ventilation which had been previously adopted. This may at least be sufficient to draw attention to the point. [In the epidemic of Gibraltar, of 1828, to which allusion has been so often made, the practice adopted by the medical staff of the British army here no resemblance to that of the private practi- tioners of Gibraltar. The mortality under the plan pursued by the former was one in four and a half. The Spanish physicians employed bleeding very moderately, and only at the commencement of the disease ; opened the bowels by gentle laxa- tives, or in the advanced stages by enemata, and gave mercury only in a few very severe cases. The mortality of this plan was one in six, a pro- portion which led the population of Gibraltar to consider the Spanish physicians to be much more successful than the British. It is affirmed, how- ever, by M. Louis (op. cit.) that the difference was more apparent than real. All the patients treated by the military surgeons were, with few exceptions, robust and in the vigour of life. The male patients in the city, on the other hand, were, as a class, less robust than the soldiers, and a large portion of the civic patients was composed of women and children. It was found that strength and vigour of constitution appeared to be unfavourable to recovery, the ratio of mortality among children, as before observed, being one in seven, that of females one in five and a half, and that of males one in four and a half. Still, as elsewhere remarked, (Practice of Medicine, 2d edit. ii. 467,) the management of the Spanish phy- sicians would appear to have been judicious, and equally favourable with the more heroic practice of the British army practitioners.] Contagion.—Those who have in the least en- tered into the subject of yellow fever must be aware of the total impossibility of giving, here, even a slight sketch of all that has been brought forward from time to time on this part of our sub- ject. The discussions regarding a great mass of details, up to a certain period, may be said to be condensed in the works of Blane, Fellows, and Pym, on the side of contagion; and of Bancroft, Jackson, Maclean, and Burnett on the opposite side. The elaborate works of Dr. Bancroft espe- cially (" Essay on Yellow Fever," " Sequel to an Essay on Yellow Fever") embraced whatever could at the time be deemed the most essential points for consideration. From his analysis of the events of 1793 in the West Indies, as well as from statements furnished by other writers and the details given in the first part of this essay, it must be evident that Dr. Chisholm could not have been acquainted with the history of the dis- ease when he stated that it made its first appear- ance in those islands in the year just mentioned. Dr. Bancroft's arguments against the importation of the disease in that year by the ship Hankey are greatly strengthened by the facts brought for- ward in a pamphlet on yellow fever by Dr. Veitch, of the Royal Navy. It is usual to refer to Pere Labat's statement of the alleged importation of the disease into Martinique, in 1682, by the ship Oriflamme, from Siam ; to which it is objected that he has merely given vague reports of circumstances which oc- curred several years before his arrival in that island ; and that if, as he states, the disease had been contracted at Brazil, where the ship touched, it was palpably erroneous to say that it had been imported from Siam. In the second volume, page 119, of Dr. Chisholm's work on the fevers of the West Indies, he gives an account, also, of an im- portation of the yellow fever into the island of Martinique while in our possession in 1796, which is very circumstantially proved to be erroneous in a paper to be found in the eighth volume of the Medico-Chirurgical Transactions, by Dr. Fergus- son, inspector-general of hospitals, who happened to have served at the time with the troops on board the ship alleged to have imported the dis- 268 FEVER, (YELLOW) ease. There can be no doubt that among those who supported the views of Dr. Chisholm on con- tagion, respectable names are to be found; but even so soon after the periods to which he refers as 1801, when it fell to our lot to witness devas- tating epidemics in Martinique and Dominique, our experienced medical chief, Dr. Theodore Gor- don, did not think it expedient to suggest any measures applicable to contagious diseases, nor did an apprehension upon the subject of contagion ever escape the lips of any of our seniors with whom we served. As regarded the men and offi- cers on this occasion, an individual coming in contact with the disease for the first time could hardly, perhaps, form an opinion worthy of much attention ; but a most remarkable circumstance was the total exemption of women and children under a certain age, as already noticed in the his- torical part of this essay, although no steps were taken in the way of precautionary measures. In examining the official documents to be found in the office of the Army Medical Board in Lon- don, the following passage, contained in the report of inspector-general Tegart, dated 10th of March, 1823, is particularly striking: "In the various annual reports of the medical officers in this com- mand, I have not seen one favouring or supporting the theory of contagion : they are all on the other side." This seems the more remarkable, as isola- tion of yellow fever cases, to a greater or less ex- tent, was a measure approved of a short time before by Mr. Inspector Green, one of those gen- tlemen who had previously served in the West Indies about the time of Dr. Chisholm. Mr. Tegert, referring in his report to certain cases which occurred at Antigua in 1801, says, " The result is that this was decidedly yellow fever, and that the disease ceased on removal from the place, and was confined solely to those persons who oc- cupied the room. Here is cause and effect." It ~nust be admitted that, among the advocates of the contagion of yellow fever, very few are to be found in the West Indies in the present day. Dr. John Arthur, however, in an official report from Barba- does, of the 17th of March, 1821, furnishes a mass of details, the result of his own observation, favouring that side of the question ; and although most of his details on this point may be consi- dered by some as only simulative of contagion, (the great error of former observers,) as they re- late to individuals exposed equally or nearly so to other general causes prevalent at the period, the document is one which deserves on every account to \e referred to, and especially should a parlia- mentary investigation on the subject of the con- tagion of yellow fever be again instituted in this country. Among the few who have of late years advocated the doctrine of contagion in the disease as it prevails in the West Indies, surgeon Callow of the 84th regiment is to be mentioned. In an official report, detailing the events connected with the epidemic of 1827, in his corps, at Fort Au- gusta, Jamaica, he states that, after a certain time, " strong evidence of the disease propagating itself began to appear." His chief reasons for coming to this conclusion seem to be that the attendants about the sick of every denomination suffered re- markably, and that the surgical patients were also attacked. In the report itself, however, unbiassed persons will discover the following reasons for hesitating before they draw similar conclusions:— 1st, he states, that previous to the breaking out of the epidemic, he made an official report on the de- fects of the building occupied as an hospital, and situated close to the lagune, whence disagreeable odours arose : 2dly, that, during the epidemic, the winds in the night " had generally blown from s. w. very strong for some hours, a very unusual circumstance," the more prevalent winds from e., s., or s. w., preserving, as he states, the low sandy point on which Fort Augusta is built, from more frequent sources of sickness. 3dly. He describes the barracks as being in three ranges or divisions, and that, up to a certain day, every case which had occurred had been at the extremity of each range of barrack, " and in no other,-" a very re- markable fact, certainly. 4thly. It appears that, after his regiment removed from Fort Augusta to a camp-ground near Stony-Hill, it became healthy, any fresh cases being, as he admits, traced to their origin in the Fort.- some of the men confessed, indeed, that they had been ill previous to the move Dr. Weir, physician to the forces, in commenting on these events, in an official report dated Kings- ton, February 13, 1828, remarks that " there are some circumstances connected with the history of the lately prevailing epidemic, which, viewed in the abstract, might seem to favour the theory that this disease is endowed with a self-discriminating property ; but, on the other hand, such would ap- pear to be far out-balanced by many powerful facts : of these no little weight is due to the sim- ple and well-authenticated truth, that a change of locale invariably and almost instantaneously ar- rests the destroyer in its progress, and that too without any bad consequences, as is well instanced in the above, and in the removal of the 33J and 22d detachments to Port Royal, where the royal artillery occupied the very same barrack, without suffering in the slightest degree." We have, in the circumstances just referred to respecting the 84th regiment, several points within a small com- pass, which should never be lost sight of in the consideration of such questions. The exemption of hospital attendants, in the following instance, will by many be probably ascribed to the circum- stance of the building occupied as an hospital having been in a more healthy situation than that of the Sith regiment, at Fort Augusta.— " I have now, however, the heart-felt satisfaction of stating that, from the 20th of June, 1821, to the 20th of February, 1822, which includes the whole period of the sickly season, not one medical officer, white servant, or person employed in any capacity in the Naval Hospital* establishment, had been attacked with yellow fever, or any spe- cies of fever."+ Dr. Bone has resided in the West Indies for many years, and has from time to time drawn up elaborate reports upon yellow fever, frequently re- ferred to by the members of the department to which he belongs ; it may, therefore, be stated, for the benefit of those in search of information on this subject, that he says, in the same report, " the * A splendid establishment, appropriated for some years past to the accommodation of the sick of the army. t Official report from Dr. Bone, deputy-inspector-gene- ral of hospitals, Barbadoes. FEVER, (Y first important result which I have proved in the Naval Hospital is, that the yellow fever, as it is called, cannot by any possibility be communicated from one person to another." He states that thirty- five white servants had been employed, and con- cludes by observing, « So few in the West Indies believe the doctrine [contagion] that they may very safely be permitted to enjoy their own opinions: they cannot do much harm." We cannot pass over the official statements of Mr. Hartle, deputy inspector-general of hospitals, who has served in the West Indies through the various grades of the medical department of our army, during a period of more than thirty consecu- tive years. His report for 1822 contains particulars of a most interesting kind relative to the introduc- tion (without subsequent diffusion of the disease) of many cases of the yellow fever into the island of Antigua: in one place he remarks, " It is a pleasing reflection, and a source of great gratifica- tion to me, that, notwithstanding one hundred and seven cases of yellow fever, as distressing and malignant as any I have before witnessed, have been by three vessels imported into this island since September, 1821, we have not a single instance of any individual but those directly exposed to the local causes [ships] having been attacked." He states that the sick received on shore from one of those ships (Dasher transport) were attended by Europeans. Mr. Hartle's account of the yellow fever on board the Pyramus frigate, which arrived in Kingston Harbour from Barbadoes, with many of her crew affected with the disease, on the 3d of January 1822, is highly important. The follow- ing are the principal facts recorded by this gentle- man. Neither the. officers nor men had been ex- posed to solar influence or other exciting causes. One of the principal reasons assigned for the breaking out of the disease was that this ship had been «injected with coal-tar, which, with bilge- water, caused remarkable effluvia." The only ships on the station injected with coal-tar, were the above, the Esk sloop of war, and Dasher transport, " all of which suffered, the former and latter espe- cially, with a similar type of disease, yellow fever, in its most malignant form." He states that the crew of the Pyramus were landed and the ship dismantled. When the limber-boards were re- moved, the effluvium from the hold surpassed every thing which he had " ever before experienced." A boatswain looking into the hold from the lower deck, while an inspection by proper officers was going on, fainted, and passed afterwards through a formidable attack of the disease. Mr. Hartle him- self, who was one of the officers appointed to examine into the state of the ship, escaped with slight indisposition. This gentleman states, respect- ing the others, that " every individual present at the opening of the holds and limber-boards was attacked by the prevailing disease." Although the frigate had been only six months from England, and was believed to have been a short time out of dock, four large mud-boats of filth were removed from her at Antigua, which was nine inches in depth in the hold. The negroes employed in re- moving this mass were obliged to go on deck occa- sionally, so insufferable was the stench, and three of them had the characteristic disease. The after- magazine, immediately under the gun-room, was x* fELLOW) 269 found in the worst state, and this accounted, in the opinion of Mr. Hartle, for every officer's servant and servant of the gun-room mess having suffered. Objections having been made to the removal of the crew beyond the dock-yard, after their landing on the 15th, several cases occurred up to the 30th, in consequence, as was discovered, of the men having gone on board clandestinely ; the crew were therefore encamped at some distance from the dock- yard, while a cleansing and thorough purification took place ; and on returning on board, their general state of health continued good. Within the last few years much valuable inform- ation upon yellow fever has been from time to time furnished by Dr. W. Fergusson, inspector-gene- ral of hospitals ; and it is to be regretted that want of space precludes the possibility of extract- ing, as freely as would be desirable, from docu- ments furnished by a gentleman of such great experience, tact, and candour. His paper in the eighth volume of the Medico-Chirurgical Trans- actions is particularly interesting, and refers chiefly to transactions which occurred while he was prin- cipal medical officer in the West Indies in 1816, &c. Dr. Fergusson is quite adverse to the doc- trine of contagion in yellow fever; and it will be admitted, as we conceive, that the facts which he has adduced in the paper just mentioned, are cal- culated of themselves to make a powerful impres- sion. He shows, that, without restraint as to intercourse, situation alone has given great com- parative exemption from yellow fever to raw sol- diers from England over civilians; that the dis- ease " is confined, in all the islands, to the sea- coast ;" and that, " at Barbadoes, our hospitals, of late years, have been in a regular course of im- portation of the yellow fever from the navy ; but not even inoculation has been able to produce the disease upon any member of the hospital corps, by whom I may truly say that the sick have been received with open arms ; for the anti-social doc- trines of ideal contagions are not preached among us here, to the prejudice of duty and humanity." Speaking of the general impression of St. Domin- go, on the subject of contagion, during our occu- pation of that island, he says, «I never even heard the idea started, nor do I recollect a single precaution, advice, or observation, that acknow- ledged the existence of contagion, ever being di- rected to the medical staff from any quarter. I appeal to the writings of Dr. M'Lean, the living evidence of Mr. Weir, Dr. Jackson, Drs, Theo- dore Gordon, Borland, Inspector Warren, and all the medical officers who served there, to bear me out in this assertion. I appeal to the evidence of every medical officer now serving in the West Indies, that has ever had experience of the dis. ease (for there may very probably be found con- tagionists among those who never saw it) to say wnether in their lives they ever met with a case of yellow fever that could with greater feasibility be traced to personal communication with a sub- ject labouring under the disease, than to the ordi- nary natural causes from which it has been proved to originate." Dr. Fergusson's remarks go to corroborate the curious fact occasionally to be found in authors as to " different parts of the same town being differently affected ; and so lim- ited often is their influence, that one story of a 270 FEVER, (YELLOW) house,* or one section of a ship, will be strongly af- fected by it, while other parts of the same tenements remain healthy." In the paper from which these extracts are taken, will be found details of the highest value relative to the disease in question, as it prevailed among the crew of the Regalia transport, employed in carrying black recruits from the coast of Guinea to the West Indies in 1816; and from which it appears that the crew were in good health previous to taking in many tons of green wood at Sierra Leone; that great sickness (chiefly dysentery) prevailed among the blacks during the voyage; and that several deaths took place; but the yellow fever was altogether confined to the crew ; and, in the words of Dr. Fergusson, " the ship, on her arrival at Barbadoes, was not put under restraint or quarantine, but communicated freely with the sea-ports of Barba- does, the Saints, Antigua, and Gaudaloupe ; land- ing the severally ill or dying subjects of that dis- ease amongst the inhabitants, and at the Hospitals at Barbadoes and Antigua, without communicat- ing infection at any of these places; and finally, after having undergone a thorough purification, sailing from Gaudaloupe for Europe, crowded to a very qreat degree with rebel French prisoners and their families from the jails, under the most dangerous circumstances of health, with a case of yellow fever actually dying on board the day before she left Basseterre roads, but without com- municating any such fevers to the unfortunate ,»assengers, leaving any behind her at Gaudaloupe, >r importing any at the ports she ultimately reach- id." Dr. Fergusson, when speaking of an epi- demic which took place in the following year, says, " what a different interpretation the facts I have collected would have borne, had the present epidemic that afflicts the islands broke out in the ordinary course of the seasons, a year earlier, at the time the Regalia was here." We shall only offer one more extract: "At Martinique they established a strict quarantine, particularly direct- ed against Guadaloupe, and they have been con- sumed with yellow fevers; but at Dominique, Tobago, St. Vincents, &c, where they established none at all, they have not had, in as far as I have learnt, a single case, although at the last-mentioned islands both the Tigris and Childers ships of war imported distinct well-marked instances of the disease from Point au Pitre, on the evacuation of Guadaloupe." Previous to closing this sketch of the question of contagion as connected with the importation of yellow fever into our West India colonies, it may be worth while drawing attention to an extract of a letter from Mr. Showers, ten years colonial sur- geon of Sierra Leone, the first being the very year (1816) in which the Regalia sailed from that place : —« During my ten years' stay at Sierra Leone I never saw any other fever, [the ordinary * At Gibraltar, during the epidemic of 1P28, we observ- td this lo have been the case in a very remarkable man- lier in some instances; and Dr. Uamsay, surgeon to the tore-., states, in an official report, dated Barbadoes, 20th D. o-mber l--,. that "in certain barracks and hospitals the v.-ry diagonal of particular apartments will afford a tolerably accurate demarcation of safe and unsafe posi- tion of beds." See on this point also Dr. Wilson's work on ye low fever (l£v>7), in which the disease is shown to have b.eii confined to men whose berths were on a par- "cular side, or in a particular part of a ship. fever of the country;] but when a fever broke out there similar to the yellow fever of the West In- dies, (the year 1823 is here referred to,) attended with black vomit, which was supposed to have been brought there from the Mediterranean by a ship called the Caroline, this I recognised as a dif- ferent fever from the one I have just described, from the common fever of the country; and to my knowledge none of the medical men then at Sierra Leone had any difficulty in distinguishing it as a | new and different disease."-)- Mr. Showers adds, at the close of his tetter, that respecting the fever of 1823, he had " his doubts whether it was im- ported or contagious ; I am much of opinion that it proceeded from the atmosphere;" which doubts he was the more justified in entertaining from the known fact that for two years previous no yellow ' fever epidemic existed at any port in the Mediter- ranean. To those who had been led to believe that the true black-vomit fever had been not un- frequently exported from the coast of West Afiica, its reputed birth-place, this visitation as a perfect stranger, and its alleged importation from Europe, I must appear somewhat strange. The healthy state of the Regalia transport previous to her sailing from Sierra Leone, together with what appears by Mr. Showers' letter as to the non-existence of the ' yellow fever there in 1816, would seem to favour Dr. Fergusson's idea of its having been produced by the great quantity of green wood| just laid in previous to her sailing, and to " foul ballasting | that had not been changed for years." However it may affect the question of contagion, it would, considering the mass of evidence now before the public from various sources, be quite idle to deny the spontaneous breaking out of yellow fever on board of ships in the West Indies, and, more rarely, in other places : one of the best authenticated instances is that of the Bedford, seventy-four, in Gibraltar-Bay, so far back as 1794, of which there are official records at Somerset House. In that year yellow fever was not prevalent in the garri- son, and the crew arrived in perfect health from the Mediterranean on the 24th of August. On j Sunday the 6th of September, the crew having been mustered, every man answered to his name; but in the course of the week one hundred and j thirty were sent to the hospital, with fever pos- sessing the characteristic symptoms . eleven died j before the 24th of September, and others were left | dangerously ill on the departure of the ship that ; day. In this case the only feasible cause assigned I was the shifting of the shingle ballast, after the ! ship arrived, with the object of trimming her. The disease did not extend beyond the sailors of this ship. The fact (considered at one time as an indubitable proof of the propagation by contagion) of the sailors of the British brig of war Carnation having been attacked with the disease when put on board the French brig Palinure, by which she was captured, near Martinique, in 1808, as stated in the Dictionnaire des Sciences Medicates, would admit of the explanation of their having, in com- t Seo Mr. Showers' Letter, dated Malta, 27th July, 1830, in Dr. Aiton's Dissertations on Malaria, &c., IKS. I In the official report of Mr. Hartle, lately referred to, it is stated, on the authority of Mr. Mortimer of the Royal Navy, that the Nayden frigate having taken in green wood at Douiinico, lost one-third of her cievv by lev '-r. FEVER, (YELLOW) 271 mon with the previous cSses existing in the Pali- nure, originated from sources within this ship, and independently of persons. The following is among the most recent instances of the spontane- ous irruption of black-vomit fever on board ship. His Majesty's ship Blossom had been for sometime employed in the summer of 1830, in surveying the Honduras coast; and in the month of August the disease commenced, which obliged the captain to go into Belise harbour, to obtain medical assist- ance from the garrison, into the military hospital of which forty-eight cases were received between the 11th and 30th of August: two officers and eight men died, and " these cases were attended with black vomit," according to the gentleman who had charge of them, assistant-surgeon Watts, of the second West India regiment, who had pre- viously served in Jamaica, and who forwarded notes of the circumstances in his official return to the Army Medical Board for the quarter ending the 24th o'f September, 1830. Mr. Watts adds that the disease did not extend to the other ships, or to persons on shore. In a report from Dr. Lindsay, surgeon to the Blossom, to the heads of his department, relative to the event in question, he says, " I am of opinion that the cause of the present illness arose in the ship herself." Among the naval surgeons of the present day, of practical knowledge in this disease, we do not find many supporters of the doctrine of contagion'; and among the observations on this point published of late years, Dr. Wilson's stand pre-eminent. The fol- lowing from Mr. Mortimer, while serving as prin- cipal naval medical officer at Barbadoes, are forci- ble : " We do not allow the fever of the West In- dies, commonly called 'yellow fever,' to be at all infectious in any of its forms or stages. We have never known of an instance of its communication to patients at the several naval hospitals, whilst under cure for other complaints, though such pa- tients have never been interdicted, on the contrary encouraged to offer every additional aid for the greater comfort of their suffering brethren." (See Communication to Commissioners of Transports. —Med. Chir. Rev. vol. viii.) Passing now to the American continent, our limits admit but of a few brief remarks. Up to the year 1793, almost all the medical men in the United States were believers in the communicable nature of yellow fever ; but each successive epi- demic diminished the numbers, so that in 1825, according to an American commercial almanack, while five hundred and sixty-seven were against the doctrine of contagion, twenty-eight only re- mained in favour of it, throughout the whole coun- try ; the latter number being in all probability now reduced, as some of those mentioned were very aged. The public manner in which the cele- brated Dr. Rush, once a believer in contagion, re- tracted his opinion, after farther observation, is matter of historical notoriety. At New-York the doctrine of contagion is still ardently supported by two physicians in particular, — Professor Hossack and Dr. Townsend, who have both written much upon the disease. The facts which presented themselves to Dr. Beck in the course of the last epidemic at New-York (1822), caused his public retraction of faith as to contagion in the following year, (New-York Med. and Ph. Journal, No. viii. p. 472); and Dr. Townsend appears to have admitted (Chervia. De I'Opinion des Medecins Americains, p. 11,) that, of about two hundred persons of all grades of the profession in that city, three or four only believed lately in the transmis- sible nature of yellow fever. "In 1793 the pro- fession were almost unanimous in the belief of ire contagious character, and no little courage was required to brave the storm an opposite opinion would have awakened. In this generation an equal unanimity prevails in the profession as to the non-contagious nature of the disease; and he who advances the opposite doctrine seriously, is deemed no more worthy of notice, much less a refutation, than would be an advocate at this time of the Ptolemaic system." (See Amer. Journ. of Medical Sciences, August, 1829, p. 523.) Upon this highly important question, the following un- published statement from the pen of M. La Roche, French consul at Philadelphia, cannot but be im- portant: it is extracted from a letter, which we have had in our possession, to a friend of his in Paris, dated the 20th of July, 1830. « A friend of mine, Dr. Morrel, has lately arrived from the Havannah. During a few days' passage three per- sons died of yellow fever on board, and a fourth, taken ill on board, died in the New-York quaran- tine establishment. The sick were all cabin pas- sengers, and received the germs of the fever in the port. The other passengers, who merely embarked at the moment of departure, without having waited in port, remained well, and that notwithstanding the inevitable contact arising from twelve or fifteen persons sleeping in a small cabin. Dr. Morrel and the other passengers were placed in quaran- tine, but during the time every body went to see them." Much interesting matter relative to the evidence on the subject of contagion in the yellow-fever epidemics which have from time to time prevailed in America, may be obtained by consulting various pamphlets published by Dr. Chervin of Paris, who has made the subject of yellow fever his particular study for many years of his life. In those pam- phlets will be found evidence of zeal in the cause of science quite unparalleled, as well as of impar- tiality in his proceedings in search of truth. It is quite impossible in the present day, to meet the subject of contagion of yellow fever fully, without a knowledge of the nature and extent of his re- searches. Here, with a view of showing their value, we may give a few extracts from the com- mission appointed by the Academy of Sciences in Paris, in 1827, to adjudge the prize designed for labours in medical science. The commissaires were MM. Portal, Boyer, Chaptal, Dumeril, Du- long, Gay-Lussac, de Blainville, Frederic Cuvier, and Magendie. The report made by the above gentlemen, after stating some unusual steps taken by Dr. Chervin to ascertain the contagious or noncontagious na- ture of the yellow fever at Guadaloupe, to which place he had proceeded from Paris, for the sole purpose of making investigations, proceeds thus:— " This is nothing ! — It was, on the contrary, then that Dr. Chervin conceived the wisest and vastesi plan that ever a medical'man formed for the inte- rests of humanity. " It was no longer sufficient for him that hel.au 272 FEVER, (YELLOW) satisfied himself that the yellow fever was not con- tagious in Guadaloupe; it became necessary to ascertain whether it did not possess that character in other localities and in other latitudes and cli- mates. It was above all things necessary to con- vince the governments of Europe, so that com- merce might be freed from unnecessary precau- tions, felt to be burthensome, and that nations might be saved great expense in sanitary establish- ments. In attaining his object, Dr. Chervin was only impelled by his ardent philanthropy—no other means, but the sacrifice of his patrimony — no support but his own inclination and physical powers — let it be declared to the honour of hu- manity, that by such means alone enterprises of this kind could be accomplished; and in fact, what a powerful government could scarcely hope to ob- tain at great expense, Dr. Chervin proposed to himself to obtain. " Dr. Chervin performed this gigantic under- taking, to which the history of medicine furnishes no parallel, in a fortunate manner, but with un- heard-of efforts, and perseverance above all praise." Speaking of his having collected the evidence of hundreds of medical men in all parts of the world where the yellow fever is known to prevail, the report continues — " He visited, in eight years, all the colonies belonging to France, England, Spain, Holland, Denmark, Sweden: he visited all parts of North America, where yellow fever has shown itself, from New-Orleans to Portland, in the state of Maine; so that from Cayenne to this last place he traversed over and made investiga- tions in 37 degrees of latitude." " It [the commission] therefore proposes; to ad- judge him a prize of 10,000 francs: undoubtedly a poor reward for the many sacrifices, which he must have made ; but when a person has, like Dr. Chervin, merited so much from science and hu- manity, and shown such disinterestedness, on voit la couronne et non pas sa valeur." In a work of high character (Dictionnaire de la Medicine et de Chirurgie, vol. v. article Con- tagion) Dr. Chervin's labours in the cause of truth are thus alluded to : " Observe, in regard to this last subject, [viz. the error of attributing to contagion what should be referred to local causes,] what occurred respecting the yellow fever epi- demic of 1821, in the unfortunate city of Barce- lona. Read the work of the French Medical Com- mission* appointed to examine into that epidemic, and it will be impossible for you, (admitting as true the statements therein contained) not to ad- mit the existence of contagion. But afterwards, when you have read the precious documents col- lected by Dr. Chervin with a degree of zeal and patience truly admirable, you will rest convinced that thu circumstances which led you to be of the same opinion with the commissioners as to the reality of contagion, are any thing but conclusive; thencefoiward the idea of contagion will be effaced from your mind, comme un vain songe; and, pressed on every side by the evidence of observa- tions, you will be compelled to attribute to local infection]- those circumstances which, misled by * At the head of which was, be it remembered, Mons. Pariset, Medical Chief of the Quarantine Department. t We know that in France the word infection is ex- clusively applied to places, not to transmission of a dis- ease, directly or indirectly, from person to person. inaccurate statements, you had placed to the ac- count of contagion." That in North America the disease has not been propagated by the removal of persons labouring under it, even when carrying with them their bedding, &c. has been shown by observations made there during many years by medical men (some even professed contagionists,) in instances of upwards of thirty cities and towns, according to a report upon Dr. Chervin's documents, read at the Academy. By those documents it also ap- pears that attendants of all classes on yellow fever patients constantly remained exempt from the dis- ease in that country, where the hospitals wen placed out of particular local influences. This it appears was the case at the hospital at Bush- hill, near Philadelphia; in that of Belle-vue, near Fort Stevens ; in that of the navy, at New York; also in those of Norfolk, Baltimore, Providence, Newport, Boston, and New London. /These most important facts are verified by Drs. Chapman, Redmond Coxe, Mease, Lehman, Mitchell, Par- rish, Jackson, Perkins, Miller, Tucker, Thomas, Bache, Harlan, Coates, &c. of Philadelphia; by Drs. Anderson, Brown, Walker, Drake, and Os- borne, of New York ; by Dr. Archer, of Norfolk; by Dr. M'Cauley, of Baltimore ; by Dr. Weaton, of Providence; by Drs. Turner and Waring, of Newport; by Dr. Townsend, of Boston, and Dr. Lee, of New London. Proofs to the same effect collected in the West Indies, were laid before the Academy in 1827, by Dr. Chervin. Dr. Pariset, medical chief of the quarantine de- partment in France, has admitted that the yellow fever " is not contagious in America,—whether it had ever been so, or had ceased to possess that property."^ With respect to South America, the points bearing upon this part of our subject have per- haps been more fully entered upon by Humboldt than by any other person. In his Political Essay, (vol. iv.) he mentions that at Vera Cruz the idea of the importation of the disease from the Havan- nah and other places had been from time to time entertained; but by the facts which he furnishes, there seems to be no reasonable cause for doubt as to the disease being indigenous at the former place. The subject of contagion is investigated by this celebrated man in the spirit of philosophy for which he is so remarkable: we are shown by him to what an extent one test of the communi- cable nature of a disease—that of taking people, actually ill of a disease, into healthy districts- has been applied, and the result proved to be en- tirely against the doctrine; that not only at Xalapa, and higher up in the interior, but at the farm of Eucero, a short distance from Vera Cruz, the dis- ease is found to confine itself to the persons of those who may arrive with it in their systems from the latter place, notwithstanding the freest inter- course with others. Every observation made by Humboldt throughout his works, relative to yel- low fever, is of high interest: one seems peculi- arly deserving of attention ; which is, that although the disease usually prevails among the newly ar- rived every year at Vera Cruz, it never prevailed \ " N'est point contagieuse en Amerique, soit QU^"e ne 1'ait jamais ete, soit qu'elle ait cesse de l'etre." Bui letin des Sciences Med., torn. xii. p. 126. FEVER, (YELLOW) 273 epidemically there between 1776 and 1794, al- I though the intercourse with the Havannah and other places where the disease continued to pre- vail, was quite free. He even says that during the eight years preceding 1794, » there was not a single example of the vomito, although the con- course of Europeans and Mexicans from the inte- rior was extremely great, and the sailors gave themselves up to the same excesses which are now laid to their charge."* Such a fact is the more worthy of notice, as it does not appear to have depended on unusual atmospheric states during this period ; and one can scarcely concede any very great degree of importance to the circum- stance of the streets of that city having been for the first time paved in the year 1775, seeing that the disease has recurred so often since 1794, and has prevailed so frequently in the well-paved streets of St. Pierre Martinique, of Cadiz, Seville, Gibraltar, &c. To turn now to a view of the question as to whether this disease has been proved in Spain to have possessed the property of propagating itself from person to person, immediately or mediately, it appears that so far back as 1761, (21st Octo- ber,) a royal edict was issued at Madrid, which set forth that all experience of the intercourse be- tween the Havannah and Cadiz had proved that the black-vomit fever was not contagious. It would appear from this that the opinion of the court physician Cervo, sent to inquire into the nature of the Cadiz epidemics of 1730 and 1731, had been more regarded than that of Navarette, who attributed their origin to importation from America. It seems very curious that the late Dr. Arejula of Cadiz should, when he wrote his work on yellow fever in 1806, and which is so valuable in many respects, have laboured under the great error of the black-vomit disease of the Havannah, Vera Cruz, &c. being a different disease from that now so generally known by the name of yellow fever, and admitted to be identical. He appears in the strange dilemma of contending for the con- tagion and importation of the disease under one denomination, (yellow fever,) while he admits freely that in America " a succession of ages proved to the medical men that the disease was not communicable :" — and speaking of Spain, that " our ships never brought the germs of the black-vomit, even though they had the disease on board when leaving our possessions." This phy- sician, with Drs. Coll and Amellor, also of Cadiz, made a declaration that the medical men commis- sioned to inquire into the causes of the epidemics of 1732 and 1734, pronounced it not to have been propagated by contagion. In all subsequent epide- mics, a great majority of the Spanish practitioners have favoured the doctrine of importation and contagion ; but it would appear from the assertion of Professor Salva, of Barcelona, in his Trozos ineditos, that the public opinions of some had been influenced by political or other causes, for he does not hesitate to state, that when with a view to illustrate the subject of the contagion of * Political Essay on the Kingdom of New Spain, vol. iv p. 194. Dariste, who practised in Martinique for some years, informs us of a similar exemption at. that island between the years 1807 and 1816.; and that old in- habitants remarked intervals of even twenty five years between epidemics. Vol. II___35 yellow fever, he applied for information, private opinions as to its not possessing that property were obtained from some of those who had pub- licly declared the contrary. A commission, insti- tuted at Cadiz to inquire into the origin of the epidemic of 1810 in that city, declared that in none of the six epidemics which had appeared previous to 1805, could the origin of the disease be traced.-j- The importation of the disease alluded to by the commission as having taken place in 1805, had reference to the disembarkation of about two hundred cases from the fleet of Admiral Gra- vina on its arrival from the West Indies. The commission admit that though many of the cases had the most characteristic symptoms, and though the communication with the city was completely free, " the disease did not spread, nor was it in any way communicated." It is also stated that though many cases were sent to the Aguada Hos- pital at Cadiz from a French fleet in 1807, with which a free communication was permitted, the disease did not spread. In addition to the autho- rities cited at the commencement of the present subject, many details connected with the origin of yellow-fever epidemics in Spain up to the year 1820, and which cannot possibly be entered upon in detail here, are to be found in Hurtado's " Nueva Monografia" in his " Decadas,•" in Mr. Dough- ty's book; in the writings of Dr. Pariset; and in various pamphlets published in Paris since 1827 by Dr. Chervin. Regarding Gibraltar in particular, we may be allowed to state that a residence there within the last few years brought us into frequent contact with a gentleman who had been present during the existence of the disease in the years 1810, 13, and 14, — Mr. Amiel, many years on the medical staff of Gibraltar, and now surgeon to the 12th regiment. The evidence of this gentleman, com- prising the fullest details upon every point, goes to refute the statements made regarding the im- portation of the disease at any of the periods in question, and is fully corroborative of the evidence upon the subject placed before the public by Sir W. Burnett and Dr. Bancroft. The only forms in which Mr. Amiel's statement have come before the public are, a short memoir printed at Gibraltar, and a paper to be found in the Edinburgh Medical and Surgical Journal for April 1831. We have been assured by him that the impression given (see Pym on the " Bulam" Fever) by the present superintendent of quarantine in this country, as to the disease having been cut short in 1801 by his recommendation of segregating the cases, is utterly fallacious; for, as has also been specially certified to us by Dr. Bobadilla, another practi- tioner resident during many years in Gibraltar, the progress of the disease was stopped as it is always found to be, by the setting in of a cold wind from the north. It must be obvious that placing a point like this on its true footing is of the highest importance to the public. Notwith standing the body of evidence on record against f " En ninguna de estas epocas, exceptuada la de 1805 en que vino de fuera, se ha podidoaveriguar con exacti- tud, el origen de esta calamidad publica." " At none of these periods, except 1805, (in which it was imported! could this origin of this public calamity be determined with exactness." Extract from the Report of the Com mission. 274 contagion in all the Gibraltar yellow-fever epide- mics up to the year 1814, and though from Ban- croft's works it' appears that among the medical men of that garrison the majority of opinions had been greatly against it, it was nevertheless impos- sible that unbiassed persons should be uninfluenced by the statements published by two officers of the quarantine department, (Ibid.—Fraser's (W. W.) Letter to Lord Chatham), who, having been on the spot, had ample opportunities of arriving at the truth on such points. The circumstance here alluded to is the assertion that, during the epide- mic of 1813 at Gibraltar, the people employed in the dock-yard there, having been strictly separated from the rest of the garrison, remained free from the disease. Here, then, was evidence fully in support of the utility of quarantines, and of the propriety of separating, on future occasions, the healthy from the sick. But what was the astonish- ment of the profession on finding that mis-state- ments had here taken place of facts, as shown by Dr. O'Halloran, (O'Halloran on the Yellow Fever of Spain, p. 168,) who had served in a regiment at Gibraltar for some years subsequent to the period. During a residence at Gibraltar, we had ample means, by referring to the declarations of the official authorities at the dock-yard, of con- firming the assertion of Dr. O'Halloran as to se- veral cases of the fever prevalent in 1813 having occurred there, as well as some deaths; indeed the names of twenty-three (of which seven proved fatal) could be here given were it necessary: so that regarding the original statements, no impres- sions favourable to the accuracy or candour of the quarantine officers who made them can be entertained ; and. in the justly severe remarks of Dr. O'Halloran on the subject, to which no reply has been made, future observers of circumstances connected with the public interest have received a salutary warning. The terrific epidemic of 1831 at Barcelona gave a new impulse to the question of the contagion of yellow fever. The statements furnished by the medical commission sent from France* to make researches into the nature and origin of that dis- ease, left a strong impression on the minds of many in the profession favourable to its possessing a communicable property ; and the " Histoire Medi- cale" displays literary powers of a high order on the part of Dr. Pariset, who was at the head of the commission. The same gentleman, however, (Dr. Chervin,) who had devoted so much time and labour, as already shown, in procuring authentic information in the West Indies and America rela- tive to the question of the transmissible nature of the yellow fever, followed Dr. Pariset step by step some time after, not only at Barcelona, but through all parts of Spain where circumstances had been detailed respecting the propagation of the disease. The result has been,—not a mere series of asser- tions against assertions,—but a collection of docu- ments duly authenticated, such as had never before deen laid before the public on any question of this kind. As elucidating a long-pending question of * Dr. Pariset, medical chief of the quarantine depart- >n£iit, with Drs. Francois and Bally. This is not an oc- casion to enter on the alleged political motives by which this commission might have been influenced, with a view to favouring the adoption of the famous cordon sanitaire, previous to the invasion of Spain in 1822. FEVER, (YELLOW) high importance to society, their value may be judged of from the opinion of the Academy of Medicine, which has been already referred to. We regret that space will not permit our furnishing many valuable extracts from the works of this gentleman, published in 1827 and 1828.f We are furnished with the statements of Dr. Pariset and others regarding a multiplicity of events connected with the appearance and progress of the yellow-fever epidemics of Spain; and it cannot but be admitted, we think, that Dr. Chervin has shown, in a manner the most conclusive, that many inaccuracies had crept into those statements, and that the events warranted conclusions quite opposite to those which had been come to. Dr. O'Halloran, who went to Barcelona to observe the epidemic of 1821, had, previously to Dr. Chervin's visit there, pointed out some of the most important errors of Dr. Pariset; and in his book, already referred to, some interesting statements are furnished relative to occurrences at other points. An event very remarkable in the history of yellow fever, and but little spoken of in England, occurred in 1823 at the little port of Passages in the province of Guypuscoa, a place well known to many British naval and military officers, it having been the rendezvous for transports while the British troops occupied the Pyrenees in 1813-14. It is difficult to give an idea of this singular port, situ- ated at the bottom of the Bay of Biscay, and forming a sort of appendage to St. Sebastian's, from which it is distant but a very short way. The entrance is between precipitous rocks, and is so narrow and oblique as to be with difficulty dis- coverable at a very short distance. This miniature town consists for the most part of one small street, placed as it were on a shelf of scarped rock, and so narrow that it. does not admit of the passage of carts or horses, while the rock forming the base of the mountain of Olearso is in some places literally in contact with the houses, which are badly venti- lated, filthy, dark, and crowded. Let us take the events in question from the account given of them by Dr. Arrutti, a'physician long resident in that part of the country, and who, while he would lead us to believe in some places that he considered the disease within certain points contagious, yet relates the f.icts wdiich took place under his obser- vation with such perspicuity and candour, that it is impossible to perceive the smallest intention on his part to mislead. We are informed that, in June 1823, a brig named Donostiarra sailed from the Havannah with a clean bill of health ; and that having lort one man on her voyage, (from ordinary disease as far as was known,) she obtained pratique in the usual way at Corunna, after ten days' quarantine. She subsequently put into St. Andero, and arrived at Passages on the 3d of August, with all on board in perfect health. This t In the " Revue Critique" by Dr. de Fermon of Paris, printed in 1S-29, a resumi of the occurrences here spoken of may be found.—Ur. Reiiler, of Vienna, who has also made yellow fever the subject of particular investigation, and undertook, for the purpose, voyages at different times to the West India Islands and the American con- tinent, states, in a memoir published at Vienna in lfc2S. that the disease " was never imported into Europe or anywhere else ;" and that " it never originates in, or is propagated by contagion " He deplores the manner in which governments are misled, and the best interests of humanity sacrificed, by those who endeavour to mainiuin the present system of quarantine. FEVER, (YELLOW) 27b vessel had been latterly employed in the trade of these ports. As she had been at Corunna and St. Andero previous to her arrival at Passages at the date just mentioned, she was not put into quaran- tine at the latter place. The cargo consisting chiefly of sugar and tobacco, was discharged soon after her arrival; and for several days a great many people of all classes went on board, but without any disease having broken out among those indi- viduals, among the crew, or in the part of the town where the cargo had been deposited. On the 15th, a custom-house officer, who had been several days on board, was taken ill, and he died on the third day, black-vomit having appeared. This man was said to have been much engaged in the hold looking after contraband goods. On the 22d, a man who had been down for some time in the hold surveying the ship's timbers, likewise died. Some of the planks of one of this vessel's sides having been found greatly decayed, twelve carpenters were em- ployed in removing them, and six of the twelve were attacked in quick succession. The opening in the side of the ship commenced on the 19th, and on the 23d the disease began to appear in an unequivocal form in the houses close to which she was moored. Dr. Arrutti proceeds to show in detail, and in the most satisfactory manner, that the dis- ease did not extend beyond a certain number of houses at or near the Plazuella de la picdad, opposite the ship; that where others were attacked whose habitations were at a distance, it was occa- sioned by their having remained for some time within the space to which the malaria from the ship appears to have been limited, and the names and occupations of those persons are given. The heat was excessive in the middle of September, being, as he states, 28i° Reaumur, (about 96° Fahr.,) and the course of the wind favoured the conveyance of the noxious emanations from the ship to the houses near it: he gives the number of each house in which persons were attacked, and names the points beyond them to which individuals labouring under the disease went, and where, not- withstanding the adjuncts of crowded, filthy, and badly-ventilated habitations, the disease did not spread beyond the individual; for as he says, " whether they died or recovered, to none out of the focus was the disease communicated." (Page 70.) In the same page he says, " The inhabitants of Passages took the precaution of not making long delays in the focus of infection; they visited their relatives and friends, and performed towards them all the rights demanded by humanity and society, and the disease became extinct almost in its very origin." He observes, " It therefore results that this fever, examined according to the character it presents, does not offer a character of contagion from individuals." (Loc. cit.) And again, " It was after- wards discovered that many, evading the sanitary regulations, passed out without certificates of health, and took with them clothes, even from the houses where people had died ; but notwithstanding this, there was not the least spreading of the disease in the neighbouring country. If any deaths took place in Loyola, Renteria, or elsewhere, the disease in such cases had been contracted within the focus of infection." Finally, Dr. Arrutti observes, " If this disease had been transmissible by individual contact, what could have put a stop to its progress 1 —no human power: for the people who had been in the closest contact with sick, convalescents, and clothes belonging to the sick, distributed themselves, when the cordon was about to be placed, at St. Jean de Luz, St. Sebastian's, Bayonne, and other places." Here then, as we are necessarily obliged to conclude, is an instance—not of yellow fever imported,—nor, rigidly, of the cause of yellow fever imported, but a development of the disease by the concurrence of a certain number of agents. On other occasions yellow fever has been observed not to break out, until vessels had been cleared of their cargoes; and in this instance the great heat which is stated to have occurred, reverberated as it must have been from the mass of rock close to which the lightened ship was moored, may be easily understood as having been highly favourable to the extrication of a noxious principle from her decayed planks.* In another account of this epi- demic, given by Dr. Montes in the 14th vol. of Hurtado's Decudas, its origin is attributed to sources within the town itself, and totally indepen- dent of the ship, as publicly declared at the time by Dr. Zeubeldia; and that a similar epidemic prevailed there in 1780.-J- There is no discrepancy, however, in the statements as to the disease not having been propagated from person to person ; though, as before intimated, Dr. Arrutti seems to apply the word contagion} to the extension of the disease within the limits of the noxious emanations from the ship. It appears that no inspection, such as took place in the case of the Pyramus, had been instituted here.' From Dr. Arruttrs statements we can now comprehend the possibility of some fever cases having occurred among, the men of this last ship, white they were living in the dock-yard at Antigua, even without their having, as stated, gone on board secretly. As, in the same year in which the above occur- rences took place at Passages, another remarkable circumstance occurred, which has been frequently alluded to, it may be here mentioned, previously to referring to the events connected with the sub- ject of contagion in the last epidemic to be no- ticed. By an official report drawn up and published in 1824, by Dr. (now Sir William) Burnett, one of the commissioners of the Medical Department of His Majesty's Navy, it appears that in the early part of the preceding year a fever made its appearance at Sierra Leone in a form different from the usual remittents of the country, and * The origin of this disease at Passers, from sources on board unconnected with the death of the individual during the vi'vage, has been, on one occasion at least, admitted by Dr. Audouard of Paris, a professed conta- gionist.—See Revue Medicate, Sept. 1824, p. 38. t We were not aware that yellow fever had appea.ed at any other point on this part of the Spanish coast, till lookifnr over lately the official report from Dr. Bone al- ready referred to. "This gentleman says, "At St. Ander, in 1813, none of my assistants, orderlies, [army attend- ants on sick,] or nurses, employed with the cases of yellow fever treated in the Casa blanca in the quarantine hospital, uere attacked with it." | We had been Ions in communication at Gibraltar with a Spanish practitioner of great experience, (Di Bohadillu), and considered him for some time a believer in contagion, in the sense of direct or indirect transmis sion of a disease from one person to another; but to our surprise he assured us, that, at an hospital in i.os Bai rios near Gibraltar, some years ago, he explained to every body how the attendants of all classes on yellow fever patients were not more liable than others to attacks 276 stated to possess symptoms characteristic of yellow fever. The importation of this disease by the merchunt-ship Caroline, as at one time alleged, is completely refuted in this report; and at page 24 an extract of an official document from the gentle- man at the head of the medical department at Sierra Leone is given, in which it is stated, that from all the evidence which could be procured in the colony, there was reason to conclude that the disease was non-contagious. A curious circum- stance, to which there is perhaps no parallel on record except that which, as formerly stated, oc- curred under our own observation in the West Indies in 1801, is related by this gentleman, viz. " that European females and children were per- fectly exempt." Under date of the 23d December, 1823, a state- ment was circulated through the army by Sir Gil- bert Blane, calculated certainly more than any thing which had previously appeared to prove the importation and subsequent diffusion of yellow fever by persons labouring under it. It appears that His Majesty's sloop-of-war the Bann left Sierra Leone for the Island of Ascension at the latter end of March, 1823; that a malignant fever, of which several died, prevailed among the crew, during and for some time after the voyage ; and that, on the eighteenth day after her anchor- ing at Ascension, a disease alleged to have been similar, and in some instances accompanied with black vomit and yellow skin, broke out in the small force composing the garrison of that island, which consisted of thirty-five individuals, officers and men of the marines and artillery, besides women and children. It appears by the details given in Sir William Burnett's report, that an error (of little importance perhaps) had crept into Sir Gilbert's statement regarding the perfect health of the crew of the Bann when she left Sierra Leone; but what is of very great importance has been omitted by the latter gentleman in his letter, though supplied in the very candid statements of the former, — viz. " On reference to the journals of medical officers who at different times had charge of the garrison before the appearance of the late epidemic, an abstract of which is in the Appendix, not only has dysentery and hepatitis been very prevalent, as well as occasional attacks of fever, but likewise a fever called the bilious remittent, in the year 1818, attacked almost every man on the island, which the assistant-surgeon attributes to an unusually wet turtle-season, when the men are much exposed by watching at night to turn these animals. Moreover there is, in the journal of Mr. Robert Malcolm for 1818, a case of this disease, which commenced on the 1st of June, and terminated by death on the next day, with all the symptoms of yellow suffusion and black vomit, &c, which are said to characterize the yellow fever; and having shown this case to the surgeon of the Bann, now in London, he de- clares it to be exactly similar to the cases of fever which lately proved so fatal in the Bann, and amongst the marines at Ascension." (Page 10.) Here then, whatever might have been the nature of the disease which prevailed in the Bann and at Ascension in 1823, we have evidence of the ex- 'stence of the same disease in the island, and about the same time of year, in 1818, without FELLOW) the remotest suspicion of its having been then imported. This, on the obvious principle that what may in one year happen on a small scale, may, from an extension of the cause, happen on a larger scale in another year, greatly enhances the force of the concluding part of Sir William Burnett's sixth position, " that a disease similar to the fever in the Bann might have prevailed in that island though the Bann never had any com- munication with it." (Page 52.) He tells us that " the principal medical officer at Sierra Leone has come to the same conclusion in his official report;" and we suspect that, closely investigated as questions respecting the present subject have lately been, and greatly augmented as the facts bearing upon the question of contagion have been within the last few years, the majority of the pro- fession who have paid attention to yellow fever will be likely to come to the same conclusion, rather than admit as a propter hoc that which, as far as any evidence goes which has yet appeared, was simply a post hoc. Sir William, though fa- vouring, under all the circumstances, the belief of the importation of the disease on the above occasion, candidly leaves the question open, and furnishes all the details within his reach, to ena- ble the profession to form an opinion. He points out erroneous statements as to the particularly healthy state of the island from the period of our occupying it (1815) to the epidemic year 1823. He says, " Out of one hundred and thirty cases of disease which are recorded in these journals, twelve died and nineteen were invalided; and though perhaps all the fatal cases are inserted in the journals, it is well known that those docu- ments seldom contain more than a third of the cases which actually occur." He tells us that, although at the time of the arrival of the Bann, the little garrison was in good health, and that, according to the medical gentlemen in charge, al- though at a period immediately preceding this event " they were on the whole very healthy, yet they were by no means exempt from disease." (Page II.) He admits " that after a most careful inquiry it is impossible to trace the fever in ques- tion directly from the Bann to any individual of the garrison of Ascension," (page 53) ; and in- deed it appears that the first person attacked with the characteristic symptoms was not one of those known to have been in the ship or in contact with the sick, but a boy, on the 11th of May, respect- ing whom " it is neither known nor believed that he had any nearer communication with the sick of the Bann, than passing daily at no great dis- tance from the tents to feed his father's poultry, and he was never on board that ship." (Page 14.) The tents here alluded to were, as pointed out by Sir William at page 5, occupied as an hospital for the accommodation of the sick from the Bann im- mediately on her arrival, and were situated at about five hundred yards from the garrison, and all intercourse was interdicted. He informs us that up to this time the restrictions on the inter- course between the ship and the garrison had not been much attended to, several individuals having been on board after the landing of the sick; but that from the time of the boy's illness " every proper precaution was taken for preventing the extension of the disease to the outposts; notwith- FEVER, ( FEVER, (YELLOW) 277 standing which, «:x men, two women, and seven children, were taken ill at Springs, but fortunately none at the Green Mountain, though one of the men belonging to that post had been on board the Bann at the sate before mentioned." We shall only add that the surgeon of the Bann, » an ex- cellent and intelligent officer," ascribed the disease to the long stay of the ship in port at Sierra Leone, where the crew had been much exposed to the sun's rays in refitting her rigging, &c.; and that when this vessel had been, in 1821, on the Jamaica station, a fever, with yellow skin and black vomit in some of the cases, appeared among a party of forty men, put on board for a passage, who had suffered imprisonment with hard labour at Panama for four months, (page 47); which disease, according to the surgeon's journal, did not extend to the crew, nor could he " trace a single instance of disease to contagion," although " the smallness of the vessel, and other circumstances, would not admit of a separation between the sick and ship's crew." That there were, on a prima facie view of the irruption of the fever in Ascension, reasonable grounds for suspecting the agency of contagion, there cannot be a doubt; but, as may now be seen, it is far from being established by any thing like legitimate induction from evidence, that the one was the cause of the other ; and, added to all that is now known upon the subject of yellow fever, many will probably join with us in believing that, admitting the transmission of this disease from individuals in this instance, would be illogical and nothing short of admitting that to be vrai which is shown to be only vraisemblable. We shall close this essay by referring to some of the facts bearing on the subject of contagion, as they occurred during the yellow-fever epidemic at Gibraltar in 1828,* when it fell to our lot to observe its rise, progress, and termination. For minute details, full of interest, we can confidently refer to what has since been published by the fol- lowing gentlemen of unquestionable veracity :— Mr. Wilson,-)- attached for many years to the du- ties of the Civil Hospital at Gibraltar; Mr. Hugh Fraser,t in charge of the Civil Hospital for some years, having previously served there in the 12th regiment; Mr. Amiel, (Edinburgh Medical and Surgical Journal, April, 1831,) now surgeon to the 12th regiment, a gentleman who has been for more than thirty years in His Majesty's service, and had witnessed the disease at Gibraltar in the former years specified, as well as sporadically on other occasions; Dr. Smith, (Edinburgh Medical and Surgical Journal, No. 106,) surgeon to the * Here as matter for future reference, a view of the mortality from yellow fever at Gibraltar is given forfive years in which the disease appeared there to a remark- able extent, from 1804 inclusive. Years 1804. 1810. 1813. 18)4. 1828. Military and 1 their fami- \..... 869 .... 6 .... 391 .... 114 ...507 lies.......) Chilians..........4,864 ... 17 .... 508-... 132..1,170 Total. .5,733 ... 23.--- 8!)9.... 246.-1,677 Thee papers in Nos. 352, 353, and 354 of the Lancet, which were translated into French and notes added by FY. Chervin, in 1830. I Papers in London Medical and Physical Journal, March. April, and May, 1831, and in Medico-Chirurgical Journal, January, 1831. 23d regiment; and Dr. Chervin,§ one of the mem- bers of the medical commission which arrived at Gibraltar from Paris towards the close of the epi- demic of 1828. Besides these, the French go vernment has published a series of documents fur- nished by the medical commission, to which is appended, on the part of one of them (Dr. Cher- vin), a declaration that statements of some conse- quence afterwards shown to have been erroneous, had obtained a place in the collection. After having paid the utmost attention to every point connected with the first appearance and pro- gress of the epidemic in question, it would be an utter dereliction of our duty towards the public, to attempt, under the guise of extreme candour, to cast unwarrantable doubts on the many import- ant statements made by the gentlemen whose names are above given, in proof of the disease not having been imported, and of its not hav- ing, under any circumstances, been communicat- ed from person to person : we are enabled, on the contrary, to declare that most of the import- ant facts cited by those gentlemen in proof of non-contagion, were verified under our own obser- vation while on the spot. A reference to some of the publications pointed out in the notes will show how individuals have been publicly denounced to the world as having garbled and distorted circum- stances in a manner which must for ever hold them up to the indignation and contempt of the profession at large. Indeed we cannot but regret that usage will not permit, on an occasion like this, an exposure of the conduct of interested per- sons, whose foul labours were directed to pervert truth on a question upon which, for generations to come, the lives of thousands must depend, and for which they so well merit exposure and pun- ishment. At the commencement of the epidemic there were very few medical men in the garrison who could be called anti-contagionists. Conceiving that our then medical chief, the late Dr. Hennen, was disposed to make up his mind too soon against importation and contagion, some of us wrote to him, indeed, confidentially, requesting that he would give further attention to the reports regard- ing the importation of the disease by a Swedish ship from the Havannah, called the Dygden ; but an impartial consideration of all the facts which passed in evidence before us subsequently, left no doubts in our mind as to the cause, though myste- rious in its essence, being of a strictly local nature. At the strangely-constituted board appointed at Gibraltar to inquire into the origin of the disease, and at which, to the astonishment of all who had read the works of Bancroft and Burnett, the pre- sent superintendent of quarantine in England was named president, much passed over which a veil must be drawn here; and we shall only place on record the full opinions of two of the members, they being certainly most entitled to weight with the public. Mr. Judge Howell says, " Upon a careful review of all the proceedings before fhia § Lettre a Monsieur le Docteur Monfalcon. Reponse a. Monsieur le Docteur Lassis. Reponse a Monsieur Ouyon. Letters in the Gazette desHopitaux, 27th August and 10th September, 1831. || Dr. Smith. 23d regiment, and the writer of this, sur- geon at the time to the 43d regiment: the letters herw referred to were found in Dr. Hennen's office after hn death. 273 FEVER, (YELLOW) board, I am of opinion that the evidence brought forward has totally failed to prove that the late epidemic disease was introduced from any foreign source, either by the Swedish ship Dygden or by any other means; and I am further of opinion that the late epidemic had its origin in Gibraltar." Colonel Chapman (now Major - General Sir Ste- phen Chapman, Governor of Bermuda) says, « Judging from the evidence produced before the board, the manner in which it has been given, together with the description of persons who have been brought forward as witnesses, I am decidedly of opinion that the late epidemic disease is of local origin. As to the importation of the late epidemic, I am of opinion that the attempts to prove the introduction of the disease, after months of pre- vious inquiry, by those who wished to prove it, have totally failed." The latter part of this needs, we presume, no illustration. Three voices, in- cluding that of the president, were in favour of the importation of the disease ; according to another member, it might have been from foreign and local causes conjoined ; while the seventh (the captain of the port) declined, through delicacy, recording an opinion.* On the above occasion the exami- nations of some of the medical gentlemen attached to the army were most imperfect, the progress of the disease among the men under their charge not having been entered into,- and several of them were not examined at all! That a local cause of yellow fever, unconnected with persons, was in operation through a certain space at Gibraltar, in the latter months of 1828, was amply demonstrated in every possible way in which such a point could be proved. To some of the most striking occurrences bearing on the subject we shall here revert, leaving, for want of space, many valuable details, as they have been furnished by the several gentlemen formerly re- ferred to. The failure of proof as to the importa- tion of the disease has been admitted by the army medical board in England, to whom a copy of all the procedings of the Gibraltar commission was sent for examination. It was shown that the dis- ease made its appearance exactly about the same time of year as on all preceding epidemics at Gibraltar and other parts of Spain ;| and that, as on all former occasions, the morbific influence was limited to the western face of the rock, and to a small village (occupied by fishermen and by a small military post) situated at the base of the rock, on its eastern side. On the sandy plain called neutral ground, several thousand of the civil population, as well as three regiments of infantry and some sappers, were placed under canvass or in huts, soon after the epidemic made its appear- ance : on two plateaux, situated at different eleva- tions on the southern extremity of the rock, (Windmill-hill and Europa-flats) three other regi- *To show the facility, at any time, of falling into the error of assigning, as a cause of the Gibraltar fever, that which may be only a coincidence, the above gentleman laid before the board a document showing that between 1814 and 1828, eight hundred and forty -foul- ships had entered there from different countries where the disease is known to prevail. 'The first cases usually appear in August, though nvant coureurs have been not unfrequently observed in Inly. On one occasion only, as far as we are aware of, lias an epidemic appeared earlier in Spain—that at Ma- li;;- in 1804, which broke out in June. ments, with a detachment of artillery, were also encamped. Although very great intercourse sub- sisted during several weeks between the placea where the disease prevailed and the three points here specified ; and though, up to the appearance of the last case, there were no measures in force which could be considered efficient in a disease avowedly contagious, — for medical men fresh from their full wards were daily in contact with the healthy persons in the camps,—still the disease did not attack the persons on the neutral ground, or on the plateaux, unless duty or occupation obliged them to pass certain limits, and respire, for a lono-er or shorter time, the atmosphere of particular localities — the part of the town itself, called the 24th district, being the most dangerous of any. If any cases had their origin beyond the points spoken of, they must have been very few in number, as among our army medical friends at Gibraltar, by whom the point had been frequently discussed with us after the epidemic, scarcely a single well-authenticated case could be made out, among the military or their families, where an attack had taken place among those who had not entered the regions of malaria.£ The following facts have been placed on record relative to this epidemic; it will be perceived how far they are calculated to set at rest a question of prodigious importance to a great portion of man- kind. With scarcely any exceptions, security from attacks was obtained by the military and civil part of the population at the three points of encamp- ment mentioned, as well as on board of ships lying in the bay, to which many of the latter fled. It was shown that, though many individuals who had been in close contact with the sick in the town, &c. had removed to camp, taking with them their bedding and some furniture, no spreading of the disease in the camps or huts took place. Up to about the 20th of October, the convalescents underwent no process of purification previous to their being sent from hospital to their respective camps. By reference to Mr. Hugh Fraser's papers it will be seen that this gentleman, who was sur- geon to the civil hospital, had, for want of room, been obliged to discharge a great number of per- sons from that establishment before their conva- lescence had been well established,—some indeed with hemorrhage still from their mouths, — that several of these people took with them articles of bedding to the small tents and huts in which theii relatives resided, without the disease having been transmitted to the latter. By Mr. Amiel we are shown that his regiment (the 12th) became soon free from cases after they encamped on the neutral ground, a few only having occurred among men who may be supposed to have carried out the seeds of the disease in their systems ; — that so long as this regiment sent no men into town on duty, no attacks took place; but when the town duty was resumed, cases again occurred, and exclusively among those men who had been so employed. He gives us the important fact, that " ninety-two women of that regiment, and one hundred and 1 At one time the writer of this essay, not aware that this was found to have been so generally the case, gave it as his opinion officially, that the morbific principle might, during epidemics, occasionally affect persons « few hundred yards fceyoad the rock. FEVER, (YELLOW) 279 ninety children, who never were allowed to repass Bay-side barrier, continued perfectly healthy ; and one woman only, (the armourer's wife,) who, dur- ing the period, obtained leave to enter and stay a few days in the garrison, caught the fever and died of it. Several of these women passed the night in the same beds with their husbands, attacked with and labouring under the epidemic fever ; and, be- sides, continued, as well as their numerous chil- dren, to use the same bedding, after the men had been removed to hospital; but in no instance was the disease contracted by the wife or the children after that full exposure." Were we to point out one situation more calculated than another to favour the transmission of a disease by personal contact, it would be that of several individuals living in the small space of a tent or hut; yet we see that, put to this test, there was no transmis- sion. Dr. Smith, in his paper referred to, shows that in the 23d regiment, the disease, notwith- standing exposure to direct or indirect contact with the sick, was also confined to those who had been within certain bounds; and he exposes falla- cies in certain statements relative to people on board vessels in the bay, whose safety, we can join him in averring, did not arise from their having been cut off from communication with persons or things from the town. In a regiment, (43d,) of which we had, on the occasion in question, the medical charge, we can aver that on summing up all the occurrences, the following clearly appeared: that although our regular hospital servants had been greatly harassed at an early period of the epidemic by attendance on yellow-fever patients, none of them were attacked until nearly one month after the admission of the first case ; not, indeed, until the disease had attacked individuals who were not employed in attendance on the sick, but lived on that part of the rock where the hospital* is situated :—that, in the course of the first month of the epidemic, a party of temporary attendants, consisting of from two to four, or more, was sent daily from a remote barrack or camp to do duty in the wards of the hospital for twenty-four hours; their employment absolutely comprised whatever can be conceived of the most assiduous nursing during the night as well as by day ; and the re- sult, according to an investigation made after- wards, was, that, in the first place, no greater proportion of the sixty-nine men (the total num- ber so employed) had been attacked, than of the whole mass of the regiment which had not been on this service about the sick; and that, in the next place, any of them who happened to be at- tacked within a period of several weeks after, were ascertained to have been on duty (guards, &c.) within the points where the atmosphere was most deteriorated. Here, then, we have, in a manner, an experimentum crucis, on such a scale as can- not be denied to give it the highest importance in the eyes of the profession. We took the precau- tion to have the names of these sixty-nine men, together with other particulars, duly registered and verified by the adjutant of the regiment, in a do- cument forwarded to the office of the colonial * A fine building, calculated for the accommodation, under ordinary circumstances, of the sick of five or six regiments,—situated at an elevation of one hundred feet on the S. W. part of the rock near the entrance of the bay. secretary in London. The next remarkable fact regarding attendants on the sick was, that of se- veral medical men (six or seven of whom had but lately arrived at Gibraltar) employed at an hos- pital on Windmill-hill, and at another in a low situation near the neutral ground, not one suffered from the disease: the same immunity was extended to the servants employed at those points, among whom were some who, not having passed through former attacks, could not be said to have escaped on that account. We took great pains to procure the names of the women who washed for the sick of the army during the epidemic, and it can be confidently stated that the result of inquiry, as to the numbers attacked, was quite in opposition to the doctrine of the disease being communicated indirectly by means of articles of dress, &c. An- other point to be considered is, whether immunity from attacks took place where pains had been taken to exclude all communication, direct and indirect, with the sick. At the dock-yard this did not, in 1828, prevent individuals from being attacked ; neither did prisoners confined in solitary cells at the " Moorish Castle," situated within the walls of the town, escape attacks. We are aware, too, that among the private families on the western face of the rock, who took precaution by seclusion, cases also occurred. On the neutral ground, on Windmill-hill, on Europa-flats, as well as in ships in the bay, persons who thought proper to adopt precautions may be said to have escaped ; but the same, we are quite sure, may be said of those who, living there, adopted no such precaution as shut- ting themselves up. The only step holding out security at Gibraltar or anywhere else, as Is now so generally understood everywhere, and as had been practised many years ago in some parts of Spain, is to remove quickly from the malaria points; and this, according to all experience, would seem a measure eminently entitled to the appellation of sanitary, [A recent writer, Dr. Monette, ( Western Jour- nal of Medicine and Surgery, Louisville, 1842), in a series of papers in which he has brought for- ward much evidence in favour of his views, whilst he is far from advocating "the absolute and un- conditional contagion or infection of yellow fever, and that it has the property of communicating itself from one individual to another in a pure and free atmosphere," — contends, that under certain circumstances, independently of all local accumu- lations of city filth, the local atmosphere becomes so contaminated by a healthy population, that it is peculiarly adapted for the dissemination of yellow fever, when a portion of infected air is introduced. At times, he considers, the introduction of a mo- derate quantity will be sufficient; at others, when the atmosphere is less prepared, a larger quantity is required ; and hence he deems the quarantine regulations most important for the protection of the citizens of such towns as are liable to the visi- tations of this malignant disease.] The foregoing materials, drawn from sources »o varied, will probably aid the profession at large in forming an opinion upon a long agitated question J. GlLLKREST. FRAMBCESIA. —See Yaws. FUMIGATION —See DisisrECTins 280 FUNGUS H^MATODES. FUNGUS H-EMATODES, (from fungus, a mushroom, and aliianiins, bloody ;) a term pro- posed by Mr. Hey, of Leeds, in his work entitled « Practical Observations in Surgery," published in 1803, to distinguish the particular form of disease now about to be discussed, from cancer, an appel- lation under which writers, both ancient and mo- dern, until the commencement of the present century, seem to have included every variety of ulcerative tumour which proved untractable in progress and malignant in nature. Unhappily these are features too characteristic of fungus hsematodes to have eluded the general denomina- tion ; but the peculiarity of appearances thus de- signated must in all ages have attracted notice, and in the records of various writers it is impossi- ble not to perceive that examples of what we now call fungus hsematodes have been regarded as ex- traordinary cases of cancer, or instances of anoma- lous disease. At the period when Mr. Hey suggested the consideration of fungus hcematodes as a distinct disease, it appears that the observations of Mr. John Burns, published in his valuable work on Inflammation, in 1800, were unknown to'him. Mr. Burns treated of it under* the title of spongoid inflammation. From Mr. Abernethy, in his classi- fication of tumours, (Surgical Observations,) it has received the name of medullary sarcoma, since called by the French pathologists tumeur encephuloide, cerebriforme, carcinome sanglante, cancer mou. Dr. Young has ranged it, in his system of nosology, as one of the two species of the genus carcinoma, viz. C. spongiosum,- apply- ing the term C. scirrhosum to that form of hard tumour which is characteristic of the disease com- monly called cancer. The appearances of the fungus hsematodes, the circumstances attending its origin and progress in the human body, and the purposes of practical medicine, demand and fully justify its separate consideration. That our view, however, of the distinctive differences between it and cancer may be the moje clear, we propose, in the first place, to show the analogy of the two diseases, and by which they seem to have been confounded, avoid- ing altogether as useless any subtle disquisition on the subject of their original identity, which the present state of pathological knowledge does not entitle us even to discuss. They are both apt to be manifested in persons apparently of the same temperament; to be evinced by the formation of a tumour in the same regions of the body ; often to be traced to similar exciting causes; and in each often to arise spontaneously; to be prone to ulceration, and afterwards to dis- charge matter not purulent in its nature; both often bleeding profusely : cancer, sometimes, like fungus hsmatodee. produces a fungous excres- cence, and both generally alike contaminate the absorbent system: both are destructive of the neighbouring parts, of whatever nature the struc- ture of such parts may be, and frequently affect several organs at the same time; both, also, it must be acknowledged, are most frequently untractable and destructive of life. The history of fungus hsematodes to the period we have mentioned of its separate consideration, must it is obvious, be involved in that of cancer ; but it is impossible at the present time to tract back the observations proper to this form of dis- ease, with such a degree of accuracy as to assist us in its elucidation. The difficulty of denning fungus hamiatodes, like that of defining many other diseases, consists in the variability of its symptoms in its progress ; and, therefore, to the recorded histories of it we must refer for that in- formation which is essential to its being well un- derstood. The part, too, in which it is developed, the state of the constitution, and the age of the individual, are so many other causes of variety in its appearance. But the advantages of a concise definition are too obvious to deter us from hazard- ing such a one as we conceive to be consistent with the circumstances of the disease, and the present state of our knowledge regarding it. We characterize it then as a morbid condition of the body, evinced by the development of an elastic uneven tumour, or tumours, not painful in their early stage, and becoming so only by implication with surrounding parts; tending ;o ulceration, and by ulceration presenting to view a soft and spongy fungus, rapid in its growth, readily bleed- ing in vascular textures, and emitting a peculiar serous discharge of a very fetid odour, more or less coloured with blood. A blow or injury of some kind is very often the immediate forerunner of this species of tu- mour, and the latter generally leads to the first manifestation of the disease; but in many in- stances its origin cannot be traced to any particu- lar exciting cause. It is found to occur much more frequently in the young than in persons ad- vanced in life; children from the earliest age be- ing often its victims. The persons whom it has most generally attacked have been those of a sal- low complexion, a lax and flabby texture of the skin, and a weak circulation. Observations are wanting to enable us to decide whether it is more prone to manifest itself in one sex than in the other, although the last-mentioned observations, with the recorded experience of this and cancer- ous diseases, are favourable to the supposition that females are more frequently the subjects of it than males. Climate, it is probable, has some influence on its production ; for we are told by Sir Everard Home, in his Dissertation on Tumours, that in the Island of Otaheite, and those of its neighbourhood, where fighting is the common mode of deciding quarrels amongst the women, the blows are principally aimed at the breast, which has no defence, and that cancer has never been met with in these countries. We have good authority, too, for stating that it very rarely arises in India; and these remarks, for obvious reasons, we conceive to be equally applicable to the form of disease which is the subject of this article. That the constitution favourable to the develop- ment of fungus hsematodes is transmitted heredi- tarily we cannot doubt; and that all circumstances which are of a debilitating nature have a secret influence in preparing the way for its production, we conceive may reasonably be assumed from the accumulated experience and observation of past ages on the predisposing causes of cancer. In a large majority of instances, fungus hannatodes has terminated fatally : indeed, the recorded exceptions are so rare, and pathologists of the highest repute FUNGUS HCEMATODES. 2^1 so agree in opinion as to its general fatality, that it may almost be questioned whether the instances which are related of its favourable issue are not to be referred to some distinctive peculiarity in the morbid change, unrecognizable in the present state of science, rather than to any favourable state of constitution or difference of treatment. The period to which life has been limited after the development of this terrible disease has rarely exceeded two years, whether its removal has been attempted by extirpation of the tumour, or every other expedient adopted consistent with the cir- cumstances of the case and the resources of sci- ence. It generally proves fatal in a much shorter space of time, and death too often seems to have been expedited by the removal of the local disease, even to the extent of extirpation of the part, or amputation of the limb on which it may have been situated. In those cases in which the eye has been extirpated, unless a return of the disease has produced death, the growth of a similar tu- mour in the brain has usually been the immediate occasion of it; and when a limb, or the mamma has been removed, or even the testis, a correspond- ing formation in the lungs has immediately fol- lowed, and, increasing with rapid strides, has put a fatal period to the sufferings of the individual; whilst at the same time the liver most commonly, and generally several other organs and structures of the body, have been studded with similar formations. The physical circumstances leading to the form- ation of these tumours are connected with a most important subject of pathological science, viz. the local and constitutional origin of disease. After premising that pathologists of the highest repute in this country have assigned to fungus haema- todes a local origin, it is with the utmost defer- ence we venture to assert that proofs are wanting to establish this fact, and that we consider it in- finitely more consistent with acknowledged phy- siological principles, and the changes which we know to be produced irj the elementary compo- ponents of the body in this as well as in some other diseases, to assume that a morbid condition of the blood is a link in the chain of causes of fungus nematodes, prior to its local manifestation. We should scarcely have hazarded this opinion had we not met with sanction in the observations of Bichat and Andral; and but for the fact, ad- mitted by those who have contended for its local origin, that the secondary formation is consequent to that change in the constitution which appears to us to be productive of the original tumour. No one will doubt that the blood, like the other constituents of the body, is frequently altered in its nature by disease ; and as it is secondary only to the chyle in the sequence of bodily formations, and is the acknowledged element of all secretions healthy and morbid, the question, we conceive, resolves itself into either the presence of the mor- bific matter being already in the blood, or a spe- cific adaptation of the secreting organ to its form- ation. For proof of the latter we have searched in vain ; but with regard to the former, we know that the qualities of the blood when this disease exists are changed ; that it is much thinner than healthy blood; difficultly, if at all, coagulable ; and almost wholly unequal to the process of ad- hesive inflammation; in fact materially deficient Vol. II___36 x* in the important constituent, fibrin. Andral has discovered in the blood not only different elements of secreted fluids, but, as well as other morbid productions, the peculiar one which belongs to this disease so combined with it as to alter its physical properties; occasionally limited to parti- cular vessels, but sometimes in the greatest part of the circulatory system, when at the same time a corresponding morbid production was seen to per- vade the texture-of many of the solids. Similar facts, he observes, have been mentioned by Be- clard and Velpeau ; the former having referred to a case in which the heart and the principal trunks of the vessels were filled with a solid clot, the in- terior of which presented numerous collections of encephaloid matter; and the latter to a similar formation in the vena cava. He also cites the case of a man who died almost suddenly, after having shown some symptoms of cerebral conges- tion, and in whom, upon examination, there was found through the whole extent of the circulatory system a blood of a pultaceous consistence and blackish red colour, resembling the matter of cer- tain abscesses of the liver. For further information on this part of our subject we refer to the interest- ing observations of Andral on the lesions of the blood; but we must acknowledge that there are still wanting many facts to remove all the objec- tions which may be opposed to our views. It is universally admitted that fungus haema- todes is in most instances a constitutional disease before it comes under medical cognizance, and its origin is usually referred to a " peculiarity of con- stitution ;" an observation which to us seems al- most to involve the question at issue. That the local effect is, as in the case of other tumours, a morbid secretion, is undoubted. From its consis- tency it readily insinuates itself in the interstitial cellular substance, separating the vasa vasorum from their natural attachments, and by constantly exposing the external parietes to the action of a semifluid, they may be said to undergo a kind of maceration, and hence so to degenerate as to be- come unequal to the retention of their contents, or readily lacerable by the slightest local injury. Thus we consider the hemorrhagic tendency to be secondary, and superadded to the secretion it- self; an opinion which we conceive to be verified by the appearance of the tumour, as seen in a state of ulceration in the mamma or extremities; as modified when it occurs in the glandular struc- ture of the testicle; or as inspected when sepa- rated from the body and carefully washed with water. The substance of the tumour, which from its resemblance to the brain has been called cerebri- form and encephaloid, presents itself, according to the observations of Laennec, (Diction, des Sci- ences Medicates, Art. Encephaloides,) under three different forms : 1, encysted; 2. irregularly com- pacted without cysts; 3. infiltrated in the tissue of an organ. In whichever of these states it ex- ists, its progress may be divided, says this eminent pathologist, into three, stages; that of its forma- tion, or the stage of crudity ; that of its entiie development, when it most resembles the brain ; and that of its ramollissement or softening. Ii has been remarked, however, by Andral, that we have no proof that the encephaloid matter in the 2S2 FUNGUS HCEMATODES. state of softening can only occur subsequently to the other stages; and we arc disposed to believe with him that this is in many instances the state of its primary formation,—the state certainly in which it is first recognised as characteristic of the specific disease. In its earliest stage the cerebriform tumour is lobular, moderately consistent, and appears com- posed of minute lobules closely compacted, mark- ed by lines running parallel but not cooping with each other. Its colour is a dull or yellowish white. The cyst is probably secondary in formation to the enclosed substance, as traces of cyst are often found in one part and the tumour exposed in an- other. When completely developed, it is homo- geneous, in colour milky white, occasionally tinged with red, and in consistence resembling the brain ; it is greasy to the touch, and when divided soils the knife; when cut into small slices, it is semi- transparent ; like brain also, when exposed to the atmosphere, it softens; and when the softer parts of the tumour are washed away, or when the mass is compressed, a loose filamentous texture, resem- bling cellular membrane, remains. In the mass, however, as separated from the body, a number of blood-vessels are usually to be observed pervading the whole texture. Their parietes are thin and easily ruptured ; and extravasated clots of blood are here and there interspersed, giving the whole, says Laennec, an appearance resembling the le- sions observable in dissections of sanguineous apo- plexy. The cerebriform matter does not remain long in the state described, but proceeds rapidly to that of ramollissement, and, thus rendered more misci- ble with the extravasated blood, its colour is in- fluenced accordingly, and is varied from a reddish white to a dark sanguineous hue. This state of softening is found to occur at different periods in the same tumour ; some parts being much firmer than custard, and others, harder than the most solid parts of the healthy brain. This medullary matter is very sparingly soluble in water : if ex- posed to the flame of a candle in a silver spoon, it assumes the colour of opal, and it leaves after evaporation an inappreciable, residue. With the addition of spirits of wine the watery solution threads slightly, without coagulating by the action of heat; this mixture evaporated, like the preced- ing, leaves some small grey clots. Exposed to the direct action of heat, it becomes brown, but does not liquefy like grease ; and it has a smell of roast- ed meat. If immersed in spirits of wine, it does not undergo any apparent change. In a saturated solution of corrosive sublimate it coagulates so as to form white filament, the solution remaining transparent. Acetic acid has no visible effect upon it. Slowly boiled in water the liquid remains clear, without grease; and does not jelly when it becomes cold. (See Memoires sur la Fongus Me- dullaire, par J. P. Maunoir.) The medullary structure, though often found alone, frequently coexists with other varieties of diseased production ; as fibrous or scirrhous masses, pus, scrofulous matter, melanosis, hydatids, (See Andral, vol. I. p. 219,) and in some cases ossific or earthy particles have been found intermingled with the pulpy matter. In many hsematoid tu- mours there are distinctly insulated portions much resembling boiled yolk of egg; and so often has this peculiar substance been found in those orgaru wherein fungus hsematodes has been detected, that the circumstance might almost be considered a characteristic of the disease. We have stated that the earliest notice we have of fungus hsematodes as a distinct disease has been transmitted to us by Mr. Burns, under the name of spongoid inflammation. The cases re- lated by him, five in number, were confined to its occurrence in the extremities. Of the ten cases next published by Mr. Hey, it manifested itself in five in the extremities, in three in the female breast, in one in the lower jaw, and in another at the back of the neck. Mr. Abernethy, in his Sur- gical Observations published in 1804, related a case of diseased testicle, to which he gave the name of medullary sarcoma, since used by him and by many surgeons synonymously with fungus hsematodes as it occurs in this as well as in other parts of the body, and the identity of which with the pulpy testicle described by Dr. Baillie is now universally admitted. In the best treatise we pos- sess on this subject, published by Mr. Wardropin 1809, and to which we are largely indebted, are collected all the scattered accounts which our lit- erature affords relating to fungus hsematodes prior to that period; and there we find related cases with dissections of it as it occurs in the eye, the uterus, the ovaria, the liver, the pancreas, the spleen, and the lungs. Ha:matoid tumours have since been met with, as the same writer remarks, (Preface to Baillie's Morbid Anatomy, edited by J. Wardrop, Esq.,) in the urinary bladder and ali- mentary canal, in the brain, in the bones, in the mesentery, in the omentum, and in the thyroid gland. Laennec states that he has seen two cases of encephaloid growth in the heart: in one the morbid matter formed several small masses in the muscular substance of the ventricles; in the other it was deposited in layers from one to four lines thick along the coronary vessels. M. Olivier, in his work on the spinal marrow, relates anothet case of encephaloid tumours deposited in the sub- stance of the same organ. M. Velpeau has pub- lished a remarkable case of the same kind, in which similar tumours were also found in the lungs, between the pleura and ribs, in the bron- chial glands, under the mucous membrane of the stomach, in the duodenum, in the pancreas, in the right kidney, in the liver to the amount of several hundreds, between the tunics of the gall-bladder, in the different parts of the peritoneum, in the thy- roid gland under the skin, and in the muscles of the right thigh. We ourselves remember to have witnessed a case in St. George's Hospital, which proved, and on a post-mortem examination exhib- ited the existence of the same kind of tumours, in very considerable numbers, in all the organs of the several cavities of the body, and dispersed under the integuments of the trunk, as well as of the superior and inferior extremities. The absorbent glands, though in most instances con- taminated in the early or in the advanced stages of the primary tumour, as far as we know, have never been the original seat of the disease. In some cases they grow to an enormous size, whilst in others they are but slightly enlarged. In soma the primary affection makes little progress, whilsl FUNGUS HCEMATODES. 283 the disease of the glands advances rapidly and seems to be the immediate cause of death. Their Structure is generally converted into a substance resembling the primary tumour, exhibiting a ho- mogeneous pulpy mass contained in one firm cel- lular capsule ; in this respect differing from the primary tumour, which is usually lobulatcd and intersected by cellular strata. In some cases the skin covering the gland ulcerates, and forms a foul sloughy ulcer, but rarely, if ever, produces a fungus. (See Mr. Wardrop's Essay.) The indiscriminate manner in which cancer and fungus ha?matodes have been usually regarded, renders it necessary that their diagnostic symp- toms should be particularly attended to ; we shall now proceed to an exposition of these in their general character, reserving for after-consideration their local peculiarities. The fungoid tumour before ulceration is soft and elastic, giving in most cases a more or less obscure sense of fluctuation. It does not always occasion pain; and when it does, it is of a throb- bing, and not lancinating kind. It exists very rarely beyond two years without going through all its stages, and occurs most frequently in per- sons who have not reached the middle period of life ; very often in childhood and from the earliest infancy. Immediately after ulceration has taken place a soft spongy fungus appears, and grows rapidly, emitting a discharge like scrum, which immedi- ately mixes with the blood, always to a certain extent at the same time extravasated. The ap- pearances of the fungus haematodes when taken from the body having been already discussed, we need only suggest a comparison between its pro- perties and those of a cancerous tumour. The cancerous, or, as commonly called, scirrhous tu- mour, is hard, firm, and incompressible, and in its formation and progress is always attended with lancinating pains; the integuments above the tu- mour are usually corrugated, and exhibit on their • surface several short white lines, which ate in reality so many germs of the disease. In many instances scirrhus is slow in going on t-o ulcera- tion; it often continues for many years, or until the termination of life, without it. It occurs gen- erally in persons advanced beyond the middle pe- riod of life, and is scarcely ever known to take place before the age of twenty-five. In its ulce- rated state its hard firm substance is transformed into a thin ichor ; and, generally, the tumour does not increase in bulk, but is destroyed by the pro- cess; or if a fungus succeeds, it is hard and firm in its texture. The scirrhous tumour, when sepa- rated from the body, is hard, firm, and incompres- sible, and is composed of two substances, one indurated and fibrous, the other soft and inorganic. The fibrous matter is the most abundant, consist- ing of septa, which are paler than the soft sub- stance between them. The latter is semi-trans- parent, of a bluish colour, resembling in consist- ence softened glue, but occasionally more opaque, softer, and somewhat oleaginous. The fibrous matter is more or less condensed and radiated, the interstices being filled with the softer substance; and sometimes the whole tumour, or parts of it, are converted into a substance resembling carti- lage, which is occasionally the nidus nd contiguous soft parts; so that the lumbar vertebra NISM. Galvani was fortunate in the time of announc- ing his discovery. It was an era of mighty changes and of great reforms. In the very capital of con- tinental science, the human mind, just freed from the fetters which long had bound it, became the slave of prejudices by no means unnatural. What was old was rejected, frequently because of its antiquity alone; while every novelty came recom- mended by irresistible attractions. There was also another and a very different cause to which may, at least in part, be attributed the interest ex- cited by the observation of the Italian philosopher. To many it appeared that a clue was now at length afforded for ascending to the long-sought- for source from which spring the mysterious phe- nomena of life and organization ; and that, in particular, by prosecuting the route thus pointed out, the nature and cause of nervous energy could not fail of being unfolded. Galvani was not slow in framing an hypothesis to account for the phenomenon which he had been the first to observe. According to him, a peculiar fluid existed in the nerves of the animal in a state of accumulation, which, rushing through the in- terposed metals, was precipitated upon the mus- cles, and produced their spasmodic action. Upon this theory the animal body is but a sort of charged Leyden jar : the nerves representing its internal, and the muscles its external coating; the dischargs also being effected in the ordinary manner, name- ly, by establishing a connection between the op- positely affected surfaces. This analogy was sug gested at a very early period, and was for a length of time considered as conferring a high degree of probability on the views from which it origi nated. Though this explanation was very generally acceded to, philosophers were by no means agreed respecting the nature of the fluid whose agency it employed. By some it was denominated ner- vous fluid, under the idea, no doubt, that it was identical with that power on which the functions of the nervous system depend, and this is the opinion which would seem to have be-f t!n» hepatitis does not imply the subsidence of the gas tro-intestinal disease. 4. That in the smaller number of cases the lie- patic disease has preceded that of the intestine 322 GASTRO-ENTERITIS. 5. That idiopathic hepatitis may occur without any gastro-intestinal complication whatsoever. This is the rarest case. 6. That in cases where the complication does exist, we cannot always find that the intensity of the one disease is proportional to that of the other. The influence which inflammation of the upper part of the digestive tube, particularly of the duo- denum, exerts in producing hepatic disease, has been much insisted on by the physiological school. That many instances of hepatitis are thus induced, there can be no doubt; but it is true that cases have occurred where this portion of the tube was found perfectly healthy. (See the works of Louis, &c.) We formerly alluded to the production of jaundice from gastro-duodenitis, and believe that it is its most common cause. It is a curious fact, that in the yellow fever, where gastro-enteritis is so frequent, inflammation of the liver is rarely ob- served, although considerable alteration of the colour and consistence of this viscus is common. IV. But we have yet to handle one of the most important parts of this subject, namely, the con- nection between gastro-enteritis and the pheno- mena of fever. Were we to enter into this at full length, we should far surpass the limits of this article; but we shall content ourselves with in- quiring how far that part of the doctrine of Brous- sais, which refers continued fevers to a gastro- enteritis, is capable of proof. Here we wish to correct an error which is general,— namely, that Broussais attributes all fevers to a gastro-enteric inflammation. Such is not the fact, as all candid persons will admit who consider the two follow- ing propositions of his doctrine :—" Les irritations inttnses de tous les organes sont transmises au coeur; alors il precipite ses contractions; la circu- lation s'accelere, et la chaleur augmentee de la pe&u determine une sensation pcnible : c'est ce que Ton doit appeter lafievre, qui est ici conside- ree d'une maniere generate." (Prop, cxi.) " La fievre n'est jamais que le resultat d'une irritation du coeur, primitive ou sympathique." (Prop, cxii.) (Broussais, Commentaires des Propositions de Pa- thologie, 1829.) The following is the opinion of this author on the subject of the connection of gastro-enteritis and fever. He believes that acute gastro-intestinal inflammation, when exasperated, will represent what has been called the putrid, adynamic, or ty- phous lever; and that in those cases where the sympathetic irritation of the brain is considerable, the disease will represent the malignant ataxic or nervous fevers. The truth of this proposition is not to be denied; but when he declares that all the essential fevers of authors are to be referred to a simple or complicated gastro-enteritis, we believe that he has not made out his case. It cannot be denied that this doctrine, received at first with such contempt, and scouted so gene- rally by medical professors, especially in this country, has gained ground to a remarkable extent; and although few, except the immediate pupils of its founder, go to the full length of his opinions, yet all who look at disease with an unprejudiced eye, and who enjoy opportunities for observation, now admit that in the production, progress, and phenomena of fevers, the digestive tube takes a u-.os*. important cart. In fact its pathology furnishes a key to the treatment of a vast number of cases formerly termed essential or idiopathic fevers; a denomination, happily for mankind, now begin ning to be forgotten. Will gastro-enteritis cause the phenomena of fever 1 and what will be the character of that fever ] The state of the science on this subject can be shortly expressed. Gastro-enteric inflammation may cause all the phenomena of fever. It will especially cause prostration, headach, delirium, subsultus, coma, thirst, anorexia, sordes, morbid tongue, tympanitis, petechia;. All these symptoms may subside under treatment calculated to remove a gastro-enteritis, and will be exasperated by an opposite treatment. This inflammation further may present this group of symptoms without pain or tenderness of the abdomen. On this subject we shall quote from Andral:—" Confirming by our researches the admirable observations of M. Broussais on the painless character of a great number of intestinal inflammations, we stated in 1823, that we might be exposed constantly to overlook the most intense enteritis, if we only admitted its existence in cases where pain occurred. Since the publication of these researches, numerous works published by dis- ciples of the most different schools, have shown that the intestines may be very profoundly affected without pain being present. We have seen this pain wanting, 1st, in cases of simple erythema of the mucous membrane ; 2d, in those where numerous exanthematous patches covered the small intestine; 3d, where the large intestine was affected; 4th, where there were ulcerations, either in the ileum, caecum, colon, or rectum. Wo have found the deepest ulcerations in subjects where there was no pain ; and it is to be remarked that we only speak here of cases in which the intellect of the patient was not affected." (Clinique Medicate.) The knowledge of these most valuable facts requires to be spread much farther than has been hitherto done. Many practitioners cannot separate the ideas of pain and inflammation, and it has again and again happened to us to see the most fatal results from this scholastic error. One of the most constant characteristics of the fever in this disease is prostration ; and there is no local inflammation which will so peculiarly induce this slate as an acute gastro-enteritis. The fever may be inflammatory or typhoid in its symp- toms ; it is commonly similar to the synochus of Cullen ; it may be remittent or even intermittent. To prove every part of this proposition thousands of cases may be cited. (See the works of Andral, Louis, Bouillaud, Bretonneau, Roederer and Wagler, Bois- seau, Hewett, Bright, Abercrombie, Cheyne, &c, &c.) Gastro-enteritis may, then, occur with every form of fever ; but it may also exist without fever; from which fact an argument may be drawn against the doctrine that the typhoid or adynamic fevers are nothing but examples of gastro-enteritis either simple or complicated. It is plain that these affec- tions present a pretty constant and peculiar group of symptoms, and that, even supposing gastro- enteritis to exist in them all, there must be some- thing else to give the disease its peculiar character. Let us examine the state of the digestive tube in fevers, particularly that of the stomach and small intestines. Now there is abundance of facts to prove that when death occurs in the course of a GASTRO-ENTERITIS. 323 fever, we may find the stomach healthy, and even in the cases where alterations of this viscus are found, they have no peculiar appearance so as to constitute an anatomical character; nor, as Andral remarks, are they different from those in the bodies of others who have died of various acute and chronic diseases. We cannot then affirm that every continued or typhous fever implies the exist- ence of a gastritis, or that this disease will cause the phenomena of fever in all instances. But the alterations of the small intestine are much more constant, and it was from this circum- stance that the doctrine of Broussais mainly arose. We apprehend that an inflammation of the mucous glands is much more frequent in Paris than in this country; and it was natural to consider the disease in the intestines, with regard to the fever, in the same light as an inflamed state of the lung was considered with regard to the symptoms of pneumonia. Louis also, one of the most accurate and trustworthy investigators, has declared that the inflammatory development of the mucous glands is the anatomical character of typhous fever. But even admitting that such was universally the case, still the doctrine that the symptoms of fever in these cases proceeded from this disease would not be proved, because the intestinal disease may as well be considered as secondary to the fever as the pustules of small-pox to the state of the system induced by its contagion. No one would say that the cutaneous eruption was the cause of small- pox, and we cannot help believing that the "in- testinal exanthem" in many fevers is produced by a similar process, and bears a similar relation to the constitutional affection. (See the experiments of Gaspard, Magendie, &c. Journal de Physiolo- gic) But whether the intestinal disease be pri- mary or secondary, it becomes absolutely neces- sary, in cases where it is recognised, to direct our treatment towards its removal, and carefully to avoid every thing that can exasperate it. We believe that the disciples of Broussais may have carried the antiphlogistic plan too far in fever; but if they have killed their thousands, the followers of Brown and Hamilton* have killed their ten thousands. In the treatment of fever there are two great points for the practitioner to look to,— one, the strength of the patient; the other, the state of the viscera. In the majority of cases his practice should be to remove local inflammation, for it is of this that ninety-nine out of the hundred die; but should a case arise where, from the condition of the patient, he cannot attempt to fulfil the latter indication, let him at least not exasperate the dis- ease. What is the common treatment of fever ? a bottle of wine on the one hand, and a bottle of purging medicine on the other; and this for all fevers and all stages of the fever! We do not wish to be understood as decrying the use of tonics or purgatives in all cases, but we do protest, in 'he name of common sense and humanity, against their indiscriminate employment. The experi- ence derived from the treatment of several thou- e*iid cases of lever has convinced us of this fact, that Hi the treatment of this disease, particularly in its * We must admit that much of the abuse of purginjrin fever has originated in a misconception of the real doc- trine of Hamilton. early periods, we shall be more certain of advantage from leeching the abdomen, cold drinks, and emol- lient enemata, than any other treatment whatsoever. We cannot conclude this hasty review of the subject better than by the following quotation from Andral : " Does this coincidence of lesions and symp- toms suffice to show that the dothin-enteritis causes the whole disease 1 We would willingly reply in the affirmative if we did not take the fol- lowing great facts into consideration :— " 1. When, from injecting different putrid sub- stances into the veins of an animal, we produce all the symptoms of the severe fevers of the human species, there are cases Where at the same time we cause various lesions in the intestinal mucous membrane, particularly various degrees of folli- cular tumefaction and sometimes ulcerations. At other times in these experiments the same symp- toms were produced without any trace of lesion being found in the intestine. In this second case, we cannot attribute the symptoms to a lesion of the digestive tube which did not exist. In the first case it is plain that the intestinal lesion was an effect, and that it was only developed by the introduction of deleterious substances into the cir- culation. 2. Observations formerly cited do not permit us to doubt that in the human species symptoms completely similar to those which coin- cide with dothin-enteritis, may occur without it, and without any lesion of the digestive tube. 3. The intensity of the lesions which characterize dothin-enteritis is not always in relation to the severity of the symptoms observed during life." (Maladies de 1'Abdomen.) [See the remarks on Typhoid Fever, vol. i.] But even with the facts as stated above before us, it must be admitted, that when al! those facts recorded in the present article and the 'wo prece- ding so often referred to, are duly considered, the doctrines of Broussais, with respect to gastro-en- teritis, are highly worthy of a careful examination, and do not deserve to be designated, as they so constantly are, as the vague fancies of a heated imagination. When we reflect on the vast influ- ence which gastro-intestinal inflammation exerts in the phenomena of most fevers; that in many of the eruptive diseases it is present and consti- tutes their danger ; that in the varieties of cholera it is a common occurrence; that dysentery, diar- rhoea, and a host of abdominal affections are its results; and that it produces the most important modifications in all other diseases,—complications, on the recognition of which their successful treat ment mainly depends;—we cannot help express- ing a feeling of gratitude to the great pathologist who has awakened the attention of the world to this universal and destructive disease. It is absurd to reject facts because their discoverer may have made use of them to form a theory which the pro- gress of science has partially disproved ; and it is worse than ungenerous to deny him that civk crown which he has so truly and gloriously earned William Stokes. [GLANDERS, Equinia, French, Morve, is the most formidable of all the diseases to which the horse is subject. It has been recognised from the time of Hippocrates; and according to a recer>« 324 GLANDERS. veterinarian, (W. l'ouatt, The Ihrse, p. 129, Amer. edit. Philad. 1843,) few modern veterinary writers have given a more accurate or complete account of its symptoms, than is to be found in the works of the father of medicine. Until within the last few years, the disease was considered to belon°- exclusively to the horse, the ass, and the mute; but unquestionable cases have occurred, showing that it may be communicated to man in either the acute or the chronic form. (Copland, Diet, of Practical Medicine, art. Glanbers ; and Ollivier, art. Mo rye, in Diet, de Medecine, xxv. 258, Paris, 1839.) To this affection, the term equinia (from equinus,' of or belonging to ahorse,') has been appropriated, but it has been extended by M. Schedel (Tweedie's Library of Medicine, Amer. edit. i. 422, Philad. 1842) so as to include two different affections ;—the one, a mild pustular disease, derived from the matter of grease in horses ; the other, a disagreeable scourge, of a pus- tular character, and proceeding from the glandered horse. 1. Equinia Mitis, or Grease Pox, occurs on the hands of those who attend upon horses and dress their heels, when affected with grease. The pustules are large; very similar to those of ecthyma (q. v.); elevated ; and with a red purple, tumid base. About the eighth day, they are filled with an unquestionably purulent fluid ; which, about the tenth or twelfth day, begins to desiccate, form- ing thick scabs, and leaving well-marked cicatrices. It was at one time thought by Jenner, that the matter of grease was the source of natural cow- pox ; but he subsequently modified his opinion as to the cow-pox being derived exclusively from the horse, and the idea is now entertained by few if any. (Schedel, op. cit. and the article Vaccina- tion.) The treatment of grease-pox requires but little attention. Antiphlogists internally, and emol- lient applications externally, are alone needed. 2. Equinia Qlanduloca is the serious affec- tion produced by the glandered horse. It may occur either in the acute or chronic form. Acute glanders commences with symptoms similar to those of acute rheumatism; and along with these there is much heat about the nose and trachea. A copious discharge takes place from the nostrils, which become swollen ; the nose and surrounding parts are of a bright red ; and after- wards of a livid colour; and the swelling extends to one or both of the eyelids. A profuse tenacious mucus, at first of a deep yellow, but afterwards of a bloody or dark sanious appearance, is discharged from one or both nostrils; and at times from the eyes. There is great agitation and tremour ; the skin is hot; the pulse frequent, and usually soft and weak ; the respiration short and rapid ; tongue dry ; thirst intense, and the mind incoherent or wandering. Livid patches appear on the sides of the nose, cheeks or forehead, which are soon followed by copious sweats, and a gangrenous state of the diseased parts, succeeded by delirium, tremour, and death in a few days. This form of the disease is said by M. Schedel (op. cit.) to be rarely, or never, accompanied by pustules or tu- mou'«. In the large mass of fatal cases, however, jjtism lar eruptions and tumours are seen, which constitute farcy glanders, the morve fareineuse of the French. The eruption, which usually appears about the eighth day, consists of large pustules in livid patches, and of small tumours on different parts of the body. The pustules are round, often umbi- Heated, and contain a purulent fluid, with a little coagulable lymph, in the form of a white, soft substance, very similar to that contained in vario- lous pustules, and in the pustules induced by the application of tartarized antimony ointment; the umbilicated form is, however, by no means con- stant. The size of the pustules varies from that of a pea to that of a mulberry: to the latter they often bear a great resemblance in their deep pur- ple colour. Gangrene occasionally occurs in some of these. Along with the eruption, small tumours appear on different parts of the body, having a shining red appearance, which soon changes to a dark livid brown. At first, they are hard and painful, but their surface soon cracks, and discharges a thin acrid sanies. These tumours sometimes mortify, but more frequently, they communicate with deep-seated abscesses, formed in and between the muscular parts. They have even been found to communicate with the cavity of the thorax. Other eruptions appear occasionally at the same time; not at once, but in successive crops, sometimes as late as the twentieth day. The pustular eruption does not seem to be confined to the surface of the body. It is found in the Schneiderian membrane, in that of the frontal sinuses, mouth, fauces, larynx, and even, it is affirmed, in the mucous membrane of the intestines. The general symptoms are, great prostration, thirst, frequent tremours, agitation and delirium: and, according to M. Schedel, all the cases of acute farcy glanders, yet on record, have termi- nated fatally. The discharge from the nostrils is not always apparent, and this has been explained by the matter making its way into the throat owing to the patient lying on his back. Examination after death has exhibited the lining membrane of the nasal cavities studded with clusters of small, flat, unequal, white pus- tules, with irregular ulcerations, and mortified surfaces of varied extent. The septum nasi is almost always ulcerated, and sometimes perforated; and the nostrils and frontal sinuses contain a dark viscid frothy mucus. On dividing the gangrenous tumours, the muscles often appear decomposed: they are of a dark colour ; exhale a peculiar fetid odour, and contain specks of purulent matter, with which the muscular tissue appears to be in- filtrated. White pustular eruptions, like those in the nasal cavities, sometimes also exist in the mucous membranes of the small and large intes- tines. Between the muscles, too, large abscesses often form ; and lymph or pus is found, at times. in some of the articulations. Chronic glanders is not, in general, accompa- nied by any eruption. It is confined to one or the other nostril. At other times, tumours appear slowly and successively on different parts, and suppurate, constituting chronic farcy glanders. Sometimes, both affections appear simultaneously in the same individual. The disease does not GLANDERS —GLOSSITIS. 325 essentially differ, except in tardiness, from the acute form. Chronic farcy may terminate in acute glanders. In the acute form, death may occur in a few days; but it more frequently happens about the twelfth day or later. The chronic variety may be protracted for weeks or months, and then termi- nate in health, or fatally. Causes. — According to general opinion, the diseased secretion from the glandered horse must be brought into absolute contact, to induce the disease in man; but some believe that it may be received through the air in respiration. It would not seem that glanders is a very contagious dis- ease amongst horses; for the results of observa- tion in France showed, that of 100 horses exposed to contagion, only seven or eight suffered; and on one occasion, when more than GOO glandered horses were collected together at Alfort, not one of the persons who had charge of them was af- fected in the slightest degree. It would seem, that in Ireland glanders in man is of frequent occurrence, so much so that Dr. Graves ( Clinical Lectures, Amer edit, by Dr. Gerhard, p. 314, Phi- lad. 1842) thinks the legislature is called on to imitate the wise example of the Prussian govern- ment in placing glandered horses under the surveil- lance of the police. It would not seem, however, that the average susceptibility to the poison is great, as but little precaution is generally taken by grooms and veterinary surgeons. Cases are on record in which glanders has been communicated from man to man. The analogy between the disease and that occa- sioned by the reception of some other morbid poison into the system is striking. Wounds, received on dissection, or from handling the skins of animals that have died under peculiar circum- stances, induce cutaneous affections, deep-seated abscesses, and febrile phenomena of an analogous nature, and often prove fatal. (See Anthracion.) The disease is extremely dangerous, almost hopeless, in its acute form, and full of danger in the chronic. , Treatment.—It is not practicable to lay down any precise plan of treatment. It has been sug- gested, that the chlorides of lime or soda should be given internally. It has, likewise, been pro- posed that they should be used as gargles or in- jected into the nostrils. Turpentine embrocations have likewise been advised, employed as warm as they can be borne, and turpentine has been pre- scribed internally in small doses frequently re- peated. In the chronic form, Dr. Elliotson (Lancet, June 20,1833, and in his Principles and Practice of Medicine) found great benefit from the use of creasote. In two cases, he effected a cure in the course of a few weeks, by the sedulous employment of an injection of a dilute solution (creasot. gtti.; aquae/!^j.) thrown up the affected nostril; combining, in one of the cases, the inter- nal use of the remedy. In one case, which ter- minated favourably to Mr. Travers, a principal remedy was the frequent exhibition of emetics. Fumigated or medicated warm baths, and the vapour bath, have been proposed by M. Schedel. In all cases, both acute and chronic, much has to be left to the judgment of the practitioner; who must be guided by the phenomena that present 2c themselves. The internal use of iodine, creasote and sulphate of quinia have been advised by M Delaharpe. The writer has never met with a case of glan. ders in the human subject. His description has been, therefore, drawn from others. Robley Dunglison.] GLOSSITIS, (derived from yXwo-o-a, the tongue,) inflammation of the tongue. Although in strict- ness of language the term glossitis may be applied to the partial inflammations of this organ, fre- quently induced by the direct application of irri- tants, whether taken into the mouth with food or drink ; of corrosive or acrid substances, or occa- sioned by mechanical injury, such as the forcible inclusion of the tongue between the teeth, or by friction against the ragged edges of such as may have been broken or decayed; it is nevertheless generally used to denote a specific inflammation either of the substance or coverings of the tongue, or of both, induced through the medium of the system, or sustained by a peculiar condition of the organ itself. Some diseases of the tongue, how- ever, of which inflammation has only been one of the conditions, and others in which all the charac- teristics of it have not been present, have been occasionally described under this name. The partial inflammations just noticed seldom require further therapeutic consideration than the avoidance of those causes which may renew irrita- tion, and the removal of others that may continue to exist; the operation of nature under such circumstances being almost always sufficiently sanatory without the interference of art. It must indeed excite surprise, that an organ so consti- tuted, so frequently exposed to the action of irri- tants, and so often exhibiting changes sympathetic with morbid conditions of other parts of the body, should be so little prone to incur either this or any- other idiopathic disease. The little liability to extension of inflammation excited by mechanical or chemical irritants is within proof of every one's experience; but in some instances in which the disposition to scirrhus has been latent, its develop- ment has soon followed the inflammation conse- quent to the injury; — a sufficient reason for inculcating the necessity of avoiding all causes by which it might be aggravated. The same remarks are applicable to general in- flammation of the coverings or substance of the tongue, to which some peculiar predisposing state of the organ itself, influenced probably by a parti- cular state of the constitution, added to that of an inflammatory habit or sanguineous temperament, is conducive. Of the nature of these predisposing causes we are yet ignorant, and rather than waste time in discussing the mere conjectures which have been offered to explain them, we shall avail ourselves of the technicality of science, and include them under the term idiosyncrasy. The exciting causes doubtless consist of those which are common to inflammations in geneial, and are such as contribute to repletion, either by food or drink; the suppression of accustomed discharges or of natural secretions, particularly of perspiration, either general or local, from exposure to cold ; the immoderate use of stimulating liquors; and the direct application of corrosive or acrid 326 GLOSSITIS. substances. The same mechanical and chemical irritants which we have stated to be exciting causes of partial inflammation may also produce the ge- neral affection which it is our present design to discuss. Idiopathic inflammation of the tongue, or glos- sitis, is a very rare disease, and very formidable in itself, as well as in reference to its influence on the functions of respiration and deglutition, both of which are in general materially impeded by its presence; the former so much so as to endanger life. It commences with the usual constitutional symptoms common to inflammatory diseases, ac- companied with some uneasiness of deglutition ; the tongue is rendered painful, and the patient sensible of its enlargement, which is evident on inspection : its surface, at first very red, soon be- comes coated, except at the tip and lateral margins, with viscid whitish mucus; the articulation is in- distinct, and any attempt to move the organ, or pressure upon it, increases pain : the saliva appears to be profusely secreted, but the inability and dis- inclination of the patient to remove it from the mouth accounts, in a great measure, for the accu- mulation and dribbling which are always going on. The local pain increases with the progress of the swelling, which is very rapid ; speech and the natural motions of the tongue are consequently more and more difficultly performed; and the augmented bulk, encroaching posteriorly on the space assigned to the passage of air and nutri- ment, increases the difficulties of respiration and deglutition. The pressure also is a source of irri- tation to the larynx, and occasions a cough, which under the circumstances of the disease is peculiarly harassing ; and the cavity of the mouth being too small to contain the tongue in its increased vo- lume, the organ is consequently protruded. In this state it is obvious that a mechanical impediment must exist to the free course of the blood to and from the head; and from this cause there takes place a throbbing of the arteries, an undulatory motion in the jugular veins, lividity of the com- plexion, an unnatural prominence of the eyeballs, altogether occasioning an appearance of fulness of the face similar to that consequent to strangulation from any other cause: the accompanying sensa- tions are pain of head, and generally in the ears, vertigo, sometimes indistinct vision, and confusion of mind, or even delirium ; considerable pain is also often experienced in the tract of the spinal cord and parts adjacent, from the cervix down- wards. The constitutional or febrile symptoms are in- fluenced by the local affection : the pulse is fre- quent, full, and hard, but smaller as the disease advances, and as the impediment to respiration becomes greater; the skin, which in the early stage is dry and burning, at length is bedewed with accessions of cold perspiration ; there is ex- cessive thirst, the bowels are confined, the urine is red, sparingly secreted, and deposits the lateri- tious sediment. The patient in this state can rarely sleep, and the irritability of the nervous system rapidly leads to an alarming degree of exhaustion. It occasionally happens that the in- flammation is confined to one-half of the tongue, the raphe being the line of demarcation between «* and the unaffected side. In such cases the con- stitutional as well as local symptoms are materially modified; so also are they by a variety of other circumstances, such as the extent of the inflam- mation, the age and temperament of the individual, and the habit of body which may have immediately preceded the accession of the disease. The progress of glossitis is like that of other inflammations, and terminates either in resolution, suppuration, gangrene, and change of structure, or conversion into other disease. When the in- flammation of the mucous membrane of the tongue has been excessive, the lymph effused has been formed into a distinct expansion, like that which usually is found to take place in cynanche tra- chealis; and as the tendency is probably always the same, the occurrence, we conceive, would be more frequent but for the constant interruption to its formation, to which, in the mouth, it is neces- sarily liable. A case of this nature has been recorded by Frank of Vienna, who has referred to a preparation illustrative of the disease in another instance, preserved in the Museum of Hunter. (Acta Inst. Clinici Univ. Viennae, Anno sec. p. The period which glossitis occupies, and its several stages, are very variable in different cases, and influenced by the modifying circumstances already noticed, as well as by the remedial means which may have been adopted. Its disposition to terminate in resolution is in some cases manifested so early as the second or third day, but seldom before the fifth or sixth. The indications are, a progressive diminution of the morbid bulk of the tongue, and of the pain accompanying it; its sur- face becoming-moister; the thick coat with which it was covered disappearing; a progressive return of power and inclination to use it; with a propor- tionate decrease or even cessation of febrile symp- toms, as well as of those stated to be consequent to plethora in the vessels of the head. To illustrate the progress of the disease, and its auspicious termination, we subjoin a short sketch of a case described by the writer just al- luded to. , A healthy youth, nineteen years of age, was suddenly attacked with febrile symptoms, together with pain in the head and throat, difficulty of de- glutition, and cough : these having been neglected, increased, and during the night he experienced very acute pain at the end of the tongue, increas- ing in extent and severity with its progressive swelling, which was rapid and considerable, filling the whole cavity of the mouth, and rendering him unable to articulate. The following day he com- plained of pain in the head, especially towards the forehead, with increase of sensibility of the eye to the impression of light; the tongue was remarka- ble for its red colour, increase of size, rigidity and heat; the patient could neither draw it inwards nor extend it; the sublingual glands and tonsils were tumefied; he was incapable of speech and deglutition; complained of great thirst, had a dry burning skin, and a frequent strong pulse. Copious perspiration of a sour odour came on in the night, the swelling of the tongue and tonsils subsided, and with it the febrile symptoms; the tongue be- came moist, deglutition easy, and the following day restoration to health seemed to be established. Suppuration succeeding to glottis is indicated GLOSSITIS. 327 by some diminution of excitement of the system, with an accession of coldness over the surface of the body, or a distinct rigor, the local pain being somewhat diminished if the abscess be superficial, but the swelling increasing, and at no distant time, in one part or another, becoming particu- larly prominent. Under the same circumstances the appearance at the pointing part differs from that of the surrounding structure, and to the sense of touch it is soft and elastic, showing plainly the existence of an abscess, which, if not. artificially opened, at length by natural process allows its contents to escape. When, however, the pus is deeply imbedded in the substance of the organ, there being little cellular membrane in the con- struction of the latter, it separates the parts in proportion to the quantity secreted without dif- fusing itself, and therefore acts as a wedge, and, from the condensation and sensibility of its struc- ture, the organ is little if at all relieved, as usually happens in most other parts by the effusion of this fluid. By active treatment, however, adopted in the early stage of the disease, suppuration may generally be prevented ; but when the presence of pus is ascertained, no time should be lost in re- lieving the organ of it. The termination of glossitis in gangrene is a very rare occurrence, and has happened only in constitutions extremely debilitated by intemper- ance or disease. The reduced state of the vital powers manifested in the feeble performance of the general functions of the body, and the black- ened appearance of the tongue, the peculiar odour, and loss of sensibility, of pain, and of heat, will denote the morbid changes in progress. It has been remarked that the separation of the mortified from the living parts has been particularly rapid when gangrene has taken place in this organ. A careful consideration of the symptoms of idiopathic glossitis already detailed will afford the readiest index to determine its presence, and to distinguish it from symptomatic inflammation, as well as from other morbid states. The connecting links between local injury and consequent inflam- mation can be too easily traced to admit of error; and the enlarged states of the tongue arising from the specific operation of mercury, and sometimes consequent to the absorption of particular poisons, are attended with symptoms too peculiar to them- selves, and not sufficiently characteristic of idio- pathic glossitis, to render any discussion on their diagnostic distinctions necessary. The same re- mark is applicable to the tumefactions of the tongue which sometimes occur in fevers of a ma- lignant type, as in typhus and variola; or those metastases of inflammation which, though most rarely indeed to this organ, have been found to occur in arthritic and rheumatic cases with its simultaneous subsidence in the part originally affected. Idiopathic glossitis must at all times be consi- dered a very formidable disease, and the degree of danger, in a previously healthy subject, will be proportionate to the obstacle which the tumefied organ may present to respiration, and to the op- portunity which may be offered of subduing the inflammation on which it depends. From active treatment in the early stage a favourable issue may reasonably be anticipated, particularly if a mitigation of symptoms is seen to follow the suc- cessive application of remedial means ; but if the disease be neglected in the early stage, or the vo- lume of the tongue increase, in resistance to the measures resorted to, respiration will be performed with proportionably greater difficulty, threatening extreme danger to life by suffocation; and in per- sons predisposed to apoplexy or other cerebral disease, in an additional degree, by the impedi- ment occasioned to the free return of blood from the head, and the consequent aggravation of these diseases. Diminution in the volume of the tongue, whether by artificial means directly applied, or through the medium of the system, will propor- tionately subtract from the danger and increase the rational hopes of recovery ; but if the inflam- mation should have proceeded to gangrene, the danger to life will be influenced by the probability presented by constitutional circumstances of arrest- ing its progress, and, when effected, by the extent of the mortified part: the tongue being the organ of taste, and necessary to the perfection of speech, of mastication, and of deglutition, these functions will be affected commensurately with the local destruction. When suppuration has taken place, and the bulk of the tongue is diminished by the natural or artificial evacuation of pus, and the distress of the system lessened by a freer state of respiration and circulation, a recovery may fairly be antici- pated ; but the proneness in this organ to the de- velopment of scirrhus, in constitutions predisposed to it, is a circumstance which the practitioner should be prepared to meet after this or any other excessive local irritation. Treatment.—The rapid progress of idiopathic inflammation of the tongue, arising spontaneously in a subject previously in good health, and not induced by the action of poisons or mercury, ren- ders it of great importance that the antiphlogistic regimen should be early adopted and actively pur- sued. Bleeding from a vein in the arm, in pro- portion to the excitement of the system, or from the external jugular vein when the brain is op- pressed or likely to suffer, should be immediately resorted to, and repeated a second or even a third time, at intervals of eight or twelve hours, until the inflammatory action of the system be subdued ; other means having been adopted in aid of the same intention. Leeches should be applied in considerable numbers to the tongue itself; and when the oozing of blood has subsided from their wounds, a piece of ice, or very cold water, should be frequently applied. Active purgatives, such as calomel and jalap, or sulphate of magnesia with infusion and tincture of senna, must be given without delay, and their operation aided by a stimulating enema: indeed to keep up the free action of the bowels, so essential in the treatment of this disease, a frequent repetition of this remedy will be necessary if purgatives cannot be swallow- ed ; and, under more favourable circumstances, their counter-excitant action being immediate, they are calculated to prove highly advantageous. The usual diaphoretics and diuretics will be useful adjuvants in effecting the end in view ; and, from the small bulk in which they may be given, digi talis and tartarized antimony are to be preferred, Immersion of the feet in hot water, o< in sum? 328 GLOSSITIS. cases even a general hot bath might be prescribed with advantage. A blister should be early applied across the throat, extending nearly round the in- ferior margin of the lower jaw, as tar as its angles. When respiration is so obstructed by the aug- mented bulk of the tongue that its increase or continuance threaten to impede it entirely, two or three deep scarifications must be immediately made from the base to its apex, taking care to avoid the arteriae raninae, for the means of sup- pressing excessive hemorrhage from them would probably excite a degree of irritation which would counter-balance the advantages consequent even to a moderate loss of blood. Several instances of the advantage of incisions in extreme enlargements of the tongue have been transmitted to us by M. de la Malle. (Mem. de l'Acad. de Chirurgie, vol. v.) Camerarius has recorded a case in which the patient was rescued from impending death by this operation ; and Zacutus Lusitanus, another of a child, ten years of age, where the usual remedies had failed of affording relief, and the symptoms yielded to deep scarifications. Job a Meckoen, a Dutch surgeon, who lived in the seventeenth century, (Diet, des Sciences Med. Art. Glossite,) adopted this prac- tice on several occasions with the most complete success; and it is probable, as Mr. Samuel Cooper has remarked, that a fatal issue from suffocation, subsequent to various kinds of enlargement of the tongue, might in many instances have been avert- ed by its timely adoption. In the twenty-eighth volume of the Edinburgh Medical and Surgical Journal, page 77, an interesting case of the disease is recorded, in which the free use of the scalpel was attended with the best effects; allowing an exit for puriform matter. In the twenty-first volume of the same work, page 235, there is ano- ther case, illustrative of the advantage of incisions of the tongue, in a case of its inflammation, appa- rently consequent to suppression of the menstrual discharge from exposure to cold. It must be acknowledged, however, that inci- sions are not always successful; and it may be of importance to the practitioner's credit in proposing an operation which at least has the appearance of extreme severity, that he should advise it as essen- tial in the urgency of the patient's circumstances, and the most conducive, though by no means a certain step to his recovery. An example of the inefficacy of this and several other therapeutic agents in a case which proved awfully rapid, ter- minating fatally within forty-eight hours from its commencement, was detailed in the second volume of the Lancet for the year 1827. It occurred in the Winchester Hospital, and had the advantage of the attendance of an eminent surgeon of that establishment in a little more than twelve hours after the earliest symptom of the disease. If incisions should fail in producing the antici- pated relief, there yet remains an alternative by which life may be sustained and an opportunity provided of conducting the disease to a favourable issue : we allude to the operation of bronchotomy, lor the success of which in a case of this kind we iiave the recorded testimony of Mr. Benjamin Bell. The tongue had been alarmingly swollen from the excessive action of mercury, and no relief was obtained, although a variety of remedies had been used, until an opening was made into the trachea to keep up artificial respiration. With the same view Desault would have preferred the introduc- tion of an elastic gum catheter from the nose into the trachea, (QSuvres Chir. de Desault, par Bi- chat, tom. ii. p. 406) ; a method, we conceive, which the preternatural irritability of the parts in particular instances can alone render objection- able. It will be inferred from our preceding remarks, (and the state of the patient will dispose him lit- tle to regret the privation,) that in the early stage of the disease, when the excitement is considera- ble, stimulating food and drink should be prohib- ited ; it will also be necessary, of course, that the food should be in a soft state, and that both the food and drink should be cool, bland, and unirri- taring. In some instances the impediment to de- glutition may be so great as to make it necessary to administer both medicine and food through the nose by means of a canula passed into the gullet; and in circumstances requiring such a measure, nutritive injections may be had recourse to. When the inflammatory stage of the disease has been subdued, and the tongue is assuming its natural appearance, little else will be necessary than care to avoid the direct application of irritat- ing and acrid substances; and, if need be, the restoration to a healthy state by the remedial means severally proper in the particular conditions of those organs the defective actions of which may have served to promote the accession or vio- lence of the disease. When suppuration has taken place, or is about to do so, it will be necessary to relax in the pur- suance of antiphlogistic measures, and, as soon as possible, to make a free aperture for the escape of pus, with a lancet or scalpel. From the obser- vations we have already made on suppuration in this organ, it will be understood that a deep inci- sion may often be necessary to reach the cavity of the abscess. A striking illustration of this has been recorded in the Glasgow Medical Journal, by Mr. Orgill, with other instructive cases of the dis- ease. The patient, a farmer, fifty years of age, had suffered for some days from glossitis, and be- sides other treatment had undergone local bleed- ing by cupping and leeches, as well as two inci- sions half an inch deep from as far as the scalpel could be made to reach to the tip of the tongue. The incised wounds bled freely, and the swelling was a good deal reduced, but in the evening of the same day it became as great as ever; it was scarified still more deeply, and a castor-oil enema prescribed ; this also gave great relief; but next morning the swelling had returned, with a pecu- liar lividity at the tip of the diseased half of the organ. An incision an inch deep was made with a scalpel, which gave exit to a gush of pus in a very offensive state, and in eight days the patient was well. The sensibility of the organ on the affected side remained imperfect for a year after- wards, but at length was restored. When the tongue has been relieved of the pain- ful distension occasioned by the impaction of pus, the sanatory quality of the saliva may generally be relied on for the completion of the process of cure. Astringents in most cases will be unneces- sarily stimulating, but a simple admixture of ho- GLOTTIS, (SPASM OF THE) 329 ney and barley water, or some gargle equally un- irritating may contribute to the patient's comfort by diluting the saliva, and thus forming a cool and more bland application. On some occasions it may be requisite to have recourse to other deter- gents, such as borax or tincture of myrrh in the common form of gargle. The indications as to constitutional treatment in this stage are, to allay the irritability of the sys- tem, and to restore the disordered functions of the body to their healthy state. As the means must be selected on general principles, it would be need- less to particularize them here. When inflammation of the tongue has unfor- tunately terminated in gangrene, — a very rare occurrence in this rare form of disease,—its treat- ment is subject to the same laws as gangrene in any other part: reliance, however, is chiefly to be placed on the means of improving the condi- tion of the constitution ; though it is to be feared that in most instances there can be little proba- bility of effecting this object. For the particular means we refer to the article Inflammation, rather than occupy time and space unnecessarily by any formal detail on a subject which has little notice in the records of medical literature, proba- bly because science has been unavailing in the few opportunities which have occurred for its ap- plication. The enlargements of the tongue, (some extra- ordinary instances of which are on record,) which have been occasionally consequent to the exhibi- tion of mercury, usually yield to purgatives, or injections of the same nature, bleedings, and the discontinuance of the mercurial medicine. In some cases of extreme obstinacy it may be requi- site to make incisions into the organ, or to adopt the other means of treatment which have been proposed : other particulars relative to this state will be discussed under the article Ptxalis^i. In those tumefied states of the tongue which occur in typhoid and variolous fevers attended with an atonic condition of the system, the local affection requires little consideration apart from the general disease, unless, indeed, the magnitude of the organ should threaten suffocation ; when free incisions, in the manner we have already de- scribed, and the other mechanical means pointed out, may materially relieve, if not save the patient from impending death. In such instances as are the results of metasta- sis, as of gout or rheumatism, the first step will be to invite the inflammation to its original seat, by applying to the latter a sinapism or blister, or by immersion csf the extremity in which it may have been situated in hot water, rendered still more stimulating by the addition of flour of mus- tard or common salt: should this fail in produc- ing the desired effect, or if the habit of the indi- vidual should be favourable to the continuance of inflammation, the method of subduing it must be adopted at the same time, bearing in mind that under such circumstances the local affection will partake of the same peculiarities, and require a corresponding consideration, with the general dis- order. [When the surface of the tongue is covered by a dry, white pellicle, and is ulcerated or perforated, a condition which has been described by Dr. Mar- Vol. II. —42 2c* shall Hall as psoriasis of the tongue, (Principles of the Theory and Practice of Medicine, p. 468 : Lond. 1837,) it is necessary, as in chronic cuta- neous affections in general, to act on the general system. This can be done by eutrophics, in othei words, by agents that modify the condition of the system of nutrition,—of which arsenic and iodine are among the best, especially if given in syrup, which, of itself, is capable of modifying the chyle, and, through the blood, the nutrition of the tis- sues. At the same time nitrate of silver may be applied to the tongue itself.] ,„ „ [GLOTTIS, 02DEMA OF THE, (See La- ryngitis.)] GLOTTIS, SPASM OF THE. This very formidable affection, which is by no means of rare occurrence in infancy, was till of late years but ill Understood, being for the most part confounded with croup and other inflammatory affections of the air-passages. One of the first obscure notions of it is that by Millar, under the name of the acute asthma of infants. He seems, in some respects, to have confounded it with the first stage of croup; and yet, if early discovered, he thought it might always be cured by the plentiful exhibition of as- safcetida, and the subsequent employment of bark. A further step towards the diagnosis of the disease was made by Underwood, in his division of croup into the chronic or spasmodic and the acute or inflammatory. The former of these, which seems to answer to what is now called spasm of the glottis, he states to have been known to con- tinue so long as two months, and then to have yielded to opium. " Instances have likewise been met with of children Grouping for two or three days, and being then seized with hooping-cough, which has instantly removed the croup. These circumstances," he continues, « seem to prove that species of croup to be truly spasmodic. I have seen it frequently in this form attend the cutting of teeth, being then the mere consequence of irri- tation, as we see cough and various other symp- tomatic affections induced at this period." In ad- dition to assafcetida and bark, Underwood recom- mends the occasional use of emetics and cicuta — " one or other of which must be persevered in as long as any symptom of the disease, and particu- larly the croaking noise, shall remain. He seems, however, to have had but a very imperfect notion of the disorder, confounding it in one part of his work with croup, with which it has really no af- finity, the membrane lining the larynx presenting no traces of disease on dissection ; and treating of it in another place under the head of inward fits, which is an imaginary disease. Dr. Ferriar, like- wise, in recognising a spurious species of croup, seems to have met with the affection in question, though he did not attain to a correct idea of its nature. One of the first accurate accounts of the disease is that by Dr. John Clarke, in his Commentaries on the Diseases of Children. He describes it an iter the name of " a peculiar species of convulsion in infant children," often miscalled spasmodic or chronic croup The child, according to this wri- ter, is suddenly seized with a spasmodic inspire tion, consisting of distinct attempts to fill the chest, between each of which a squeaking noise is oftek 330 GLOTTIS, (SPASM OF THE) made; the eyes are staring, and the child is evi- j dently in great distress. The face and extremi- ties, if the paroxysm continue long, become pur- ple; the head is thrown back and the spine bent, as in opisthotonos; at length a strong inspiration takes place, a fit of crying generally succeeds, and the patient, much exhausted, falls asleep. The paroxysm may occur often in the course of the day, and is most apt to take place on awakening, or on exposure to slight causes of irritation. If neglected, it may go on recurring frequently for two or three months, until at length general con- vulsions ensuing, the parents become alarmed. It seldom occurs, he thinks, after the third year, or in children who have lived by suckling alone till they have got some of their teeth, and thus escaped those derangements of the health which are con- nected with an unsuitable diet in extreme infancy. This, as well as other convulsive affections of children, he ascribes to disease of the brain, which may be induced, he thinks, by over-feeding, keeping the head too hot, the sudden cure of ophthalmia, or of cutaneous eruptions, the occurrence of fe- vers, &c. In one fatal case he discovered, on dis- section, both fulness in the vessels of the brain and water in the ventricles. A peculiar species of hydrocephalus, ushered in by spasm of the glottis, has been mentioned by Monro; and a case which seems to have been of this kind is also alluded to by Underwood. Golis, in treating of the predisposing causes of hydroce- phalus, places this affection amongst them, and describes it as " a peculiar disorder of respiration, in which infants after sudden waking out of sleep, or from terror or anger, often too without any cause, are suddenly seized with a deep shrill re- spiration, which for many seconds, sometimes even for minutes, threatens suffocation ; the whole body becomes stiff; the face, hands, feet, and par- ticularly the finger and toe-nails black or blue, and the little patients lose their breath and con- sciousness ; at length, however, with a cry of alarm, they again recover both." Dr. Cheyne has given, in the following passage from his work on hydrocephalus, a more satisfac- tory account of this affection, since called spasm of the glottis, than any of his predecessors : — « Another disease of infancy required to be briefly adverted to in treating of the diagnosis of hydro- cephalus. This disease has been known to some authors under the titles of inward fits, chronic croup, &c. It begins with a crowing inspiration, like that which takes place in the commencement 01 a paroxysm of pertussis. As at first there are long intervals between these spasmodic inspira- tions, (several days perhaps ;) as they appear to be connected with a disordered stomach and ab- sence of bile in the bowels; to arise from sudden exertion, or fits of passion ; and as the child often continues to thrive notwithstanding, the disease is not much attended to. At last, however, the spas- modic inspirations excite just alarm; they occur frequently without any apparent cause, when the tdiild is perfectly tranquil; the complexion be- comes purple, insensibility follows, and not unfre- quently universal convulsions or rigidity of the muscles, with the thumbs clenched in the hands: !bese convulsions, in seven instances to my know- tege, have ended in ueatn. However, after con- tinuing manv weeks, or even montns, this affec- tion often terminates favourably with the cutting of one or more of the teeth, or it may be relieved by effectually scarifying the gums, changing the air and diet, and alternating mercurials with car- urinative purgatives. The pathognomonic of this disease is a crowing inspiration with purple com- plexion, not followed by cough. In some cases this affection is attended not merely with a per- manent clenching of the hand upon the thumb, but also with a very remarkable fixed spasm of the toes, particularly the great toe, which gives a look of swelled deformity to the upper purt of the foot." For a further account of this peculiar swelling of the hands and feet, first accurately de- scribed by Dr. Kellie, the reader is referred to the article Dentition, Diseases of. [The presence of these symptoms has given occasion to the names carpo-pedal spasm, and cerebral spasmodic croup.] Spasm of the glottis cannot be considered a rare disease, as Cheyne had seen previous to the year 1819, when his work was published, no less than twenty cases, of which one-third were fatal. He, like Clarke, has no doubt that the brain is the seat of the disease ; but what is the precise morbid condition of this organ giving rise to these pecu- liar symptoms, or whether there be any invariable one, has not yet been accurately made out. The results of dissection in three cases are given in the appendix to this work. In the first of these, two tumours, apparently of a scrofulous nature, were found imbedded in the substance of the brain ; in the second, the convolutions were nearly obliterated, and the cerebral substance appeared uncommonly firm; in the third, the veins on the surface of the brain were turgid with blood; a considerable quan- tity of serous fluid existed between the tunica arachnoides and the pia mater, giving a gelati- nous appearance to the surface of the hemispheres; whilst about an ounce of water was discovered in the ventricles. Disease of the brain has not, how- ever, always been detected. Thus in two cases mentioned by Dr. Meniman, of children who died in these fits, no appearance of cerebral affection could be discovered. The principal deranged structure was a collection of small glandular swell- ings in the neck pressing upon the par vagum. In none of these cases was there any trace of in- flammation in the larynx or trachea. Gardien's description of this affection, under the title of " Spasme du Thorax et de la Glotte," dif- fers in some respects from most other accounts of it. He remarks on the impropriety of many of the names which have been bestowed on it. Thus by Lieutaud and Baumes, who seem to have had a pretty accurate idea of its true nature, and its alliance to convulsive or nervous affections, it has been absurdly called " catarrhe suffocante." The appellations of « acute asthma of children," em- ployed by Millar, or spasmodic asthma, used by Rush, appear to him equally objectionable. The disorder, as described by Gardien, consists in a spasm of the diaphragm, muscles of the chest and larynx, and is, he thinks, almost always fatal, if suitable remedies be not emploved during the commencement of the disorder. It occurs chiefly in children, though in some rare instances it has been observed in adults also, chiefly in nervous women and old persons. The night-mare, or a GLOTTIS, (SP ASM OF THE) 331 habit of suddenly awakening from sleep in a state of terror, he looks upon as a premonitory symp- tom, or as the first stage of the disease. Children who are liable to it are observed to cry very fre- quently during the day, and are frightened and agitated by the slightest causes. Its attacks are sudden, and occur chiefly in the night. The.ap- pearance of the face during the continuance of the spasm is variable; in some instances being pale as in syncope, whilst in others it has an apoplec- tic character. It occurs most frequently, he thinks, between two years old and seven; in which he differs from most other writers, as it is usually placed amongst the diseases of early infancy and of dentition. Children who are old enough to ex- plain their sensations complain of a feeling of suf- focation and constriction about the chest, as if it were bound with cords, and of palpitations and convulsive efforts of the thorax, with a sense of strangling about the larynx; the respiration is sometimes momentarily interrupted, and is at all times extremely difficult, and accompanied with a peculiar sound, which can be heard at a considera- ble distance. The stomach and intestines are dis- tended with air, and the patient seems as if he would die of suffocation, if eructations or vomit- ing did not come to his relief. His description, in some of its parts, suggests to us the idea of an hysterical affection. Spasm of the glottis, as al- ready stated, has also been mentioned by Dr. Mer- riman. He thinks it by no means an uncommon affection of children, and attributes it chiefly to improper food and close and confined apartments. Wichmann, the Hanoverian physician, and Schmalz, in his work on diagnosis, have taken pe- culiar pains to point out the distinctions which exist between this disease and croup. The latter seems usually to depend on a cold damp air and sudden atmospheric vicissitudes; its inflammatory nature is manifested as well in the character of its symptoms, as by the beneficial effects of anti- phlogistic treatment, and by the appearances on dissection. Spasm of the glottis, on the contrary, is excited by passions of the mind and other sources of momentary irritation, existing often in distant parts of the body; catarrhal symptoms form no essential part of the disease; it occurs chiefly in those who have a general disposition to convulsive affections ; its attacks are intermittent, and are most susceptible of relief from agents act- ing on the nervous system ; and it presents after death no traces of inflammation in the respiratory organs. Spasm of the glottis has been described by Mr. Pretty in the Medical and Physical Journal un- der the singular name of " cerebral croup." It has also been noticed by Richter, Henke, Jahn, and several other writers in Germany. [Of late years it has attracted more attention, and by many of the German and other writers has been termed, in consequence of their views of its pathology, Asthma thymicum, A. thymicum Koppii, and Laryngismus stridulus,] and in France it has been treated of by Guersent under the title of "pseudo-croup nerveux." Though it has been thus recognised by so many respectable authori- ties as a distinct and well-characterized disease, yet Autenreith and Hecker, and more recently Jurine and fibers, have treated it as a mere mo- dification of croup. From this, however, we re peat, it is broadly distinguished, as well by its in- termittent nature as by the usual absence of cough and fever, and by the sudden death which not unfrequently occurs in it. Even if a slight cough happen to co-exist, the disease may still, as Dr. Hamilton has remarked, be satisfactorily distin- guished by the cough not being a peculiarly hoarse one, and by the breathing in the intervals remain- ing perfectly free. The latest and by much the best account of the disease, is that by Dr. Marsh. The disorder, as described by this writer, begins by the muscles of the glottis; but if neglected or mismanaged, it may extend to those of the extremities, and even terminate in universal convulsions. Its occurrence is by no means rare, and its result not unfrequently fatal. It sometimes appears to be a purely idiopa- thic affection ; but in far the greater number of cases, as Dr. Marsh observes, " it is complicated with painful dentition, derangement of the diges- tive functions, a cachectic state of the system in- duced by an impure atmosphere, fever, and occa- sionally with effusion into the ventricles of the brain. The child is observed to awake suddenly from sleep in a state of alarm and agitation, to struggle for breath, and, after repeated efforts, to recover from the paroxysm with a long and sono- rous inspiration," usually described by nurses as a whoop or crowing sound. The face is swollen and purplish during the fit. As the disease ad- vances, similar attacks occur even while the child is awake, — " sometimes without any perceptible cause, but more frequently when it is vexed and about to cry." Robust as well as delicate chil- dren are liable to it, but it especially attacks those which are of a passionate and irritable disposition, and the subjects of it are observed to be easilj startled even by the slightest noises. It is only in its more advanced stage that Dr. Marsh has ob- served the peculiar swollen state of the hands and feet, and the rigid contraction of the thumbs and toes, already alluded to. [We have much to learn in regard to the pathological characters. It has been thought to be, in the first instance, a spasmodic affection of the muscles of the glottis, and that until tht disease has increased in severity, and general con- vulsions have supervened, the brain or its meninget do not become the seat of disease. The seat of the primary lesion has been presumed to be in the brain. By others, the disease has been referred to hypertrophy of the thymus gland, producing pres- sure upon the heart, iungs, and great vessels, and it has been maintained to be owing to the enlarge- ment of the bronchial or deep-seated lymphatic ganglions of the neck, pressing upon the recurrent nerves, and inducing paralysis of the muscles supplied by them. (Ley, An Essay on the Laryn- gismus Stridulus : Lond. 1836.) Judging from the character of the phenomena, the disease would seem to be primarily and essentially encephalic, and it has been suggested by Dr. Marshall Hall, that even the enlargement of the thymus gland, which is sometimes met with., may be " a natural effect of the violent convulsive efforts observed in this terrific malady."] In the treatment of the disease the chief in- dications consist in amoving a..y complications GLOTTIS, (SPASM OF THE) —GOUT, 332 which mav txist, and in improving the general health, and especially the tone of the nervous system. Difficult dentition is a very frequent ex- citing cause of this affection : when it is suspected to have this origin, the swollen gums must be im- mediately divided. In those cases where a careful investigation into the state of all the functions of the boly detects no complication, a mildly tonic plan of treatment should be had recourse to. The sulphate of quinine, or some of the mineral tonics, arc here found very useful. Antispasmodics too often disappoint expectation, and are of very secondary importance in the treatment of the dis- ease : ether and ammonia are the only medicines of this class in which Dr. Clarke had the slightest confidence. The tinctura fulginis of the older pharmacopoeias is spoken of by Dr. Marsh with some commendation. In all cases we should endeavour to improve the general health and strengthen the nervous system by country air, a well-regulated diet, and attention to the state of the bowels. By giving the child the advantage of a pure air and of a succession of good nurses during the whole period of dentition, more good has appeared to be done than by all other mea- sures put together. Dr. Marsh remarks that all his cases occurred in children of a scrofulous con- stitution ; a fact which leads him to insist still more strongly on the importance of a pure at- mosphere, healthy nutriment, and tonics. Dr. Cheyne, also, as we have seen, dwells much on the utility of change of air and of diet. Free ex- posure to the open air, and daily sponging of the body with cold water, are amongst the most effec- tual means we possess for lowering the nervous excitability in this and many other spasmodic dis- orders. When the convulsions threaten to become gen- eral, leeching the temples, cold applications to the head, and fomentation of the extremities, will generally be required. In the case of a delicate child of two years old, mentioned by Marsh, in which the paroxysms were of very frequent occur- rence, and were accompanied by general convul- sions, a tobacco enema (five grains infused in six ounces of water) was administered; it produced its specific effect in a very marked manner, and no appearance of convulsions was observed for a month after. Removal to the country appeared to confirm the cure. The symptoms, however, recurred on again returning to town to a house which had been recently painted. Several other instances are mentioned, where the disease seems to have been excited by the unhealthy atmosphere of newly painted rooms. Dr. Merriman is of opinion that this disease, when early attended to, will commonly yield to aperients, so given as to procure at least two copious evacuations daily, together with the con- tinued use of soda, or a strong infusion of burnt sponge, and proper attention to the diet and regi- men : — " When the head is manifestly affected, cupping-glasses behind the ears are required; but when the patient has cold, pale, flabby cheeks, abstraction of blood is rather injurious than bene- ficial." Dr. Hamilton has found Dalby's carmina- tive a useful medicine in this affection after the bowels have first been freely opened. We have known the disorder, after resisting the influence of purgatives and change of air, cease finally on the occurrence of a spontaneous diarrhcea. Spasm of the glottis has occasionally been mis- taken for an inflammatory affection of the lungs or air-passages, and been much exasperated by a consequent perseverance in the antiphlogistic treat- ment, and by confinement to the close air of a heated apartment. Even in its simplest and mild- est form it should never be neglected, as in the absence of every complication, the spasm of the muscles of the larynx alone has often proved sud- denly fatal. Dr. Johnson knew a case recovered by the immediate employment of artificial respira- tion, after death had apparently taken place. Before terminating this article, we may state, that fatal spasm of the glottis in adults occasion- ally takes place, under the influence of irritating causes in the neighbourhood of the larynx. Thus, in an interesting case recorded by Mr. Kirby, spasm of the glottis and death were caused by the irritation of a mouthful of food sticking in the oesophagus; and we have seen a patient with many of the symptoms of acute laryngitis die rather unexpectedly, when, on dissection, very lit- tle if any redness or swelling were discovered in the membrane lining the larynx, and scarcely any other morbid appearance than one or two minute ulcers. It is probable that the fatal result, as well as the sonorous breathing, and many of the other symptoms in such cases, depend on a spasmodic contraction of the glottis. T,T „ , W. B. Joy. GOUT, gutta, la goutte, a drop or defluxion. A name is of slight importance, provided it does not mislead by imputing to a disease a hypotheti- cal character. If used only to express the indi- viduality assigned, for purposes of convenience, to an aggregate of functional disturbances or structural lesions, and limited to this sense with- out involving any speculative conjectures respect- ing the cause or nature of disease, it need not be rigidly criticised. That which heads the present article, while it is one of the most ancient, being traceable so far back as the thirteenth century, and the most generally adopted, a corresponding term having found its way into all the languages of Europe, is also the one in common use to de- signate the disease; and as the false theory which gave rise to it has been long exploded, and is now incapable of biassing any one's judgment, it seems little worth while to change it for any other, espe- cially as, of the substitutes introduced or proposed, none is so unexceptionable as to entitle it to a preference. An elaborate treatise on gout would be unsuit- able to the present purpose, while it would be valueless if it could be introduced. To record all that has been said in the lapse of centuries would be wearisome labour to the writer, and profitless to the reader. Much has been written which may well be passed over. The facts are few, the specu- lations many, and these too often the mere phan- tasms of the brain. The former are the same now that they ever were, and therefore cognizable by every observer; and far better is it to study them in the book of nature than to take them on trust from any authority, however high : the latter have produced but little worth remembering; theories have chased each other like shadows in a magic GO UI . 333 lantern, none abiding to announce to us the essen- tial nature of gout. After ages of inquiry, we know it only by the order and character of its phenomena, and have yet to learn its intimate nature or the special cause which produces it. Happily the knowledge within our reach is suffi- cient to guide us to much useful practice, as well in averting accessions of the malady as in miti- gating them when they do occur, and in prevent- ing the disorganization and decrepitude to which gout, when neglected or maltreated, so often con- signs its miserable victims. If, from our inability to penetrate nature in her inmost recesses, we cannot detect the essence of gout, we can at least note the succession and character of the pheno- mena which constitute it; we can mark the de- viations from health which precede and attend the attack, and by contrasting them with the healthy condition, can arrive at some knowledge of what is amiss: we can thus direct our efforts to restor- ing healthy function where this is sensibly im- paired, and by so doing can second the efforts of nature in remedying the special disorder, even when ignorant of what essentially produces it. In fine, by adopting a pathology founded solely on facts, unalloyed by hypotheses, and conforma- ble to all that we know of the physiology of ani- mal life, we may establish a system of treatment supported by rational principles, and capable of rendering much more valuable service to those who need our assistance, and look to us for relief. We have it in our power in a great degree to avert the accession of the gouty paroxysm by correcting that state of the constitution which ministers to it; we can greatly mitigate the suffer- ings of the attack, abridge its duration, and pro- long the period of exemption ; by so doing we can prevent those horrid disorganizations which protracted or oft-renewed gout so constantly occa- sions, and also obviate still more fatal conse- quences which result when gouty action extends to vital organs and other parts essential to well- being. The brain, lungs, heart, stomach, liver, kidneys, may any or all participate in the derange- ments occasioned by unrelieved or maltreated gout; and the sufferings and danger which thence result may be numbered among the most formida- ble to which disease can subject the animal frame. Palsy, epilepsy, gravel, and other direful inflic- tions are too often the attendants on protracted gout, and intensely do they aggravate its suffer- ings. These views are hastily sketched, for the purpose, not of magnifying the disease or attach- ing to it any undue importance, but of claiming for it that scrutinising investigation, vigilant ob- servation, and sober judgment which may bring its practical treatment within the pate of rational principles, and divest the subject of the mysticism which has been too long suffered to surround it, to the discredit of medical science and the encou- ragement of charlatanry. On no subject has empiricism been more assi- duously or more mischievously pursued; and where its nostrums have not proved absurd from their inertness, they have been too often pernicious from their activity : witness the numberless vic- tims who fell a sacrifice to the delusive efficacy of the eau medicinale. Until the treatment of gout shall be established on the same principles which are found applicable to all other diseases ; until the contemplation of its inscrutable, or at least undiscovered, essence shall be superseded by a fixed attention to its obvious and intelligible phenomena, and the proper treatment which these demand be adopted generally and systematically by the profession, quackery will continue to prac- tise its deceptions, and gouty sufferers, hopeless of relief from the regular practitioner, to surren- der themselves the willing dupes.of every confi- dent pretender. A history of gout that would comprise all its alleged forms and modifications would be both tedious and uninstructive ; nay, instead of eluci- dating, it would but obscure the subject, involving it in inextricable confusion. Much that has been attributed to gout belongs not to the special dis- ease so much as to incidental derangements, either antecedent to, coincident with, or resulting from it, and no more an integrant part of gout than when they occur in connection with any other malady. The incidental derangements of a gouty habit are numerous enough, and often to be met with; but it can serve no good purpose to repre- sent all these as characteristic of gout, which, on the contrary, will be best and most clearly compre- hended when viewed in its natural form, divested of those complications which, however occasion- ally intermixed, do not necessarily belong to it. It has been too much the custom to attribute every morbid action occurring in a gouty habit to the influence of gout; and, however obvious their nature or character, to render their treatment sub- servient to the notions of gout which the medical attendant chanced to entertain. In this way have the apprehension of debility, the belief of a tonic treatment being requisite in gout, and the fear of injuring the constitution by any interference with the gouty paroxysm, misled many into pursuing a stimulant regimen under circumstances which, but for this delusion, would have been seen to indi- cate a very opposite course; and to the conflicting experience derived from observations made undei such misconceptions, may be ascribed much of the uncertainty and caprice which mark the treat- ment of gout, both popular and professional, even at the present day. The best history of gout for all useful purposes must be that which represents the disease in its simplest form, giving such a description as will enable the young practitioner to recognise it when presented to his view. This being illustrated, and the principles of treatment explained, the various modifications may then be advantageously dis- cussed in connection with the derangements which occasion them, and with the treatment which they respectively require ; in which course of inquiry, it cannot fail to be remarked how much this treat- ment is dependent on the same rreneral principles which guide the practice in all other diseases, and how very little consideration it admits for the special nature or character of gout. The definition of Cullen characterizes the dis- ease clearly and succinctly. " Morbus hereditanus, oriens sine causa externa evidente, sed praeeunte plerumque ventriculi affectione insolita. pyrexia, dolor ad articulum, et plerumque pedis pollice. certe pedum et manuum junturis potissimum in. festus, per intervalla revertens. et saepe cum \er. 334 GOUT triculi et aliarum internarum partium aflectionibus alternans." That this as a definition is open to objections we admit. As a description of the dis- ease, however, at once concise and correct, it seems to answer every purpose; and we are not aware of any preferable or less exceptionable character of the malady having been yet proposed. The object of a definition is so to characterize a disease that the name used to denote it shall be applied always to the same morbid condition. But it is a general character only that can be thus assigned. Perfect accuracy is not within the compass of any definition; and it is fruitless to cavil at imperfections of nosology, when of the branch of science which classifies disease the very foundations are yet undeterminate. It may be confidently alleged that of all the methodic classi- fications yet proposed, not one rests on a stable basis; and both physiology and pathology must be greatly advanced ere any arrangement border- ing on a natural and scientific classification of diseases can be practicable. The derangements of the constitution which usher in diseases, the local disturbance to which they give rise, and the re-action by which these aggravate and complete the disordered state in which they originate, are too little understood for any classification of dis- eases founded on their essential nature or charac- ter to be yet attempted. To the labours of the pathological anatomists now so diligently pursued, and to the lights which these shed on morbid actions, and the lesions which result from them, must we look for guidance in this respect if the object is ever to be attained. So unsettled are opinions respecting diseases of the most frequent and extensive occurrence, that it is yet disputed whether fever is a local or constitutional disease ; and this ambiguity is likely to endure so long as consideration of diseased conditions of the frame is taken up at the advanced period at which a noso- logical disease presents itself, without sufficient regard being had to the previous deterioration of health to which so many of these morbid condi- tions are traceable, and without a clear knowledge of which their nature and progress never can be thoroughly understood. Much A the complexity displayed in any mi- nute history of gout results from several circum- stances being comprised which do not essentially belong to it. Left as it has been to work out its own cure, derangements have ensued in its un- checked progress, which a more efficient treatment of the incipient disease would have wholly pre- vented, and which should, therefore, be considered Lather as contingent and derivative than as form- ing a primary or essential part of the malady. Peculiarity of constitution, too, whether natural or acquired, continually varies the aspect of the dis- ease ; and here to discriminate what is truly gouty from what is but casual is surely preferable to confounding the whole assemblage of symptoms by representing them as all characteristic of gout. The best mode of imparting just and clear ideas on the subject seems to be, to discuss first the disease in its simplest form ; and having illustra- ted, be far as our knowledge permits, its nature and treatment, to extend inquiry to those compli- cations which protracted malady or peculiarity of •'institution occasions, instead of regarding these as distinct and peculiar varieties; in which course of investigation the several modifications distin- guished as atonic, retrocedent, and misplaced gout, will be necessarily included. Histories of gout have been rendered with a minuteness of detail highly creditable to those by whose patient observation and faithful delineation they have been supplied. So copious has been the record of symptoms, whether antecedent to, accompanying, or consequent on a paroxysm, that there is scarcely a derangement of the fiame which has not at one time or other been noticed and included. It is full time to lay aside this tedious and profitless minuteness, — to classify those individual symptoms according to the func- tional derangements which they indicate, — to ascend from the manifestations to the causes which produce them, tracing to the disordered functions the several symptoms which denote their disturbance, — to look to the nature and character of such disturbances, and their connec- tion with the disordered functions, as the only real source of useful knowledge, the only sure guide to rational or effectual practice in this or any other disease, — to distinguish what really belongs to the disease from mere contingencies, dependent not on the specific cause of gout, but on deviations from health local or constitutional which have no necessary connection with it, and which require to be treated precisely as if they occurred independently or in connection with any other malady. Divested of this source of confu- sion and obscurity, gout becomes as intelligible as are many diseases with which we consider our- selves better acquainted ; and though after all our investigations the influencing cause of its peculiar and distinctive character is still a mystery, we may attain quite as intimate va knowledge of its pathology, as far as regards practical utility, as we possess of small-pox, rheumatism, or any other disease of the intimate nature of which we are ignorant, and which we are content to know only through the medium of the constitutional and local disturbances which mark their accession and progress. In this view a paroxysm of gout can be regard- ed only as a constitutional disturbance of an inflammatory character, attended with local in- flammation of a peculiar kind in one or more joints, running a determinate course, and in the earlier accessions terminating in health, for the most part within a very few days. Such being the character of simple gout, there is no reason why the complications so much dwelt on should be considered as specially belonging to it, or re- garded otherwise than as accidents arising from peculiarity of constitution, contingent derange- ments of health, or the lesions or morbid tenden- cies entailed by preceding accessions. That the paroxysm of gout manifests invariably an inflammatory character is a truth which all admit. The inflammation both local and consti- tutional occurs in every variety of degree; still an inflammatory character marks the whole. In consequence of the disease being identified with the local inflammation, and supposed to commence only when this appears, the seizure is generally represented as taking place suddenly, the previous good health being gratuitously assumed. This, GO UT. 435 however, is a great fallacy, no disease evincing so much constitutional disturbance or local inflam- mation, arising from a cause acknowledged to exist within \he body itself, being ever of sudden occurrence. Ample warnings of the approach always exist, and would admit of ready detection, but that the parties, unsuspicious of what is pend- ing or thinking lightly of the unhealthy deviations, overlook or disregard them; and as medical aid is not sought until the accession of the paroxysm, the premonitory indications are rarely submitted to the observation of the medical practitioner; whence, a stage of the disease of the first impor- tance, and that which is calculated to throw light on all the subsequent changes, has not received that scrutiny to which it is eminently entitled, nor been allowed the share which it ought to have, both in determining the true pathology of gout, and establishing the practice best suited to its relief. In the active gout of robust habits, the plethoric state of constitution attendant has been too con- spicuous to be overlooked, and accordingly it has received its full share of attention, although the indications of treatment which it presented have not always been acted on to the extent which they ought. It is of importance to understand that in cases where plethora is less obvious, its existence is not the less real nor the less entitled to the practitioner's serious attention. The sub- ject of plethora, its intrinsic nature, modifications, and phenomena, is too extensive to be introduced in this place, a separate discussion being required to elucidate it, which will be found under its proper head. So connected, however, is plethora with gout, that a brief notice of its pathology be- comes a necessary introduction to the further con- sideration of this disease. The elements of nutrition being supplied to eveiy part of the body by the blood, and this deriving its nutritive matter from the aliment taken, it is obvious that redundancy of nutritive matter may take place in the blood, either from sustenance being inordinately taken, or from a diminished expenditure of it in the ordinary ap- propriations. In either case the healthy propor- tions of the elements of which blood consists are altered, and a corresponding effect is produced on the several processes to which the blood is subser- vient. An accurate investigation of the actions and changes thus induced would go far to explain the origin and progress of many diseases. They should be traced, not by speculative conjectures of what might be ingeniously supposed to take place, but by carefully noting the phenomena which indicate them, and, by induction from well- ascertained facts, guided by a sound physiology, ascending to that point which connects the state of health with the morbid changes. These phe- nomena have been much overlooked or miscon- ceived, and the semblance of debility which they present has been the source of much bad practice. The plethora of a healthy and vigorous habit is familiar to all, is readily acknowledged, and seldom misunderstood. That which arises in habits more weakly by nature or depraved by vitiating influ- ences, is less known, and its appropriate phe- nomena are more liable to mislead. When ful- ness of habit arising from redundant nutriment takes place in a healthy constitution, its earliest effects display what may be termed exuberance of health rather than a state of disease. The seve- ral functions of the body are more vigorously per- formed, the nutrition of its several structures is more abundant, and it acquires increase of bulk, especially if the habits of life are not of an activity capable of rendering the appropriation of blood in the several secretions commensurate with the nu- triment inordinately supplied. Though this state cannot well be denominated disease, it yet ap- proaches very nearly to the confines, as is con- tinually exemplified in instances where acute diseases of formidable intensity assail persons con- sidered as being antecedently in unusually good health. If the excess be casual or inconsiderable, the self-adjusting powers of the body are amply sufficient to dispose of it so as to prevent the ac- cession of actual disease. And this is done sim- ply by the stimulus of the too nutritive blood ex- citing the several secretories and excretories to an increased exercise of their several functions. But when, from extent or continuance, the excess is such as to urge these powers beyond a certain point, then these corrective energies fail, and ir- regular actions and distributions of blood take place, laying the foundation of a large proportion of the special diseases to which the human body is liable. The general character of the diseases thus induced is congestive or inflammatory; by depletion and abstinence the disturbing cause is corrected, and, thus relieved, the natural powers of the constitution soon re-establish a state of health. The more early such relief is afforded, the more prompt and effectual will it be, and the more certainly will those lesions and derange- ments be averted which protracted plethora is sure sooner or later to occasion. But to relieve it thus early so as to obtain these advantages, it is neces- sary to be able to recognise its existence by those evidences which denote it, antecedently to the stage of excitement known to us as fever or in- flammation. These evidences present an equivo- cal character to those who have not closely ob- served the rise and progress of plethora, and they are continually misconceived as rather indicating a state of debility requiring support from nutri- ment and stimulants, than as calling for absti- nence and depletion. When plethora (by which is understood not a mere redundancy in the quan- tity of the blood, but an excess in the proportion of the elements, chiefly the gluten, which supply nutritive matter to the several tissues) increases so as to exceed what the excited energies of the frame can healthfully dispose of, these energies, incapable of sustained over-exertion, become weak- ened, and a condition results which is very liable to be confounded with pure debility. The pulse becomes low, oppressed, irregular, and a state of general languor is experienced. Sooner or lalei this condition passes into one of permanently in- creased action of the blood-vessels, attended with additional phenomena, the assemblage of which constitutes that state to which we apply the term.' fever and inflammation. For the full considera- tion of this subject we must refer to the article Plethora, as it would encumber too much the present essay. Some notice of it in this placi' was indispensable from its connexion with gout, 336 GOUT. and the necessity of referring to it both in eluci- dating the character and progress of the disease, and in establishing the principles on which the treatment should be conducted. A paroxysm of gout is seen to consist of a pe- culiar constitutional disturbance terminating in a local inflammation, the occurrence of which latter, so far as the simple paroxysm is concerned, seems the natural remedy of the preceding disturbance. If the various derangements which usher in an attack of gout, instead of being promiscuously enumerated with a minuteness and to an extent which confound all clear conception, were classed according to the functions severally depraved, the representation would be much more simple and intelligible. All of them admit of being traced to lesions of the circulation, alimentary canal, the nervous system, and the several secretory and ex- cretory organs. Pursuing the inquiry, it is not difficult to mark the connection of these with each other, or to detect the primary derangement in which they have their origin. Excess of nutritive matter in the blood, whether absolute or relative, has been seen to disturb the circulation, occasion- ing, first, a high activity of healthy function ; se- condly, an interval of diminished energy ; and, lastly, a state of permanent excitement. By ab- solute excess is meant that which would be ex- cessive in the most healthy state of the individual constitution, and which is always the result of in- ordinate nutrition ; by relative, that which, though it might not exceed what a state of health with active exercise might safely endure, is yet re- latively redundant when health has from any cause declined, or when from defect of wholesome exercise, the healthful appropriation has been more or less impeded. Under all these states of vascu- lar action the several secretory and excretory functions become first excited and afterwards more or less depraved, and nervous affections of various kinds ensue, produced either by irritation of the splanchnic nerves, giving rise to endless sympathies, or by disturbance of the brain itself, occasioned either by too rapid circulation, or by remora of blood within it. The series of pheno- mena here noticed may be traced with considera- ble precision, and in the ordinary succession, although, so far as regards the nervous derange- ments, these admit of considerable variation. The best proof of the correctness of these views is to be found in the efficacy of the practice to which they lead. It is this plethoric state of constitution that in- variably leads to the accession of gout, and the premonitory signs of the approaching paroxysm may always be detected by those who seek them in the derangements of function which indicate a state of plethora. These could not have been so long considered as questionable were it not for the delusive appearance which some of the pheno- mena present, the suspicion of debility which they arouse, and the timidity of the class of patients most subject to gout, which, shrinking from all active treatment, and clinging to accustomed in- dulgences, has in all ages, even the present, biassed the judgments of practitioners ; who, even when they see the right mode of treating gout, are una- ble to pursue it, and compelled to follow the es- tablished routine, however inert or mischievous, until from never witnessing the salutary effects of simple and direct treatment, they lose sight of its advantages, and at length cease to be conscious of any such being attainable. A state of plethora, absolute or relative, precedes every accession of gout, and is the principal if not immediate cause of it. The intensity and duration of the paroxysm, too, are dependent on the degree of plethora prevailing, although other circumstances may contribute to prolong the attack. But, not- withstanding this, gout is not simply plethora leading to or ending in local inflammation. There is something more from which gout derives its distinctive character, and this ideal, at least un- explained, existence it is which constitutes the essence of gout. As we are utterly ignorant of it, save through the modifications of inflammation which it produces, our best and safest course, so long as this ignorance continues, is to pay no regard to it farther than to observe the phenomena which denote its existence; to mark their order and succession, with the deviations from the ordi- nary course of inflammation which they display; and to preserve our practical procedures free from any influences derived from mere speculations of this unknown cause, however ingenious, resting them solely on well-established facts and enlight- ened experience. In simple gout we know of no good reason why the treatment applicable to the same degree of general fever and local inflammation occurring from other causes should not. be employed. Its general safety and efficacy we can faithfully attest, nor are we aware of any peculiar caution being required beyond what the accompanying state of constitu- tion and the attendant symptoms must necessarily suggest. In all diseases, however inflammatory, the state of constitution requires to be taken into account in judging the activity of practice that may be safely ventured on ; and the same conside- ration is needed in gout, but assuredly none is due in this respect to the imputed essence of gout, nor to the apprehension of interfering with it which has been too long suffered to paralyze the efforts of the practitioner in contending with this hitherto unconquerable foe. The constitutional disturbance which ushers in gout leads to a local inflammation, after the occur- rence of which the constitutional derangements subside. As this inflammation in the earlier ac- cessions quickly subsides, leaving the parts affected unimpaired, it is fair to consider it the crisis of the malady, and also its natural cure; though how it accomplishes this cure is a mystery which we are unable to solve. And were the disease to end here, the interference of art would be superfluous and improper; but it is far otherwise : renewed ple- thora leads to successive attacks; these progres- sively increase in intensity, duration, and extent of ravage ; and woful experience amply proves that the mere efforts of nature, unaided by regimen, are quite incapable of extinguishing gout. When- ever gout occurs, therefore, it is always expedient so to assist nature as to accomplish more than her unaided efforts are capable of performing both in rendering the attack milder and the recovery more perfect. The more speedily the constitutional disturbance is corrected, the less is the risk incurred of the gouty diathesis becoming confirmed, and GOTJ the greater the security against the derivative ail- ments entailed by protracted or oft-renewed gout; the sooner the local inflammation is subdued, the less will be the ravages made in the structure of the inflamed joints, and consequently the less the liability to that decrepitude which rigidity of joints, whether arising from thickened ligaments, effusion into the bursa;, or the deposit of solid concretions, occasions. The gouty paroxysm, involving as it does a state of constitutional plethora, attended with local in- flammation, and a latent influence directing and modifying that inflammation, must always be con- templated in its compound character ; but so far as practice is concerned, this must be regulated by reference to the inflammatory state, which is fully within our comprehension, rather than to the latent influence, of which we know nothing. The former, with sure and steady light, directs us safely on our way; the latter is much too indistinctly seen to afford us any guidance. If the first attack of gout were treated with due activity, as an ac- cession so decidedly inflammatory would assuredly be were it not for the prejudices so long and so pertinaciously maintained, and if the diet and regimen were afterwards regulated as the tenden- cies of the constitution and the degree of the gouty diathesis would demand, the future ravages of the malady would be slight indeed, and its victims few. To disregard of the real nature of the malady, to timidity and inefficient treatment of it when it first occurs, and to the pernicious effects of ease and luxurious indulgence in the intervals, when active exercise and abstemious regimen afford the only means of counteracting the morbid tendencies that exist, may be traced all those horrid disorganizations and broken constitu- tions which have rendered gout the opprobrium of medical science. As two elements concur in the formation of gout, the plethoric state and the unknown influence, it is clear that these may combine in every variety of proportion, and that the results will be conform- able to the degree in which either may prevail. Where the gouty predisposition is strong, a slight degree of plethora will suffice to call it into ac- tivity : where the plethora is inordinate, a slight degree of gouty diathesis will give that direction and character to inflammatory action which will identify it with gout. In either case it is the ple- thora and inflammatory state which chiefly claim the practitioner's attention, and to which his reme- dies can be most beneficially directed,—with this difference, that in proportion as the diathesis, whether hereditary or acquired, is strongly marked, should the means corrective of plethora and in- flammation be assiduously and perseveringly em- ployed, within those limits which a sound discre- tion would enjoin. In the distinction, so much insisted on in the foregoing pages, between the constitutional condition and special influence which conjointly minister to gout, it is by no means de- signed to withdraw attention wholly from the latter, or to decry any inquiry by which a precise know- ledge of it may be attained. The discovery, when- ever made, must render essential service, and no opportunity of effecting it should be neglected. But until profound research or some fortunate accident shall disclose what has hitherto been Vol. II.— 43 2d IT- 337 hidden from our view, we must be content, if we would render our practice either consistent or ef- fective, to follow that guidance which our familiar acquaintance with febrile and inflammatory affec- tions so amply affords. If the character of gout in its simplest form and highest intensity be unequivocally inflammatory, it is difficult to conceive why its various shades and modifications should be otherwise regarded. The differences are not greater than are continu- ally met with in several other diseases ; nor, when they do occur, is there any difficulty in referring the peculiarities to the particular constitution, the effects of previous disease, and other contingent circumstances amply sufficient to account for them. These circumstances may, and in numberless in- stances do require that the appropriate remedies of inflammation should be applied with caution ; but they can by no means warrant the principles of treatment founded on the inflammatory nature of gout being wholly reversed, as is too often wit- nessed. There has been too much disposition, arising from timidity, ignorance, and false theory, to transfer to simple active gout the cautions and the apprehension of interference which contem- plation of the complex and less active modifica- tions has given rise to. The converse of this rea- soning, if more generally adopted, would have led to happier results, to more prompt and effectual relief of gouty sufferers, and to a juster estimate of the practical benefits capable of being afforded by medical science. Having thus prepared the way for a clear and intelligible discussion of gout, we shall proceed to treat the subject more methodically, and, so far as we are able, elucidate the circumstances which give rise to its various degrees and modifications, so as to enable the young practitioner to discrimi- nate in the use of his remedies, and neither to withhold from gout the treatment which its pre- vailing character demands, nor to carry this be- yond the point which sound experience warrants. The paroxysm of gout has already been curso- rily noticed. It is necessary to present it more fully, so as to mark distinctly the peculiarities which distinguish it from simple articular inflam- mation. Cullen defines regular gout as, " poda- gra cum inflammatione artuum satis vehementi, per aliquot dies perstante et paulatim cum tumore, pairitu et desquematione partis recedente." Ac- counts of the symptoms which precede and ac- company the fit are rendered by all authors who have treated of the disease, to whose works we must refer those who wish to know all the morbid phenomena which may precede or attend the par- oxysm. Sydenham, who, when he wrote his trea- tise on the gout, had been a personal sufferer from the malady for four-and-thirty years, has detailed those symptoms with a minuteness and accuracy that cannot be surpassed. He represents the at tacks of gout as in general coming on suddenly, with scarcely any signs of its approach, except that the patient has been afflicted for some weeks before with bad digestion, crudities of stomach, and much flatulency and heaviness, which gradu- ally increase until the fit begins; this, however, being preceded for a few days by a numbness of the thighs and a sort of descent of flatulencies through the fleshy parts thereof, along with coo 338 GOUT. vulsive motions; and the day preceding the fit the appetite is sharp but preternatural. The pa- tient goes to bed and sleeps naturally until about two in the morning, when he is awakened by a pain which usually seizes the great toe, but some- times the heel, the calf of the leg, or the ankle. The pain resembles that of a dislocated bone, and is attended with a sensation as if water just warm were poured on the membranes of the affected purt; and these symptoms are immediately succeeded by a chilliness, shivering, and slight fever. The chil- liness and shivering abate as the pain increases, which is mild in the beginning, but grows gradu- ally more violent every hour, and comes to its height towards evening, adapting itself to the nu- merous bones of the tarsus, the ligaments whereof it affects, sometimes resembling a tension or lace- ration of these ligaments, sometimes the gnawing of a dog, and sometimes a weight and coarctation or c infraction of the membranes of the part affect- ed, which become so exquisitely painful as not to endure the weight of the clothes, or the shaking of the room from a person's walking thereon; and hence the night is not only passed in pain, but likewise with a restless removal of the part affected from one place to another, and a continual change of posture. Nor does the perpetual rest- lessness of the body which always accompanies the fit, and especially in the beginning, fall short of the agitation and pain of the gouty limb. Hence numberless fruitless endeavours are used to ease the pain by continually changing the situ- ation of the body and the part affected, which, notwithstanding, abates not until two or th-ee in the morning, that is, till after twenty-four hours from the first approach of the fit, when the patient is suddenly relieved by a moderate digestion and same dissipation of the peccant matter, though he falsely judges the ease to proceed from the last position of the part affected; and being now in a breathing sweat, he falls asleep, and upon waking he finds the pain much abated, and the part affect- ed to be then swelled; whereas before only a re- markable swelling of the veins thereof appeared, as is usual in, all gouty fits. Such is Sydenham's description, which we have given in his own words as translated, being reluctant to weaken the force of such graphic delineation by any attempt at abridgment. The little admixture of theory- evinced in the reference to digestion and peccant matter, cannot detract from the truth or value of this clear and circumstantial recital. For some days after this accession he represents that slighter degrees of pain and fever recur each evening, con- tinuing until morning, after which all disease ceases, and the patient is restored to more vigo- tous health both of body and mind than he had antecedently experienced. This is the simplest course of a gouty paroxysm, and that which it usually runs on a first attack. On succeeding seizures, especially when the constitution is robust and plethoric, inflammation, on subsiding in one joint, becomes renewed in another, and eventu- ally several joints are attacked in succession, and often two or more at the same time ; so that in this progress every variety of intensity, extension, and duration becomes ultimately encountered. To dwell on these different degrees would be useless, as they are all but extensions and modifications of the simple paroxysm, requiring no modification of treatment beyond what the severity of the at- tack and the existing state of constitution enjoin. The attack of gout is said to take place sud- denly, and with scarcely any previous warning, Yet the very accounts which so represent it give abundance of premonitory indications, which are stated as preceding the attack even for some weeks. Dyspeptic derangements, with some nervous ail- ments, are the precursors usually noticed; and the assertion of good health existing up to the period of the gouty accession seems to have rest- ed, not on any positive examination or know- ledge of the fact, but on the mere circumstance of the patient not having his consciousness so aroused, by any precise or considerable indisposi- tion as to complain of being ill. So far as we have had opportunity of noticing the state of health which precedes the gouty seizure, we ut- terly disbelieve this assertion, and are satisfied that if the phenomena which mark incipient plethora and progressive febrile action were duly noticed, the same constitutional derangements which pre- cede other inflammatory affections would be found uniformly to usher in gout. Disturbances of gas- tric and nervous functions are acknowledged; those of the circulation would be no less manifest if practitioners were more familiarly acquainted with the changes which the pulse undergoes in progressive plethora, from the stage of oppression marked by a pulse low and irregular both in force and frequency, to that of the permanently excited action of fever or inflammation evinced by a quick pulse, hot skin, and furred tongue. One of the earliest instances of the introductory stage of gout which came under our observation occurred many years ago, and served to confirm impressions which our mind had for some years preceding been gradually receiving, from a careful observation not only of gout, but of all other in- flammatory dise;ts(-s. The case was detailed in some pathological and practical observations pub- lished in the Edinburgh Medical and Surgical Journal in 1814, from which we now extract it. It will show at least how much constitutional dis- turbance, perfectly obvious and unquestionable, may exist while the person affected is unconscious of being otherwise than in perfect health. "A gentleman about forty years old, and of full habit, had been subject to gout for several years. He arrived in this country in the course of last sum- mer from America, where he had suffered several attacks of the disease. The treatment experi- enced under thein I cannot specify, but in the in- tervals he was enjoined to take a pint of wine daily, in consequence of his gouty habit. This he acquiesced in from unwillingness to put his own judgment in competition with that of his physician, although he disliked the remedy, and thought himself always worse both from wine and full living. He called on me in autumn last, to know if he should drink the Bath waters, as recommended by his American physician, at the same time stating himself to be particularly well and free from complaint. I found his pulse full, strong, and nearly 100, and his tongue whiter than it ought to be. I consequently discounte- nanced any trial of Bath waters, and gave my opinion that he stood much more in need of blood- GOUT. 339 letting and evacuations. As he professed himself, however, to be so very well, I did not feel myself warranted in pressing this, though satisfied that his habit of body approached much too nearly to a state of inflammation. This conversation took place on Wednesday, the 14th of October; and on Thursday, the 15th, he was attacked with gout in the right knee. On Friday, a second attack took place in the left foot; and on Saturday, I was sent for. I found his skin hot, tongue white, and pulse 106, full and strong. Sixteen ounces of blood were drawn, after which the pulse fell to 84. A full dose of a purgative, consisting of colocynth, calomel, and antimonial powder, was given at bed-time, and a solution of Epsom salt the follow- ing morning. On Sunday he was better in every respect, but the pulse was again up to 96. It evinced clearly a necessity for further bloodletting; but as the purgative was then operating and the local disease abating, I was satisfied to order the bloodletting to be repeated the following morning. It was not in time, however, to avert a third at- tack, which took place during the night in the right elbow. Next morning I found the pulse as much reduced as if bloodletting had not been practised, although it did not take place in conse- quence of the state of the arm. Whether this effect was owing to relief to the general circula- tion being afforded by the formation of the local disease which had occurred during the night, or whether it proceeded from a degree of syncope and nausea which were experienced at first rising, or whether they were all dependent on some com- mon cause, I shall not pretend to determine. At this time the knee was nearly well and the foot much better; and as the tendency to syncope had not entirely gone off, and he felt reluctant to have both arms incapacitated, he expressed a wish that the bloodletting might be deferred until the gouty arm got better. On Tuesday the foot was almost well, and the elbow getting better. The pulse, however, was again 96, full and oppressed, which determined me against incurring any further risk, and on having recourse once more to the lancet. About fourteen ounces of blood were taken, which induced some faintness. On Wednesday the pulse was 84, and there was no renewal of gout. Pur- gatives, salines, and low living were the only means employed thenceforward, and from this period he rapidly recovered. On the 26th he walked to my house, and could have done so some days earlier had the weather permitted. He ex- pressed himself much gratified at the treatment he had undergone, as confirming the correctness of those views of the disease which he had always entertained, and declared to me that he had never thrown off such an attack so quickly, so perfectly, ar with such unimpaired powers." On the treatment pursued in this case we shall only remark, that had it occurred to us later in life, when our judgment was more matured, and our conviction of the safety and efficacy of active prac- tice in gout confirmed by more ample experience, we should have hesitated less in affording the ap- propriate relief, and the result would have been still more favourable. The case, independently of the result, is of value on two accounts,—as ex- hibiting the unequivocal state of constitutional in- flammation which precedes the gouty paroxysm, j and as showing how far constitutional disturbarue may prevail without the party having any con- sciousness of its existence. Were it not for the accidental examination made on the day prece- ding the attack, this person, on the evidence of his own consciousness, would have been pro- nounced in perfect health up to the period of the gouty accession. The inferences deducible from the facts here stated have been uniformly con- firmed by all that we have seen of gout from that period to the present time. Although gout, then, may arise without any evident external cause, a cause sufficiently mani- fest may be discovered in the attendant state of constitution by those who seek for it. It is true that where the gouty diathesis is- strong, a slight degree of plethora may suffice to call it into ac- tivity, and in these instances the plethora and in- flammatory tendency may, if not closely investi- gated or if only loosely observed, escape detection. Our firm persuasion, however, impressed by all that we have seen of the disease, is, that in every case of spontaneously occurring gout, more or less plethora either absolute or relative, and of inflam- matory tendency sufficiently discernible, precedes the gouty accession; and that in proportion as this state is borne in mind, and the treatment regulated with reference to it, will the fit be more speedily and effectually relieved, the period of ex- emption prolonged, the ravages in the joints pre- vented, and the contingent maladies averted. From this view of the subject, it is clear that high feeding and indolence are very properly enume- rated among the predisponent causes of gout. From these fulness of habit arises, and this, as will be more fully shown in the article Plethora, leads to a series of phenomena, which indicate first an overloaded and oppressed state of circulation, and afterwards one of increased action. When the latter attains its full activity, it constitutes what we call fever or inflammation, and any ac- cident may determine the part which is to suffer most, and the function which is to be most de- praved. When this plethoric and inflammatory state arises in a gouty habit, the result is an acces- sion of the disease. A remarkable peculiarity of gouty accession is, that the supervention of the local inflammation gives relief to the constitutional disturbance, and that, having effected this, it quickly and sponta- neously subsides, at least in the earlier attacks, leaving the part so lately the seat of formidable derangement, somewhat weakened indeed, but otherwise in perfect health. The dyspeptic de- rangements connected with gout are no doubt traceable in a great degree to the luxurious living and consequent irritation of stomach habitual with those who chiefly suffer from this disease. But this is not their sole cause, for independently of the various excitements to which the stomach is subjected, the direct effect of plethora is to induce a congestive state of the capillaries of the mucous membrane of both stomach and intestines, and an increase of its appropriate secretions,—a condition which is the fruitful parent of gastric and intesti- nal maladies of various kinds. In the absolute plethora of robust habits, especially when the gastro-intestinal membrane is excited by full living and stimulants, this increased secretioo of mucua UT, 340 GO in the stomach and intestines is considerable, and its production is readily accounted for. The effi- cient cause seems to be excitement of the secre- tory vessels by determination of blood to the ca- pillaries, and by the blood possessing, from the redundancy of nutritive matter, more stimulant properties; the end,—increased appropriation of the nutritive matter of the blood, and consequent relief to the overloaded circulation from that re- dundancy which oppresses and disturbs it. In the less vigorous and more temperate a cor- respondent state arises, when from diminished ap- propriation of blood, through sedentary life, inac- tive habits, or any other cause, the relative quan: tity of nutritive matter becomes greater than can be healthfully disposed of. And this serves to ex- plain how a state of plethora and of febrile ten- dency so often occurs even in habits naturally spare ; and where no obvious intemperance has been practised. Yet even in these the evidences of a plethoric state are readily discernible, and at an early period, if the phenomena which indicate it are rightly understood ; and the effects, as dis- played in the gastric and intestinal secretions, are in them even more signal than those which positive plethora usually displays, the morbid condition of the mucous membrane being generally of longer continuance and more confirmed ere attention is directed to it. These effects, though modified, are essentially the same in both, and require similar treatment; this differing in degree only according to the different powers of the constitution so affected, and being modified only by the state of the mucous membrane, and the greater or less time during which the congestion has been suf- fered to endure. If the treatment, therefore, required for the more active and simple state of disease be once established, that of the lower gradations and more complex conditions will be sufficiently apparent, differing not in kind but degree, and combined with auxiliary remedies as incidental derangements may require. In weakly habits, and where the constitution has been suffered to struggle long under unrelieved plethora, these derangements are numerous and proteiform, harassing the patient and confounding the physician. So long as they are regarded as special maladies, and treated with- out direct reference to the state of constitution in which they originate, and by which they are up- held, the aid of medicine must be precarious and its success uncertain, conferring little benefit on the sufferer or credit on medical science. When assailed at their source by relieving the overloaded circulation, and restoring to more healthy action the several functions over which our remedies have direct and acknowledged powers, they rea- dily give way, yielding oftentimes to the general improvement of the constitution without any spe- cial means whatever being needed for their relief. To the gastric and intestinal derangements, and to those which evince disturbance of nervous func- tion, these observations more immediately apply. Digestion is impaired, and weakness of stomach is pronounced, for which cordials and tonics are deemed the appropriate remedies. Transient re- lief perhaps ensues in some improvement of sen- sation, some increase of appetite, and thus error necomes confirmed. But, unless eva( tants be adequately and discriminately combined, such re- medies ever do more harm than good. Adminis- tered alone and as the chief agents of cure, they tend directly to aggravate and perpetuate disease, repressing those efforts by which the overcharged vessels would, through increased secretions, unload themselves, and ultimately establishing organic lesions of different kinds. By continuance in their use, impression is made on the mucous membrane, diminishing its morbid secretions, and thus appearing to correct them, while the stimu- lants conjoined impart some feelings of renewed strength. Both effects, however, are eminently delusive. By suspending increased secretion, which, rightly understood, is the direct result of a congestive state of the capillaries, and the natural means of relieving them, disease is only transfer- red, not removed. It may for a time quit the ca- pillaries, or rather its character in them is altered; but it is only to be driven back on the larger ves- sels, where it leads to deep-seated congestions and to disorganization of various kinds. If the consti- tution be still entire, it is pretty sure under such circumstances to become aroused sooner or later to some febrile or inflammatory effort, for which evacuations become indispensable, and thus relief to the oppressed and overloaded organs is at length afforded ; if languid or much depraved by long continuance of the morbid condition, and still more if this condition have been' aggravated by abuse of cordials and stimulants, and by the neglect of evacuations, then the constitutional efforts are feeble, they are disregarded or misun- derstood, and a more assiduous use of wine and sustenance is urged for nurturing that strength which such means so applied never can restore. In like manner the various nervous maladies con- nected with this state of constitution run a similar course. Stimulants, antispasmodics, and narco- tics, all lend their aid, but it is to palliate only, while in reality they do mischief. These mala- dies depend much on nervous sympathies arising from disordered stomach, but they are also in part owing to direct disturbance of the brain itself, through irregular circulation and morbid condi- tion, chiefly of a congestive character, of its sub- stance or investing membranes. Stimulants may, and oftentimes do, relieve this state for the mo- ment, by rendering the cerebral circulation more active, and thus giving greater energy to nervous function; but the disease is not thus cured,— scarcely mitigated: the effect lasts no longer than the brief period during which the stimulus main- tains its influence, and the state which ensues is still further removed from that of health. This can only be restored by so regulating the circula- tion that the mass of blood shall neither by its quantity or quality cause any exlinordinary ex- citement of the vessels which convey it, nor need any increased efforts on their part for its disposal; and afterwards by rendering such assistance to the several secretory and excretory functions as shall re-establish them in the healthy and efficient ex- ercise of their respective offices. In judging of the instances in which tonic and stimulant regimen is supposed to be beneficial, and which are continually adduced in proof of its pro- priety, it is necessary not to decide hastily or ab- solutely from the immediate effects, but to watch GOUT. 341 such cases to their close, when the consequences will be sufficiently demonstrated. Many alleged cures are thus performed for which the parties have little cause to be grateful. Sooner or later formidable disease is sure to ensue, its form de- pending on the accidental excitements to which the body is subjected, and on the peculiar tenden- cies to which it is prone. In a gouty habit, re- production of gout, and its confirmed establish- ment in its most aggravated shape, can hardly fail to be the result of such a regimen. They who see much of what are termed chronic diseases must have ample opportunity of verifying by observation what is here stated. These cases present every species of internal congestion to which plethora, unrelieved by due evacuation and aggravated by stimulants, can give rise. Too often arc the lesions of structure thus occasioned beyond the reach of art, while the exhaustion and attenu- ation are such as to preclude all attempts to re- lieve, save by temporising palliatives. How much of this kind of evil the constitution can bear, how- ever, and how long an oppressed and overloaded circulation may endure without annihilating all hope of relief by rational treatment, is continually exemplified. Where there is no particular ten- dency to local or specific disease, and the effects of plethora and of febrile action are diffused over the whole frame, they may continue for months or years, still retaining all their original character, and still admitting of valuable relief from appro- priate and duly active practice. Nay, even where a special disease is engendered, if it be one of slow progress and which does not immediately affect life, it may continue for years to cause extreme distress, and yet be capable of relief from rational treatment. The following case may illustrate these several positions. A delicate female had for ten years laboured under varied and extensive disease, which from all that we could learn had been throughout of the character which we have de- scribed. Being weakly, however, and exquisitely nervous, her complaints were referred to debility, and she was pampered and stimulated with tolera- ble assiduity. Symptoms of general dropsy were superadded to her other complaints, and were making rapid progress when she applied to us. The character of the disease was obvious enough ; the remedies were equally so ; but great caution was necessary in resorting to them, both from the extreme exhaustion, and from the constitution be- ing extensively and miserably depraved. Yet was there no alternative, for without bloodletting effec- tual relief could not be afforded, and from the rapid progression of disease she must have speedily sunk. We drew blood in small quantity, which was thickly buffed and cupped; purged freely, and enforced low diet. The relief was prompt: the dropsical swellings subsided, nervous maladies declined, all her feelings were improved, and even strength was increased. Blood was afterwards taken repeatedly and more freely, and she ulti- mately became relieved from all her complaints so far as her'broken health and the ravages sustained by long-continued disease would allow. For some years she has, in consequence of this relief, had much more enjoyment of life; and so satisfied is she of the remedy to which she is chiefly indebted, that she is herself the first to call for the lancet, 2d * when, as occasionally happens, recurring plethora or febrile action indicate its employment. This case, though not one of gout, serves to demon- strate the state of constitution which we wish to illustrate, and which is continually met with in connection with gout; such cases, whether gout be incidental or not, require that the healthy ba- lance of circulation and of the circulating fluid be restored, as the first requisite ; and that the several secretions and excretions be corrected and pro- moted according as their respective derangements demand. When this is done on the principles applicable to all diseases, then may the special nature of gout receive any peculiar consideration to which it may lay claim. But so long as a plethoric state of constitution exists, — a point on which no deceptive appearances should be suffered to mislead,—and the several secretions and excre- tions are depraved, must all special treatment of gout by imputed specifics be subordinate to those corrective measures by which the constitutional derangements are rectified, and general health re- stored. As some have cavilled at the term constitutional as thus applied, and with a subtilty of criticism more ingenious than profitable, have denied that any such thing as constitutional disease can exist, inasmuch as every morbid action must affect some part of the system, I shall here remark that I em- ploy the term constitutional in reference to the general condition of the frame, and the collective exercise of its several functions, the due balance of which constitutes a state of health. Derange- ment of these functions is more or less attendant on all diseases, yet it is not always considered as forming a part of them, and is in consequence too apt to be overlooked. The general health dependent on these functions we consider as having a claim to attention in every disease, even superior to that of the special malady ; it is this state to which the term constitutional is applied, and we know not how it could be so well expressed by any other. In gout it is this which is entitled to our very first consideration, for not only is constitutional de- rangement attendant on every accession of gout, but some degree of it is essential to the formation of the paroxysm. In proportion as gouty diathesis prevails, will greater or less degrees of constitu- tional derangement arouse it into activity; but some previous disorder of the general health, some antecedent disturbance in the healthy balance of functions, is necessary to this end, for without such there would be no paroxysm. On a just conception of this truth all prophylaxis must de- pend. After the foregoing discussion of the nature and character of gout, we might at once proceed to the curative treatment, were it not that this essay, which is to serve for an elementary as well as practical treatise, demands a detailed exposition of several circumstances which have not yet been noticed. For the sake both of perspicuity and brevity, we shall, in what remains, follow the order which methodic treatises on diseases usually observe. Our general remarks on gout have been hitherto confined to those circumstances which more parti- cularly indicate its character, and mark the morbid conditions which tend to produce it. Several 342 GOUT. others, however, squire to be noticed ; and here, as well as in the subsequent sections into which the subject will be divided, we shall occasionally borrow from what we have ourselves already pub- lished ; and this not from indolence, but from the persuasion which we entertain, that where opinions are founded in truth, the original expression of them is more likely to be terse and correct than any repetition clothed in a different phraseology. Dr. Cullen's definition represents gout as an hereditary disease. It is so generally, but by no means universally; and so far this character is improperly introduced into a definition. The general truth, however, of a predisposition to gout being entailed on offspring, is too well established to admit of dispute. Cases no doubt continually present themselves where no hereditary taint can be traced, manifesting that this is not essential. Dr. Scudamore, in some interesting tables, has shown that of a given number the greater portion acknowledged no hereditary claim to the disease. The fact of hereditary disposition, however, is not thus set aside, but has been too strikingly exem- plified in numberless instances to be easily shaken. From the very slight influence which this point has either on pathology or practice, it is, in truth, of little real importance. The only consequence of admitting such predisposition seems to be, that when it is supposed to exist, gout may be expected to take place under circumstances which', inde- pendently of this tendency, would not have power to originate it; and that hence a salutary caution may be suggested to those who have any con- sciousness of hereditary claim, to guard with par- ticular care against the various causes which excite gouty action. While false theory prevailed, and the establishment of gout in the extremities was considered essentially desirable as relieving the constitution from peccant humours supposed to be thrown on the affected joint; and when the suspicion of a gouty diathesis led to a free use of stimulants as a means of repelling the enemy from vital parts; when the supposition of hereditary taint was not harmless, the regimen enjoined tending directly to arouse what might have lain dormant, if not to create what might otherwise never have existed. But if rational principles of gout, its nuture and treatment, were generally established, the admission of its being hereditary could lead to nothing but good, and might effect such changes as would in time cause the evidences of hereditary disposition wholly to disappear. In- deed it would be well if the fact of hereditary transmission were more generally received and more deeply impressed, as many who would prefer the liability to gout to any sacrifice of luxurious indulgences, so long as they regarded the choice as affecting their own persons alone, might exer- cise some self-restraint if assured of the conse- quences which their excesses might entail on their offspring and descendants. Though the paroxysm of gout usually occurs in the way described, and without any evident exter- nal cause, yet any accident or injury of a joint occurring in a gouty subject, may, instead of sim- ple inflammation, bring on a fit of gout, or rather the local inflammation excited may assume all the characteristics of that disease. The precedence of gastric derangement is not necessary to constitute gout, many being uncon- scious of any such up to the accession of the local inflammation. In advanced cases, however, and in broken constitutions, this premonitory indica- tion is rarely absent. Pyrexia so generally attends that it may well be considered a characteristic feature. In those cases where, from languid or enfeebled powers, it is less obvious, and where to superficial observa- tion it might appear not to exist, more careful investigation of symptoms would rarely fail to de- tect it, Women, though not exempt from gout, are less subject to it than men. Dr. Gregory used to state the proportion as one to fifty in England, one to one hundred in Scotland. For this relative im- munity in females they seem indebted to their greater temperance, and also to the facilities which the female constitution possesses of throwing off redundancies by natural outlets. Dr. Gregory had observed among his patients, that the women who suffered from gout had antecedently been subject to profuse hemorrhages, such persons being gene- rally plethoric through indolence, sedentary lives, and high feeding, and hence predisposed. Vigorous and robust constitutions are most subject to gout, though no spareness of habit affords security against it. The cholero-sanguine temperament is said to be that which is most liable. Gout is most generally a disease of middle and advanced life. Its attacks usually occur from the age of thirty-five onwards. When the predisposi- tion is strong, however, it may commence much earlier. Dr. Gregory met with it oftentimes among his pupils, young men from 18 to 22, and who had not earned it by intemperance. The relief to the general health imputed to the supervention of the paroxysm, though an observa- tion partially founded on truth, becomes progres- sively less speedy and less signal as the disease advances. It has ever been too much relied on, and has led to much pernicious practice, both medicinal and dietetic. So many causes, both remote and immediate, have been assigned to gout, that they require to be noticed ; for though most of them are merely contingent and accessory, they all merit attention where regard to the juvautiu and kedentia is so important. Hereditary disposition has been sufficiently dis- cussed, as have also the influences of plethora and of the unascertained cause from which gout de- rives its distinctive character. Whatever induces a state of plethora may become a cause of gout, whence luxurious living, indolence, and sedentary habits, have ever been the chief means of exciting or producing it. By these is the gouty predispo- sition urged on to active disease; and, so far as our knowledge extends, they are fully capable of originally producing it. The extremes of luxury, or of indolence, however, are not required to pro- duce this effect. Lesser degrees may induce ple- thora sufficient to destroy the balance of health, and thus beget disease. A slight redundancy of nutritive matter in the blood, whether arising from excessive supply or diminished expenditure, may create an inflammatory state, which, in a habit predisposed, may lead to gout, even where tha GOUT. 343 habits of living may appear temperate, and where moderate exercise is taken. No terms are more loose in their general application than temperance and exercise. Credit is continually claimed for the former, where the animal food and wine ha- bitually taken far exceed what nature requires or can bear; and the name of exercise is oftentimes given to bodily exertions so gentle that they lead to no increased expenditure of blood, while, by in- creasing appetite, they too often tend to augment and enrich it. Gout is a disease of the rich and indolent, not of the poor and laborious; and this truth, so obvious and incontrovertible, ought to have had more influence on medical opinions than it has been allowed to exercise. If there were no other fact whatever ascertained, this alone might suffice to point the way to the efficient prevention and treatment of gout. In Scotland there is an old saying worthy of being held in remembrance, that any man may free himself from gout by work- ing for and living on sixpence a-day. Next to plethora, whatever causes induce debi- lity of stomach have been regarded as principally influential in bringing on gout. The observation is to a certain extent true ; yet the facts on which it rests have been egregiously misconceived, and much pernicious practice has in consequence re- (ulted. Weakness of stomach being assumed, tonic and invigorating regimen was of course considered as indicated, and long and pertina- ciously has its use been persisted in, notwithstand- ing the utter failure of such treatment to mitigate, much less subdue the disease. Had the nature of this assumed debility of stomach been more closely investigated, it would have been seen to present a character very different from what tonic or stimulant remedies could essentially relieve. It might, at least in the earlier stages, have been clearly traced back consecutively to inordinate and depraved secretions, turgid condition of the mu- cous membrane, congestion of the capillaries, and general plethora, all readily relievable at the com- mencement by evacuations and abstinence, all ag- gravated by nutritive diet, stimulants, and tonics. All reference, therefore, to debility of stomach as a cause of gout should extend, not merely to the alleged weakness, but to the several causes, both coincident and consecutive, by which the impor- tant function of digestion becomes weakened or disturbed. Various causes are instrumental in exciting the paroxysm, but they are all subordinate to those mentioned, and incapable of such effect unless where depravation of health has prepared the way. Excess of venery is an acknowledged exciting cause, as is also abuse of spirituous liquors, as well as indigestion, whether occasioned by the quantity or quality of the food taken. To the immediate effects of this last cause may be referred many cases of imputed gout in the stomach, which have been wholly independent of gout. Dr. Gregory used to relate a case where he was called to a pa- tient said to have been seized with gout in the stomach; but he found his complaint caused, not by gout in the stomach, but by pork in the sto- mach, of which difficultly digestible food he had too liberally partaken. By getting rid of it he was perfectly relieved, and there was nothing more heard of gout for that time. [A recent writer, (Dr. W. Budd, in Tweedie's Library of Medicine, 2d Amer. edit. iii. 587, Philad. 1842,) is disposed to think— and the ob- servation of the writer leads him to the same be- lief— that malt liquors tend, even more than wine, to produce a gouty diathesis, and the evidence, which he adduces on this subject, is striking (see vol. i. p. 179).] Intense study has brought on gout. It is stated by Sydenham that one of his most severe attacks was occasioned by immoderate application in wri- ting his essays on the disease, and that gout re- turned as often as he attempted to go on with the work. Purging has been said to bring on the parox- ysm, and such a coincidence no doubt occurs; but it would be a great error to suffer this observation to deter from a judicious use of purgative remedies. Continued costiveness is a more probable cause, yet this can only be regarded as an incidental de- rangement, depraving, so long as it continues, se- veral other functions, and adding to the disorder of the general health. Change from activity to indolence has been of- ten noticed as leading to gout, a circumstance rea- dily understood. Change from low living to high is equally intelligible. But sudden change of the opposite kind has been marked by the same effects, as was signally exemplified in the patients of the celebrated Dr. Cheyne. He' as all know, was the advocate of temperance, and having enjoined it to his gouty patients rather too absolutely, and with- out sufficient discrimination, he had the mortifica- tion to find that his directions, so far from obvia- ting the attack, hastened the paroxysm, which af- forded great exultation to the opponents of his doctrines. Their triumph, however, was far from complete, although it served for a while to confirm existing prejudices. The hypothesis of gout being caused by a spe- cial morbific matter, eliminated and expelled by means of the paroxysm, has been fully and ably refuted by Dr. Cullen. There is no proof what- ever of any such existing; and assuredly it is not, as was long imagined, identical with the concre- tions deposited in gouty joints. Cold, heat, external injury, depressing passions, too great exercise, especially in walking, have all been enumerated among the causes capable of ex- citing gout; but they can only be regarded as mere accidents, having no power to induce the disease, save when the habit is on the very verge of the paroxysm. The diagnosis of gout must be derived from its history and general character, for there is no pa- thognomonic symptom whatever to distinguish it from rheumatism, the only disease with which it is liable to be confounded. Each disease, perfectly formed, is sufficiently distinct from the other; but the intermediate degrees approach each other so nearly, that to discriminate with absolute certainty would require a more intimate acquaintance with the essence of both diseases than we can take cre- dit for possessing. All that can be done here, then, is to note the peculiarities of each, and then to leave it to the practitioner's own judgment and observation to decide to which any equivocal case may belong. Gout is generally a disease of advanced life, no< 344 GU UT. occurring for the most part till thirty-five; rheu- matism most frequently attacks the young, that is, from the age of eighteen to thirty. Yet the converse of this is so often true, that the observa- tion furnishes no ground of accurate diagnosis; rheumatism attacking every age, while, as has been shown, not even childhood is exempt from gout. Gout in its earlier attacks fixes on one joint, extending not beyond; rheumatism, even on its first seizure, most generally involves seve- I ral. Gout, while simple and incipient, runs a de- finite course, the local inflammation spontaneously and completely subsiding in a few days ; rheu- matism has less tendency to spontaneous decline, and, unless arrested by prompt and active treat- ment, usually continues much longer. The sub- sidence, however, of local inflammation in rheu- matism under active treatment resembles very closely the natural abatement of gout. In gout the constitutional disturbance sensibly abates on the supervention of the local inflammation ; this does not appear to be the case in rheumatism, where, on the contrary, the articular inflammation is often attended with increase of fever. In gout the part inflamed is red, tense, shining in a high degree ; in rheumatism it is less so in all these respects. Desquamation of the cuticle has been regarded as a criterion of gout; but the cuticle is oftentimes detached in rheumatism much more extensively than ever occurs in gout. We have seen the cu- ticle so completely separated from the hand and wrist in rheumatism as to admit of being drawn off like a glove. In gout the pain is exquisite, even when the part affected is at perfect rest; in rheumatism it is much more moderate when the part is at rest, though most acute on the slightest motion. Gout is more apt to be preceded by gas- tric derangement than rheumatism. After all that can be said on the subject of diagnosis, much un- certainty must still attach to many instances, while there are modifications which partake so much of both, that it would be impossible to assign them with certainty to either; and accordingly we find the term rheumatic gout, though not recognised by nosologists, in familiar use among the vulgar, and not scorned even by practitioners. Are we yet prepared to decide to which the very peculiar disease known among medical men as as nodosity of the joints belongs 1 It is usually classed with rheumatism, yet there are quite as many grounds for allying it to the gout. After all, the distinction is of little real importance, for if the pathology of gout, which we believe to be true, be established, the treatment of the individual case will not be very different to whichever genus of disease it may be assigned The prognosis of gout must depend on so many circumstances, that it would be impossible to af- firm it positively or with any precision. Simple gout occurring for the first time runs a determ nate course, ending generally in health, and can- not therefore be regarded as a disease of much value of the remedy and the enjoyment of the years so prolonged. In advanced gout the state of constitution, the ravages already sus a.ned, the organs incidentally affected, and even the princi- pies on which the treatment of the particular case is conducted, must be taken into account ere any conception either of the probable duration or event can be formed. It has been customary to represent gout as in- curable, and for ages it has been pronounced the opprobrium of medical science. Ere proceeding to discuss the treatment, it may be worth while to consider how far this reproach has been justly at- tached. Whether there be or not a cure for gout, is a question of which the answer must depend on the sense in which the term cure is used. It is a common error to contemplate diseases as if each, instead of consisting of an aggregate of functional disturbances, were itself something individual and specific, — some element superadded to the frame producing a specific derangement of health, and capable of being corrected or neutralized by its proper remedy, as a poison by its antidote. Thus the doctrine of specifics has ever prevailed, and it continues to hold its ground even at the present day. It has even been imagined that as mercury is an imputed specific for syphilis, cinchona bark for intermittent fever, there must for every disease exist in nature some peculiar and appropriate re- medy which it is the business of physicians to dis- cover. No disease has been more signally sub- jected to this misconception than gout, and the search for a specific capable of extinguishing it has been often and anxiously renewed. To those who thus judge of diseases and their treatment, it may be confidently replied that there is in medicine no cure for gout, for no remedy capable of realising such expectation ever has been discovered, or ever can he. To such delusion gouty sufferers are pe- culiarly inclined, for, habituated for the most part to luxurious indulgences, and reluctant to forego them, they lend a willing ear to every vain boast which affects to cure them without a sacrifice of their sensual enjoyments. The consequences of this error have been doubly injurious, not only by diverting attention from that investigation of the disease which could alone explore its real nature and devise its proper treatment, but also, where any remedy of peculiar efficacy was happily dis- covered, by causing such indiscriminate applica- tion as to render it in the end more injurious than serviceable, and at length to destroy the reputa- tion to which it might justly lay claim. But if gout be regarded as it really is, an assemblage of functional derangements, traceable respectively to intelligible causes, and, when rightly understood, admitting of correction by suitable agency, then, though there be a superadded cause in the essen- tial principle of gout, of the precise and intimate nature of which we are still ignorant, the disease may be pronounced curable in the same sense in which we apply the term to other maladies, pro- danger ; on the contrary, it has, by a strange de- vided practitioners, instead of vainly seeking for 1 specifics, pursue the course of treatment which true medical science enjoins, and patients be con- tent to follow that regimen by which alone the end can ever be attained By medicine alone we can do little to obviate the predisposition which leads to gout; but by suitable regimer) duly and lusion, been customary to hail its presence as con s.ervative of health and a guarantee for longevity ! However the supervention of the paroxysm may occasionally obviate greater evils, we should greatly doubt the desirableness of its occurrence, and must teave it to gouty sufferers to appreciate both the GO inflexibly persevered in, we may render it harm- less, so that even in cases of high susceptibility, where, notwithstanding our best care, paroxysms may occasionally recur, these will be slight, and productive of but little evil. But even this lia- bility, if manifested in the earlier periods, should be regarded as owing to some imperfection in the use of preventive means; for if these be fully and judiciously employed, the renewal of paroxysms may, as long as the general constitution. is still uninjured, be wholly and effectually prevented. This assertion, as now expressed, is of course limited to those cases where gout on its first acces- sion is subjected to proper discipline both remedial and prophylactic; for where the predisposition is strengthened by repeated accessions of the disease, and disorganizations have taken place in the joints, or any of the viscera have, through the effects of gout, become depraved, the hopes of complete success must be proportionally weakened. In this sense, then, it may be boldly averred that gout is not an incurable disease. We can cure the pa- roxysm, and can restore the patient to perfect health, which it is in his own power afterwards to preserve; and if he, in defiance of right counsel, renews the disease by continuing the luxurious and indolent habits which foster it, the reproach should lie, not on medical science, the precepts of which he disregards, but on his own weakness and wilful perseverance in injurious practices. Other diseases as well as gout, nay all, are liable to recur on the predisposing and exciting causes becoming renewed; yet they are not thence considered in- curable, nor are they deemed a reproach to medical science merely because medicine alone cannot secure against relapse. There is no reason why relapse of gout should not be equally referred to a renewal of the causes which lead to it, and as the principal of these are obvious and capable both of prevention and correction, the incurableness of gout should not be alleged so long as the means of cure are neglected or inadequately employed, nor should medical science be reproached when its clearest dictates are discredited, and its most urgent remonstrances unheeded and despised. The most important treatment of gout is the preventive; for if this, however successfully the paroxysm may be relieved, be not assiduously pursued, disease will recur, and acquiring force by repetition, will eventually inflict ail its wonted penalties. The principles, too, of the preventive treatment are the same which should govern the practice through all stages and conditions of the disease, modified only by contingent circumstances, but never superseded nor reversed ; on which ac- count a full discussion should be given in the first instance to the prophylaxis of gout. If the views exhibited in the foregoing pages be not wholly fallacious, the establishment of a ra- tional and efficient prophylaxis of gout can be neither difficult nor doubtful. It has been seen that to constitute gout two circumstances must concur,—a predisposition to this form of disease, and a loss of balance in the constitution through excess of nutritive matter, creating what is termed plethora, and arousing the predisposition into active disease. It would be useless to dwell on, or affect accuracy in deciding which of these conditions is the more active, which the more passive,—which Vol. II___44 UT. 345 should be called the predisposing cause, which the exciting. The main point to consider is, that their concurrence is essential; for if there be no ten dency to gout, plethora may induce any other form of local inflammation or fever, but will not give rise to gout : if there be no plethora, even a strong hereditary disposition may lie dormant, and the elements of gout, of whatever nature they be, will not show themselves by the formation of a pa- roxysm. Of these causes one is utterly unknown to us, and consequently we are unprovided with any positive or direct means of acting on it; but the other is completely under our control, and however great the tendency to it in any instance, we have ample power when it does arise to remove it by means of depletion and abstinence, and to prevent its recurrence so as with certainty to keep within the bounds of health by temperance and exercise. To these few and simple instruments of prevention may be referred all the procedures required for prophylaxis ; all further discussion of which must consist of pointing out the degree in which they may be severally required, and the modifications necessary in applying them so as to attain the end desired without hazarding other evils, to obviate redundancy of nutrition without with- holding adequate sustenance; to repress hyper- sthenic orgasm without inducing asthenic debility ; and, in averting an inflammatory disease, not to beget others of an opposite character, but to pre- serve the constitution in that due exercise of all its functions which perfect health implies and requires. Though the instances may not be many of gout being eradicated or kept quiescent by means of regimen, inasmuch as gouty subjects have been at all times singularly averse to pursuing such discipline, yet have they been quite sufficient to establish the fact of the capability ; and it should be borne in mind that by no other means has the end ever been attained. The late Dr. James Gregory of Edinburgh was a signal in- stance of the perfect success of the regimen which he ably advocated and strenuously enforced. With a strong hereditary predisposition, gout having existed in his family for generations, and his father having been an early victim of it, he was himself seized with the disease at a very early age; but subduing it by abstemious living, he was disposed to congratulate himself on having obtained ex- emption. The effects, however, of slight indul gencc during a casual visit to Oxford, admonished him that he could take no liberties ; and from that period he abided steadily by the regimen which he had laid down for himself, the safety and efficacy of which he had proved, and by adhering to which he was never afterwards visited with gout. This account of himself he used to deliver annually to his class ; and when the writer of this article heard him do so in the sessions of 1802 and of 1803, he had reached his fiftieth year with- out experiencing a return. In instancing his own case, Dr. Gregory's objec n was not so much to adduce proof of the efficacy of preventive regimen, as to show that the very spare living and bodily labour which some had inculcated, and which deterred many from attempt ing to pursue a rational course, were by no means requisite; but that a very moderate degree of both would, if persevered in with steadiness, fully suf-. JT. 946 GO rice. He was accustomed to appeal, in proof of this, to his own person, the robust form and fresh complexion of which gave arrple assurance of its being sufficiently nourished, and to conclude his remarks with saying, "You will allow, gentle- men, that I am no starveling." The consideration of preventive regimen may be conveniently subdivided under two heads,—the prevention of plethora, and its removal whenever its appropriate phenomena JVenote its presence. For the first, it would be impossible to lay down any express rule of diet that would be suitable for all habits and constitutions; and to this head all the doctrines advanced in the article Plethora apply. Where there is a predisposition to gout, with a tendency to fulness of habit, great care should be taken not to minister to fulness by too much or too nutritive diet. Animal food should be sparingly taken, and fermented liquors should be cautiously avoided. The quantity of food necessary for full health and strength is very moderate, especially where bodily exertion is in- considerable; and the majority of mankind con- sume habitually far more than is good for them ; whence arises a large portion of their diseases. The doctrine is unpalatable, and the physician who enforces it will hardly be a favourite with the many ; but it is not the less sound ; and so long as mankind persist in closing their eyes to the truth, they must suffer the consequences of their wilful blindness. When the time arrives, as come it must, that a knowledge of the animal economy shall form a part of liberal education, and each individual shall be capable of comprehending the structure and functions of his own frame, such truths will be more readily acknowledged, and pnysicians will have fewer obstacles to contend with in the conscientious discharge of their duties. The temperance necessary for lessening the ten- dency to gout has been often and ably enforced ; yet, judging from the ravages daily witnessed, and from the accounts of early treatment and of regi- men pursued which such sufferers report, but little progress has yet been made in establishing gene- rally sound principles of management for gouty subjects. Nutrition is still encouraged as a means of supporting strength, wine is enjoined to keep gout from the stomach, and excesses of every kind are committed; while credit is taken for modera- tion merely because they are not carried to ex- treme, nor as far as inclination might prompt. Whatever is taken beyond what the wants of nature demand is excess ; and numbers are guilty of it who are unconscious of being so. In a healthy frame the natural energies are ever active in appropriating and throwing off" the redundan- cies, and in this way apparent health may be long preserved ; but if the excess be continued, disease is sure sooner or later to result, when medical dis- cipline, now indispensable, carries off, by one out- let or other, what the constitution can no longer endure. It is the part of wisdom to avoid this issue by maintaining habitual temperance, the practice of which will ever ensure a rich reward. Dr. Cullen has judiciously laid down as indica- tions of treatment in gout, to moderate the parox- ysm, and to prevent its recurrence. The practice of many gouty sufferers seems exactly the reverse, namely, to hasten the paroxysm and to increase its violence, under the false impression that a severe attack eliminates and expels from the sys- tern more gouty matter than a weak one. The doctrine claims to be founded on fact and experi- ence, yet is it eminently untrue. The fact that the accession of gouty inflammation brings relief to pre-existing constitutional derangement belongs only to the earlier seizures, and does not hold true generally of gout; and the belief of the paroxysm purifying the constitution of gouty matter in pro- portion to its violence, resulted entirely from a false hypothesis respecting the materies morbi of gout, and though supported by the high authority of Sydenham, is utterly untenable. There can be no doubt at the present day, that the indications of Cullen are those which ought to be followed. Next in importance to regulating the ingesta, is preserving a state of free and adequate excre- tion. However moderate the diet, if through neglect of exercise or other causes nutritive mat- ter be imperfectly appropriated, and excretions .become defective, a loss of balance must result; the blood must become charged with both nutri- ent and excrementitious matter in excessive pro- portion, decline of health ensue, febrile excitement become aroused ; and in a gOuty habit, such pro- gressive depravation will be pretty sure to end either in a paroxysm, or in an abortive effort of the constitution to form one. These are the cases which have involved the subject of gout in so much obscurity, and by their equivocal charac- ter have ted to the abuse of stimulant treatment, It is obvious that the state of constitution here referred to may be relieved in two ways, appa- rently opposite; either by exciting the constitu- tional powers to increased efforts for appropriating and expelling the redundant matter, or by dimin- ishing this so as to keep it within the ordinary powers of nutrient action and excretion. On a fair comparison and just estimate of the relative value of the two modes, there can be little room for hesitation in giving a decided preference to the latter. Far better is it to prevent plethora by temperance in diet, and to promote appropriation and excretion by exercise, than to keep the ener- gies of the frame overstrained by continued use of stimulants. The superiority would be great were we to regard only the general ill effects of continued excitement, which not only exhausts power, but creates a necessity for the stimulus to be progressively increased ; it becomes far more so when we take into account the destructive lesions of important organs, to which stimulation of over- charged vessels almost necessarily gives rise. If plethora be obviated by temperance and exercise, or removed by depletion and abstinence, the seve- ral organs and functions of the frame are left in their natural and healthy state, in which the natu- ral powers, unaided by stimulants or tonics, arc fully capable of preserving them. But when it is attempted to remedy plethoric ills by increas- ing the energies which nature exerts for their re- moval, the several functions, even when success- ful in effecting temporary amendment, become exhausted and debilitated, their ordinary efficiency is impaired, congestions ensue, leading to loca inflammation and organic lesions ; and a host of maladies severe and untractable are the eventual result. By rational prophylaxis all such conse- GOL qucnces may be effectually and certainly prevented, while daily observation too clearly shows how little they gain who combat such ills by stimu- lants and tonics. So long as temperance is ob- served, the several functions of health will be so performed as to need little assistance from art. Still, as no casual care may suffice to give full security against casual derangements, attention should be given to the several excretions, the most important of which are those of the bowels and the skin. The bowels should be kept free, and the skin perspirable; mild aperients will serve the former purpose, active exercise the latter. After temperance in diet, and adequate excre- tions, the next agency available for obviating ple- thora by promoting the appropriation and final expulsion of what is taken into the system is ex- ercise, which in the prophylaxis of gout is of the highest importance. However complete and un- deviating the temperance which a person threat- ened with gout, and anxious to avert it, may ob- serve, the aid of active exercise will still be neces- sary to give the security which he seeks, and which his case admits of. Indolence in him may beget evils directly analogous to those which re- pletion produces, and, though modified by circum- stances, leading to similar results. Whatever the sustenance taken, it requires to be expended in all of its several appropriations; and the effete mat- ter which it continually displaces needs to be dis- charged from the system by active and adequate excretion. If nutritive appropriation fail in health- ful energy in any of the tissues of the frame; if, through defective exertion, the effete matter con- tinually passing through the appropriate outlets be not fully thrown off, both nutritive and excre- mentitious matter must accumulate in the blood in undue proportion, and induce a condition of the body generative of disease. To promote both purposes, adequate exercise is the natural agent, the use of which cannot be superseded by any medicines however valuable or however lauded. Bloodletting may remove redundant nutritive mat- ter from the circulation ; purgatives, diaphoretics, and other evacuants may succeed in rendering the excretions more active and efficient; but no sound mind, judging even by common sense, much less if at all aware of the relative effects of preventive and remedial courses of procedure, can hesitate which to prefer. It is much better not to overfill than to be obliged to empty ; it is far more health- ful to prevent accumulations of excrementitious matter through active exercise, for which the body is so admirably constituted by nature, than to re- move them by any evacuants, however certain in their operation. The two simple terms, then, temperance and exercise, convey whatever is essen- tial in the prophylaxis of gout; and, if rightly understood so as to be strictly practised, they would be amply sufficient for all useful guidance. Further discussion could only regard the degree to which each should be carried so as to ensure its good effects without hazarding contingent evil. To pursue the subject minutely in this place would swell this article beyond its allotted extent. They who comprehend the doctrines advanced, and im- bibe their spirit, will be at no loss so to regulate regimen as to produce nothing but good. It may be remarked that extremes in either respect are IT. 347 quite unnecessary; and the evidence of Dr. Gre- gory's personal experience has sufficiently shown that gout may be thus effectually prevented with- out extraordinary macilency, or any privations in- compatible with rational enjoyment of life. But notwithstanding all the care which the most cautious can take, irregularities of diet, in- terrupted exercise, and other inevitable deviations from the prescribed course, will induce occasional plethora leading to derangement of health. The evidences of this, and the means of abating it, become then the next subject of consideration. When fulness of habit begins to appear, the diet, however moderate, should be still further abridged; animal food should be more sparingly taken, fer- mented liquors discontinued, the bowels kept more free, and the exercise rendered more effective; and these attentions would be expedient even while the increasing fulness presented no evidences but those of health. Should they suffice, nothing more will be needed. But if plethora advance so as not to be thus removed, if consciousness of health becomes disturbed by morbid feelings, and these be accompanied by a labouring circula- tion ; if, finally, a hot skin, quick pulse,- and white tongue, denote the stage of febrile action to have commenced, then, though no local conges- tion or inflammation should yet have occurred, blood should be taken, purgatives employed, and the whole regimen should be strictly antiphlo- gistic. It may be deemed that at this incipient stage bloodletting may be dispensed with, and certainly it is not the general practice so to em- ploy it; but this we attribute to practitioners not being sufficiently aware of the real state of con- stitution, nor of the great advantages derivable from early bleeding. It is true that this stage is not immediately dangerous; that it may be suf- fered to advance somewhat without much hazard, it being the consecutive derangements rather than the incipient plethora or febrile action which beget danger: that it may even get well, and without ulterior mischief, although bloodletting be not practised. But these admissions will not alter the question either of the real nature and tendencies of plethora, or of the remedies which most safely, promptly, and effectually relieve it. Of these re- medies the most direct, and unquestionably the most eligible, is bloodletting. It removes the cause of disease more effectually than any other reme- dy ; it more promptly restores to the several func- tions the healthful energies of which plethora with its consequences deprives them ; it supersedes the protracted use of other evacuants ; and by quickly suspending the exhausting effects of con- tinued febrile action, it virtually preserves strength instead of wasting it. For this purpose large or repeated bleedings are never needed. A single venesection to twelve ounces, with purging and low diet, will oftentimes suffice to arrest progres- sive disease, and re-establish the sanative efficiency of the natural powers. And here, again, early bloodletting saves even blood, if this were au ob- ject, (and it is an object that it should never be unnecessarily nor superfluously taken;) for mode- rate bleeding early employed will avert severity of disease, which, where it does ensue, often demands profuse depletion to save life, and thus consigns to tedious convalescence, if the party be fortunat* UT, 348 GO enough to escape a more fatal result. It might be beneficially laid down as an axiom, that, abstract- edlv, bloodletting is the direct remedy of febrile action, its use and modifications being determined by circumstances. In idiopathic fevers produced by miasmata, and attended with prostration of power, its employment may be questionable, and great caution at least is required in applying it; vet when early and judiciously employed, it has proved a powerful agent in arresting the progress and mitigating the symptoms even of typhus, as the records of medicine abundantly prove. In such cases much requires to be taken into account, which the skilful practitioner will not overlook; and especially the character and tendencies of the prevailing epidemic should be allowed their full influence on his judgment. In febrile action of an ordinary character the same caution is not necessary; and here the solicitude should be not to escape bloodletting, but to discover sufficient evidences of a labouring and disturbed circulation to encourage the having recourse to it; for when timely used, the duration of disease is materially shortened, the necessity of medical discipline con- siderably diminished, while the constitution is spared the ravages which protracted fever, even when ultimately cured, too often entails. With these remarks on the means of preventing plethora in a healthy subject, and of remedying it when it does occur, we may now dismiss the prophylaxis of gout. From all that has been stated in the foregoing pages of the nature and character of gout, it is obvious that antiphlogistic treatment is that which is essentially required for its cure ; and were it not for the complications produced by false theo- ries, improper regimen, and the perverted use of remedies, the establishment of this truth might almost suffice for all practical guidance. When the prophylaxis of gout shall be more clearly un- derstood, and more generally practised, these com- plications will decline, and simple treatment will alone be needed. But until that happy day shall arrive, it must be necessary to specify the various practice required, so as to mark its adaptation to the several varieties of constitution, stages of dis- ease, and morbid complications, which are sure to present themselves for a long time to come. On the practical instructions which follow we wish to observe, that, however they may seem to flow from the principles laid down, they have not re- sulted from merely speculative views, but are sup- ported by the best experience of the profession, as handed down by distinguished writers for ages, and are established to our own firm conviction by all that we have ever seen of the disease or its treatment. A first attack of gout affords, of course, no op- portunity for prophylactic treatment. It comes on, if not unannounced, at least unexpectedly, the party being first warned of it by the actual seizure. The treatment of the paroxysm, therefore, in its simplest state, becomes the first subject of practical illustration. There can be no doubt that the more this is treated on general principles, and the less the special nature of the disease is heeded, the more prompt and effectual will be the relief given, and the more perfect the correction of that morbid condition of the system in which the attack has its origin. If there be a full habit, with active fever, as marked by a full and frequent pulse, hot skin, and white or loaded tongue, then bloodletting, purging, and antiphlogistic treatment, should be employed as freely as if the fever and local inflam- mation passed under any other name. In mild attacks and where constitutional disturbance is less strongly marked, such active treatment may, perhaps, be waived, and the tendency to sponta- neous subsidence already noticed, be trusted to without immediate ill-consequence resulting, espe- cially if, after this admonition, a prophylactic regimen be steadily pursued. Still, however mild the attack, except it take place in a broken con- stitution, or under circumstances decidedly adverse to direct depletion, we would deem it wise prac- tice to take some blood, so as to render more com- plete the purposes for which nature institutes the paroxysm. Of this treatment of a first paroxysm we certainly cannot adduce cases ; but as in more advanced gout we have bled freely, both on the approach of the paroxysm, at its height, and on its decline, regarding only the state of constitution, and not the special malady, and this not only with perfect safety, but with eminent advantage, we feel fully justified in applying to a first attack of gout the principles which we would not hesitate to follow at later periods, and under circumstances less favourable to their full and beneficial opera- tion. It has been seen that the simple paroxysm runs a definite course, terminating in a few days in renewed health. And if the gouty effort be slight, and the existing plethora inconsiderable, this alleged restoration of health may be so com- plete as to need no interference from medicine. But if there be much plethora, then the fever aroused may not subside on the gouty nisus having effected its purpose of establishing a local inflammation. The pulse may remain high, the skin hot, the tongue loaded, with the various other depravations usually attendant on a febrile state. Under these circumstances no question can arise on the propriety of effecting by art what nature fails to accomplish. Bleeding, purging, cooling salines, with antimony, and low diet, should all be employed in proportion to the acuteness of the symptoms, and the constitutional energies display- ed. But whatever hesitation there might be in interfering with a first paroxysm, on the ground of its not being needed, and of nature being equal to accomplishing her purpose, there can be none, when the disease recurs in a constitution otherwise healthy and vigorous, in resorting to the same constitutional treatment which would be applica- ble in any other active inflammation. The ple- thora and inflammatory action are abundantly demonstrated by the attendant symptoms, there being a full, strong, bounding pulse, with hot skin, white tongue, and all the concomitants of active fever. The local inflammation, so far from militating against the employment of active prac- tice, affords additional reason for promptly resort- ing to it; for if not speedily allayed by suitable depletion, severe pain is unnecessarily prolonged, disorganization is hazarded, and greater debility of parts ensues, with more impeded motion of joints, and more tedious convalescence. On the accession, therefore, of the paroxysm in an other- wise healthy subject, if no earlier opportunity be GO UT. 349 afforded, a full bloodletting should be employed, and the bowels should be freely purged with a competent dose of calomel and colocynth, followed by a saline cathartic. If these means succeed in making impression on the system so as to reduce the pulse nearly to the healthy standard, the general fever may be treated by saline antimonials and aperients, like any other febrile excitement. Should the pulse again rise in frequency, force or hardness, with renewed heat of skin and whiteness of tongue, the bleeding and purging would re- quire to be repeated. The only distinction which we know between such an attack and any of the simple phlegmasia, regards the topical applica- tions; for so long as the local inflammation is removable by constitutional treatment, topical re- medies should not be employed, unless demanded by an urgency of suffering, such as, when consti- tutional treatment is properly employed, will very rarely occur. The local inflammation has a na- tural tendency to subside, as has been stated ; and it is perfectly justifiable to await this, at least for the usual period, without resorting to topical remedies. When it lingers, the fault lies not in the joint, but in the constitutional state, which keeps up the inflammation, and to this state are remedies best directed. There is a distinction, both in the febrile state and local inflammation, that deserves to be noticed. Both to a certain extent belong to the paroxysm, constituting it and subsiding with it; but both may continue beyond the time when the pa- roxysm, running its natural course, would spon- taneously subside; and this is dependent, not on the gouty nisus, but on the constitutional condi- tion. Relieving this condition by depletion and febrifuge regimen will subdue disease in both respects. If the local inflammation, however, have been suffered to establish itself, it may keep its ground even after the plethora and febrile action have been sufficiently abated; and here it is that local treatment may be needed for expedit- ing and completing the relief of the inflamed joints, and averting these structural lesions which protracted inflammation is sure to occasion. To abstract blood locally before the general circulation is sufficiently unloaded, gives no effectual relief; for if the constitutional state be not corrected, the local inflammation, however it may be allayed by topical bleeding or cooling applications, is pretty sure to recur, while some risk is incurred of the inflammation being transferred to some other joint, if not to some vital organ. Leeches, therefore, though their use is sanctioned Dy high authority, should assuredly not be employed in the ordinary treatment of the paroxysm, nor until the continu- ance of local inflammation after the removal of the constitutional disturbance manifests that the local disease has acquired an independent exist- ence. In this state leeches and other local reme- dies may be safely and beneficially applied, but antecedently to it their use is not appropriate. If leeches be unsuited for what may be strictly regarded as the paroxysm, repellent applications are still more so; and though in slight cases they may appear to succeed, their use as a general remedy for gout is eminently hazardous. If the constitutional treatment be conducted as it ought, they will be rarely needed ; and far better is it 2e that the local inflammation should yield to the constitutional correction, than that it should sub- side under local remedies. In the one case its decline affords evidence that radical relief is ob- tained, an assurance which must be incomplete when topical treatment is trusted to, however successful it may in any particular instance prove. That the final cause of a gouty paroxysm is the relief of the system, and that it accomplishes this to a certain extent, are truths sufficiently establish- ed ; and if the relief were complete, the interfe- rence of art would be superfluous and improper. But there is strong reason for believing that the paroxysm does not sufficiently relieve the sur- charged system ; and hence the assistance of art becomes necessary for seconding the operations of nature. But this assistance requires to be directed to the constitutional state rather than to the local ailment. So much is effected by the gouty effort, whatever its intimate nature may be, that it would be unwise to interfere with it otherwise than by removing the necessity which incites it. This may always be safely done by abating plethora and restoring general health; but until this pre- caution be taken, it cannot be expedient nor always safe to arrest suddenly the local malady by local bloodletting or repellent applications. As subsidiary to the constitutional treatment, there can be no objection, in highly nervous temperaments, and where inordinate sensibility prevails, to soothe by cold or tepid sponging, or by any equally harmless adjuvant; but as was before remarked, if the constitutional treatment be adequately em- ployed, such remedies as these will be little needed. In treating the paroxysm of gout, the indications are to relieve the constitution, and to moderate the local inflammation, so as to prevent the disor- ganization to which its violence or continuance would give rise. Both are best fulfilled by the constitutional treatment already directed. The converse of this practice, or that which, disregard- ing the constitutional derangement, directs its efforts to subduing the local inflammation by any means capable of producing such effect, has been at times confidently advised, and was revived with high commendations some years ago, but no treat- ment can be more hazardous nor more at variance with sound pathology. By promptly relieving the paroxysm through means of constitutional treatment, suffering is abridged, danger averted, convalescence accelerated and rendered more per- fect, the recurrence of disease obviated so as to be thoroughly capable of prevention by prophylactic regimen, and at least rendered more distant; and the gouty diathesis, which the long continuance and repetition of paroxysms invariably strengthen, is weakened and suspended. Were incipient gout always treated on these principles, and the premonitory signs which give notice of its recur- rence detected in sufficient time to employ the depletion and abstinence necessary for averting the paroxysm; and were prophylactic treatment afterwards pursued to the extent and with the steadiness necessary for ensuring its effects, the victims of reiterated gout would be few, and the disease would soon cease to be the opprobrium medicorum which it has been so long considered. It must be borne in mind that the foregoing re- marks and practical instructions apply to gout a* 350 GOUT. occurring in its simplest form, and in a constitution otherwise healthy and of unimpaired vigour. When it arises in a habit naturally feeble, vitiated by other diseases, or injured by repeated accessions of gout itself, the treatment, though similar in principle, must yet be greatly modified; and on the accuracy with which the necessary measures of relief are adapted to the existing powers, and suited to the concomitant derangements of function or structure, will the ultimate success depend. The perfect health of each and every function should be the standard by which all deviations should be judged ; and the endeavour should be to restore severally, and by the treatment appro- priate to each, whatever may appear disordered. Far preferable is this simple and intelligible pro- ceeding to regarding any symptom as character- istic of gout and applying to it some supposed specific, without reference to the direct operation of the remedy, or the physiological changes which its administration effects. Abiding by such a standard, which has the advantage at least of being real and definite, and ceasing to connect both symp- toms and remedial effects immediately with that * conjectural and indefinite entity, a nosological dis- ease, practitioners would in all diseases see their way more clearly, and proceed more directly and effectually to their object. Such mode of observing disease, too, would render the misconceptions and discrepancies of practical writers harmless, and enable the practitioner to unravel any complication of symptoms however intricate. As diseases are too much regarded in their complex and individual- ized character, so is it too much the habit to view the operation of remedies in connection with the more remote curative effects, rather than with their more direct influence on physical functions. The former mode leaves out of view much that requires to be intimately known, and may well be charac- terized as empirical; the latter alone can lead to just and accurate conceptions of morbid actions and remedial agencies; and in proportion as it takes a lead in guiding the practitioner's treatment, is his practice entitled to be considered rational and scientific. Some correct views on this subject have lately been presented by Dr. Spillan of Dublin, in a small volume entitled " A Supplement to the Pharma- copoeia." Even where remedies evince what is deemed a specific operation in the cure of certain diseases, their effects can be very generally resolved into their primary and direct influence on certain functions of the frame, and their curative agency be thus satisfactorily accounted for. This, at least, should be attempted in all cases of alleged specifics, although, however minute and accurate the investi- gation, something will ever remain undisclosed in the properties of each drug, to give it its peculiar character, and distinguish it from others of the "lass to which it belongs. Rhubarb, jalap, aloes, colocynth, are all purgatives, and with a view to their purgative effect are they principally employed; yet practitioners discover grounds of choice which lead to selection and preference independently of their relative strength as purgatives. When they are administered, however, it is the purgative ope- ration that is sought for, and through this operation the curative effect is expected. It should be so with all remedies so far as our knowledge of their direct agency admits. To this ajency we should more particularly direct our attention, at the same time that we avail ourselves of every advantage which unexplained properties may afford in com- bating diseases. A specific for gout has always been considered a desideratum, and mankind have ever been deluded by the vain hope that one would be discovered. Absurd as is the search pursued with this view, it has conferred one advantage at least, by making us familiar with a medicine which, though not entitled to be called a specific, is yet highly valuable, not only in gout but in almost all inflammatory diseases. The medicine to which we allude is colchicum, and from a tolerably ex- tensive employment of it for several years, we can faithfully add our testimony to the several records which attest its virtues and utility. When we were first induced to make trial of it, we took some pains to ascertain by close observation its real powers, and the best mode of administering it; and as our subsequent experience has made no change in the conclusions at which we then ar- rived, we cannot do better than transcribe here the account which we rendered of it in a small volume published in 1822. " A full dose of this medicine purges copiously, allays pain, and lowers the pulse. These effects are produced with greater certainty if the fulness of circulation be previously reduced by bloodletting, and the mucous secretions of the intestines evacuated. When inflammation is high, as marked by a strong bounding pulse, hot skin, and loaded tongue, bloodletting should always precede the use of colchicum. But in cases where arterial action is more moderate, and direct deple- tion from any cause questionable, this medicine may be resorted to with peculiar propriety and eminent advantage. Its operation seems to com- bine the several advantages of bleeding, purging, and sedatives, and is therefore particularly adapted to those cases where active depletion is inexpedient. In treating hereafter of the several modifications of gout, in so many of which venesection must be sparingly employed, or wholly withheld, I shall have occasion to recommend the free employment of this valuable remedy. And as the forms in which this medicine is given, and the modes of administering it are of much importance, I shall fully explain my own practice in both respects, without presuming, however, to limit the applica- tion to those methods which I have been led to prefer. Various preparations and different modes of exhibition may, in the hands of other practi- tioners, be quite as salutary as those which I em- ploy ; for as I observed on a former occasion, the effect, not the form, of prescription deserves regard. The preparations which I have tried are the vinous tincture of the root, the vinous and spirituous tinc- tures of the seeds, and the powdered seeds. Of these I decidedly prefer the tinctures of the seeds, as being more uniform in strength, and more cer- tain in operation. It might be reasonably expected. from the virtues of colchicum being found to reside in the seeds as well as in the root, that the former would yield a medicine of greater uniformity, being in a state of more perfect and determinate maturity, requiring less care in the collection and preserva- tion, and being less liable to have their powers impaired. My experience of the several prepara- tions fully confirms this supposition GOUT. 351 «It has been already remarked that colchicum purges, abates pain, and lowers the pulse. Its sedative powers, though sensibly connected with its evacuant, are not, however, wholly dependent on them. The motions produced are copious, frequent, and watery, and the operation seems more analogous to that of the saline purgatives than of any other cathartic. The number of motions is sometimes considerable, without any proportionate depression of strength ensuing. I have known even twenty stools occasioned by a dose of colchicum, the patient not complaining of the least debility. «These circumstances will guide our employ- ment of this medicine as a remedy for gout. Where the plethora is considerable, undoubtedly blood- letting should precede its use, for colchicum seems to remove the more fluid parts of the blood only : and these being quickly renewed, the relief obtained by this medicine alone cannot be so perfect or permanent as when bloodletting is also employed. Though the sedative powers of colchicum are valuable assistants to bloodletting in abating arterial action, they are yet no perfect substitute for this remedy in cases of high inflammation ; neither are its evacuant qualities capable of superseding those cathartics which expel mucous secretions. In cases, then, of active gout occurring in a full habit, we would invariably bleed, and purge with calomel and antimony before having recourse to colchicum. It is possible that colchicum might occasionally diminish pain and abate inflammation more speedily if administered earlier; but it should never be forgotten that in the treatment of this and all other diseases the important object is not to allay pain or combat symptoms, but to restore general health with the least possible injury to the functions or structure of particular parts. In this respect the physician's province seems analogous to that of the Roman dictators, who were appointed, not to combat an enemy nor quell an insurrection, but to take care that the commonwealth received no injury. In like manner the physician should provide not for the relief of a mere transient or other incidental ailment, but should so conduct the disease to its termination that no permanent injury be inflicted on the constitution. Unhappily, far from being left to the uncontrolled exercise of his judgment in accomplishing this end, he is too often compelled by prejudice and caprice to adapt his practical treatment, not to the real nature of the disease, but to the preconceived notions, impatience, and ignorance of those by whom he is surrounded. When colchicum is to be employed, it may be given either in full doses so as to purge actively, or in divided doses frequently repeated. A drachm, drachm and a half or two drachms, of the tincture of the seeds should be administered at night, and repeated, if necessary, next morning. This quantity will generally purge briskly, but if it fail, a third dose the following night will be pretty sure to succeed ; at least I have seldom found it necessary to exceed these doses. The full operation being thus obtained, I usually continue its use in smaller doses, ordering twenty minims three times a day in any of the common saline mixtures. Even this dose will occasionally purge so actively as in a short time to require its discontinuance, in which case the antimonial salines should be given with- out it, so long as febrile symptoms render neces- sary." Such were the views which careful observation of the properties and medicinal effects of colchi- cum led me to form ten years ago, and it is some- what in proof of their accuracy that a tolerably extensive use of the remedy in the intervening period has induced no change in them, white it has increased our confidence in the efficacy and utility of the remedy when used as an auxiliary to more active and direct treatment. What might be regarded as its specific powers seem resolvable into those more simple and direct influences which it exerts on the animal frame. It purges, allays pain, and lowers the pulse. These effects are ac- counted for by assigning to it a cathartic and se- dative operation, and it is this combination per- haps to which its peculiar virtues are to be ascrib- ed. The reduction of pulse might appear a result of its purgative operations, but it can, without purging, lower the pulse. That it possesses seda- tive properties is abundantly shown by its effect in allaying pain, and this where no purging is occasioned; and, so far as we have been able to observe, we should consider the reduction of pulse as produced by its sedative rather than its evacu- ant properties. We are also disposed to regard the sedative properties as those from which it de- rives its chief value. These discussions are im- portant, as they assist in reconciling the discord- ant testimonies which are still offered on the sub- ject, and when finally closed, will establish that discriminating use of the remedy which will en- sure its fullest advantages. It has been alleged, repeatedly and on highly respectable authority, that colchicum does no good unless it purges. This we disbelieve, because our own experience contradicts the fact, and because it is inconsistent with what we have witnessed of the other properties possessed by colchicum. On the principle of a purgative effect being required, several practitioners combine the remedy with pur- gatives, and with advantages veil ca'culated to confirm the propriety of so dc-ing. This mode we repeatedly tried in our early use of the medi- cine, but saw no inducement to pursue it. Oil the contrary, if we had a difficulty in exhibiting colchicum, it arose from its too great readiness to purge, and the consequent necessity of relinquish- ing it. When we need its availing powers in allaying the inflammation of gout, rheumatism, or any other disease, we are always best pleased when it does not speedily purge. In other words, we look for benefit more to its sedative than its evacuant operation; the latter can be supplied by other and better means ; in the former it possesses advantages peculiarly its own. The explanation of these different opinions is not difficult: it must be sought in the views of those who administer the remedy, and the practice which they conjoin with it. If it be used as a specific, and without previous bloodletting, then we can readily under- stand that unless it purge it will be of little avail; but if the pulse be lowered by adequate bloodlet- ting, and the bowels cleansed by calomel and colo- cynth, we would then say that a purgative effiM from the colchicum itself is not needed, nor at all essential to its beneficial operation. For the ac tive gout of vigorous habits we would not giv»' 352 GOUT. colchicum in full doses; or with a view to purge, but we would bleed and purge as in the ordinary treatment of the phlegmasiae, and then conjoin colchicum in small doses with the ordinary febri- fuge salines. Even when given in this way it will oftentimes purge actively, and, as we consider, to a disadvantage; for when it begins to excite the bowels, it must be at once relinquished, the continued irritation becoming intolerable, and, as we suspect, not very safe, although, having ever been cautious, we have never witnessed an in- stance of mischief thus occasioned. The views here presented we would wish to be scrutinized, for if correct, they would lead to a use of the remedy more precise and direct than yet obtains, and encourage practitioners to profit by its aid even when no sensible effect is immediately pro- duced by it. And here we cannot resist offering a remark which appears to merit attention. In former times, the Materia Medica was encumbered with a mass of frivolous and inert medicine, and thence ren- dered so unwieldy that some retrenchment became indispensable. The more worthless were cut off with no sparing hand, and it may be doubted whether some were not thus expunged from the list which might have been beneficially retained. However this be, there sprung from this kind of investigation a scepticism respecting the virtues of all medicines which did not evince a direct and determinate influence on some function or other of the frame. The same feeling carried into prac- tice demanded that each dose of a medicine should produce a sensible effect, and from this tendency it is that we think error has sprung. Although in active and urgent disease, requiring prompt relief, we would employ the full and adequate agency of remedies, yet in a large portion of med- ical practice, and especially where long-established or habitual morbid actions are to be corrected, we are persuaded that more good results from their more gradual and oftentimes imperceptible opera- tion. When morbid actions have continued for a certain time, and still more where structural changes have commenced, the organs and tissues concerned are not capable of sudden change, nor can they by any activity of treatment be brought back immediately to a healthy condition. As the morbid change is gradual, so also must be the cor- rective process, whether instituted by nature or promoted by art. In effecting it nature is ever slow and deliberate, and in this respect art would oftentimes do well to follow her example. When it is once ascertained that a medicine does possess active properties, it should not be suspected that these should be evinced by every dose of the rem- edy administered, nor should it be concluded that the remedy is inert merely from the absence of immediately sensible effect. This consideration would be to us a sufficient reason for placing a certain confidence in small doses of colchicum, even if we looked only to its specific or curative effects. When we regard the simpler properties into which these effects are resolvable, we are still more confirmed in the propriety of not withhold- ing such doses on the mere ground of their not acting on the bowels. Many remedies are continually administered from confidence in their accustomed properties, without an immediate or directly sensible effect being expected. Antimony is conjoined with salines to render them more febrifuge, and the effect is expected to result from its primary opera- tion on the stomach: yet the evidence of nausea is not always insisted on, nor is it inferred, from the absence of nausea, that the antimony is use- less. When the primary operation of colchicum comes to be better understood, it will be given in imperceptibly operating doses, with as much con- fidence as is now felt in the exhibition of anti- mony. [For the different forms in which colchicum is administered in gout, see the author's New Reme- dies, 4th edit. p. 179 ; or his Practice of Medi- cine, 2d edit. ii. 607.] By the treatment prescribed in the foregoing pages the paroxysm of gout may be promptly and effectually relieved, the constitution re-esta- blished, the powers of the affected limb preserved, and the gouty disposition diminished. A due attention to prophylaxis may afterwards prevent its ever recurring. The value of such practice is most conspicuously displayed when contrasted with the negative treatment so generally resorted to, by which the paroxysm is greatly prolonged, the constitution very imperfectly relieved, the struc- ture of the joints sooner or later utterly disorgan- ized, and the gouty diathesis confirmed and ren- dered inveterate. If gout were always of an active character, and confined to constitutions naturally vigorous, it is highly probable that the medical treatment would never have been perverted so egregiously as it has been. But this disorder occurs under every condition of health, and in all degrees of animal power, from the highest vigour to that helpless debility which can scarcely gene- rate a paroxysm. Cases of this latter description will not bear active discipline; if employed, the patient must sink rapidly under it; and the dan- ger arising from such maltreatment has no doubt been often the means of exciting an alarm well calculated to make a deep impression on those who are more peculiarly liable to this disease. The too frequent error, too, of prescribing for the name of a disease rather than its peculiar con- dition, may have oftentimes caused extensive in- jury to result from ill-judged activity of practice, and thus have contributed to bring this method of treating gout into disrepute. Be the causes what they may that have so often occasioned active practice in gout to be resorted to by prac- titioners and again abandoned, it must be evident that, if this disease in its simplest form and high- est intensity is so essentially benefited by the mea- sures here prescribed, a modification of the samt. practice must, upon every principle of sound rea- soning, be applicable to all inferior degrees of the same malady. From this conclusion not even the most timid need take alarm, for as the circum- stances of each case sufficiently indicate what evacuations may be safely employed, no rational practitioner can ever be tempted by the doctrines here maintained to carry them beyond the point of safe and salutary endurance. Indeed there are many strong inducements to keep far within it; and provided the principles of treatment be not compromised from vain apprehension or too great pliancy of disposition, we should not be anxious GOUT. 353 in a great number of cases for the practice to be carried to the utmost limit of even safe and salu- tary employment; for as medical aid must neces- sarily be administered by men of various capaci- ties and acquirements, all of whom may not be equally qualified for adapting accurately, in the details of practice, what principles enjoin, it will be the safer course to fall short somewhat of that activity which would most effectually relieve, rather than run any risk of exceeding it. These prudential considerations will have their full weight with every piactitioner however enlightened. The more intelligent and experienced will of course feel more confidence in their own powers of accu- rate discrimination, and will pursue proper means with greater energy and less hesitation. All, how- ever, must yield occasionally to prejudices long established, and to fears which the sensitiveness of friends cannot always relinquish or control. But the practitioner will give way to such impe- diments with greater safety to his patients and more satisfaction to his own feelings, by keeping steadily in view the principles here inculcated, and regulating his practice in modified obedience to their clear and forcible dictates. Before dismissing the consideration of the sim- ple and active paroxysm, a few points more are to be noticed. It has been remarked that in the local inflammation two stages may be occasionally distinguished, one being primary, the product of the paroxysm, running a determinate course and spontaneously subsiding; the other secondary, dependent more on the general inflammatory dia- thesis than on the gouty nisus, and tending not to spontaneous decline, but to disorganizations de- structive of the mobility of the joints, and leading to eventual decrepitude. Under the natural course of the paroxysm, and especially when the violence of this is subdued by suitable constitutional treatment, the first or purely gouty inflammation needs no local applications. The secondary requires direct and suitably active treatment for its removal. Leeches, cold or tepid lotions, and eventually blisters, may all be neces- sary. On this head it may suffice to remark that the safety and efficacy of such local treatment must ever be proportionate to the relief antece- dently given to the general constitution. If the constitutional derangement be corrected, the gouty nisus will not recur ; and the secondary inflamma- tion may be subjected to ordinary and appropriate treatment without hazard of metastasis either to other joints or to vital organs. So soon as decline of inflammation, whether primary or secondary, permits, early return to moderate exercise is of the first importance. It becomes then the best agent in restoring free cir- culation to the several weakened tissues, in obvi- ating morbid depositions, and promoting the ab- sorption of whatever may have taken place; thus preventing the thickening of ligaments, rigidity, and the contractions so apt to ensue, and enabling the party speedily to enter on the more active exer- cise which prophylaxis enjoins. And the precept is the more to be relied on, as it applies equally to other articular inflammations from whatever cause they arise, whether rheumatism, accident, or any other. Provided the cavity of the joint be not involved, (and in a large proportion of cases the vol. II. —45 2e* inflammation is wholly exterior to it,) protracted rest is injurious, and the source of much mischief. Under it parts become rigid, of which early return to exercise would preserve the flexibility; deposi- tions take place, producing permanent thickening of ligaments, or loading the bursas of the tendons with glairy mucus, in either case impeding motion. The muscles, too, consigned thus to inactivity, in time waste and become enfeebled, and eventually complete decrepitude with broken health ensues. From what has been said respecting the prophy- laxis of gout, it must be evident how sedulously every source of impeded motion should be avoided by gouty patients whose joints have yet escaped disorganization. Such patients have themselves remarked that, when compelled by circumstances to use their limbs early after a paroxysm, they have recovered with less impaired powers than when they have been enabled to indulge in rest. The principle is unquestionable, and no sensibility to slight pain, nor any vague apprehension of renewing the paroxysm, should be suffered to pre- vent the early renewal of moderate exercise, so necessary for promptly restoring the mobility of the joints, and preserving to the individual the power of still further re-establishing his health through their instrumentality. The attenuated limbs of gouty and rheumatic subjects are more owing to suspended exercise than to any effect of the special maladies. So convinced are we on this point, that we would in our own person in- finitely prefer hazarding a renewed paroxysm either of gout or rheumatism, to encountering the mani- fold evils which protracted rest is sure to occasion. Only one source of constitutional derangement has been hitherto noticed in this essay as con- nected with gout, namely, that which arises from excess of nutritive matter in the blood. Another no less important requires now to be discussed, as materially concerned in the several modifications of gout which are yet to be considered. It is the vitiation of blood which arises from the excremen- titious matter continually carried back to it by the absorbents, not being adequately excreted and expelled. Health requires that the nutritive mat- ter taken into the system should be duly appropri- ated to all the structures which compose the body ; it also requires that the effete matter, which, having done its duty, is displaced by the nutritive parti- cles deposited, and which in the ordinary course of animal functions is carried back into the blood, should through the admirable agency provided by- nature, be from thence regularly and adequately discharged. If nutritive matter be taken in excess, it either increases the bulk of the body beyond the bounds of full activity and vigour, or, produc- ing excitement tending to its own appropriation or removal, but also if too long continued genera- tive of disease, it begets a state of fever or inflam- mation more or less active. On the contrary, if the excrcmentitious matter be not adequately ex- pelled, it accumulates in the blood, vitiates its quality, and depraves the nutrient and other secre- tions, thus impairing, by a slow and insidious process, health and strength, and laying the foun- dation of a direful class of chronic maladies. Temperance in diet is the only safeguard against the former, but it is a certain one; exercise is also necessary for obviating nutritive plethora, by pro- 354 GOUT. moting the healthful appropriation of the nutri- ment taken, while it is the chief means of keeping in due activity the several excretory processes by which the effete matter of the system is eliminated and expelled. Of excrementitious redundancy only a brief account can be rendered in this place, the fuller discussion being more appropriately given in conjunction with Plethora, with which it is so continually intermixed. As excess of diet gives rise to nutritive plethora, and as deficiency of exercise both contributes to the same end by retarding the appropriation of the nutriment supplied, and promotes further vitia- tion of the blood by loading it with excrementi- tious particles, it is obvious that the two states of redundant nutritive matter and accumulated excrementitious particles may co-exist in every conceivable proportion. As each in its simplest state is characterised by its appropriate pheno- mena, the several combinations admit of being detected by enlightened and diligent scrutiny; and to this end would inquiry be far more pro- fitably directed than to searching after specific agency in drugs for correcting evils which, having their origin in a primary depravation of the source of all nutrition, can never be radically cured but by means corrective and preventive of the primary mischief which occasions them. These patholo- gical views point out the high importance of tem- perance and exercise as means both of preserving health and correcting disease. So far, at least, as the former purpose is concerned, all theories will concur in this recommendation, which is too firmly founded on common sense to be shaken by any speculation, while the advance of true pathology will maintain the equal importance of bearing the principle in mind in combating diseases. From not being provided with a better term, we have on former occasions designated the ac- cumulations of excrementitious matter in the blood as excrementitious plethora; and though we like not the name, we must continue to em- ploy it. We do so with less reluctance from the necessity which exists for considering both nutri- tive and excrementitious plethora in conjunction, their various intermixtures being such that it would be impossible wholly to sever the discussion of them. Some future day, when the pathology of the blood shall receive the attention which is pre-eminently due to it, better terms than either can be readily substituted. Gout being a disease no le=s of indolence than of repletion, it is manifest that its subjects are among those whose blood is vitiated by retained excrementitious matter as well as by redundancy of nutriment; and this consideration explains why mere abstinence, unassisted by active exercise, can rever be expected to eradicate gout. Though the diet be temperate, yet indolence begetting general languor of frame, and this languor being confirmed and perpetuated by the effects of excessive excre- mentitious matter, causes a languid and imperfect appropriation of whatever sustenance is taken ; a degree of nutritive plethora thus relatively ensues, and the elements of acute disease are thus sup- plied. To distinguish both states and their multi- plied combinations, it becomes necessary to display their separate conditions, and by contrasting them with each other, to furnish indications by which the prevalence of either, or the intermixture of both, may at any time be detected. The phenomena of nutritive plethora, its in- crease, and final transition into a febrile state, have already been sufficiently described. Excre- mentitious redundancy in the blood begets a very different condition, but one no less marked by its appropriate indications. These are a sallow aspect and dusky skin, the pulse low, soft, and easily compressible, the surface of the body for the most part harsh, dry, and obviously deficient in natural transpiration, the tongue moist, clean, red ; the appetite capricious, often craving, with an endless train of dyspeptic ailments; the alvine discharges inveterately foul, dark, slimy, pitch-like, and exhi- biting no traces of healthy faeces; the urine high- coloured, often fetid, and depositing more or less of sediment: these several evidences, or a certain portion of them, with decline of flesh and strength, are sufficiently characteristic of this state. The condition itself we believe to arise from imperfect elimination of excrementitious matter; and the depraved state of the several excretions we regard as resulting from the laboured though inadequate efforts of the constitution to accomplish its own purification. How much this state is combined with the more advanced and complicated condi- tions of gout will be readily perceived; and it is by bearing in mind this source of vitiation, as well as that furnished by nutritive plethora, that the treatment will be most judiciously and successfully conducted. The direct effect of excrementitious plethora is unhealthiness of nutrient secretion, producing feebleness of the organs thus imperfect- ly nourished, and progressive decline of strength, The efforts of the constitution to throw off this oppressive load fail of success, and their ineffectual renewal, as well as the progressive unhealthiness of nutrient secretion, cause still greater feebleness, and eventually attenuate the frame. According as more or less of nutritive plethora becomes combined with this state, the constitu- tional efforts are greater, and various degrees of febrile and inflammatory excitement ensue. In proportion as this excitement is energetic, and as suitable means are employed to relieve it, is the vitiated state of the blood corrected, secretions and excretions are improved, and general health and strength are renewed. Increased secretion from the bowels seems the principal discharge by which nature in general aims at getting rid of such im- purities, and to promote them by suitable purga- tives is clearly indicated, care being taken at the same time to support strength by light yet nutri- tive diet. When relief to a certain extent is thus afforded, the powers of the constitution rally, and a febrile effort is made to assist in the work of purification. As this advances, depletion requires to be more active, and the diet less stimulating. When sufficient excitement is aroused to warrant the employment of bloodletting, we may then consider the curative process in the most favoura- ble train. Perhaps the powers of the constitution are hardly adequate to rectify any high degree of this peculiar derangement, without the agency which febrile excitement supplies ; and hence we see experienced practitioners often hail the ap- GOUT, $55 oearance of febrile symptoms in chronic com- plaints, as announcing a more remediable form of disease. These remarks on excrementitious plethora, though cursory and imperfect, will suffice to pre- pare the way for the remaining discussion of gout. To pursue this methodically through all the alleged varieties would be both tedious and valueless. If Jie principles be clearly' laid down, there can be little difficulty in applying them to whatever va- riety or complication of the disease may present ■tself. On a first accession of gout it should be the inflexible determination of the party assailed never to subject himself to a return. That this is prac- ticable is abundantly proved ; and if the means so clearly pointed out be not employed, blame should not be imputed either to the inveteracy of the malady or the imperfection of medical science. Nature has endued all matter with determinate properties, and living beings are subjected to cer- tain organic laws, by obedience to which health and physical welfare are maintained, while a vio- lation inevitably begets disease. They who will neither learn those laws, nor abide by them when proclaimed, must suffer the penalties of their own :gnorance and perverseness. When successive attacks of gout have taken i.ihee, the hope of effecting complete exemption 'inist be sensibly weakened. Still, if there be no disorganization, the end may yet be attained, and ut all events the attempt to accomplish it will be amply repaid; for should attacks recur they will be slight, at long intervals, easily subdued, and will commit no ravages, but leave the general health and even the gouty limbs tolerably sound. Disorganizations of course enhance greatly all the difficulties. They evince a more confirmed gouty diathesis; the local weakness encourages renewed seizures from slight causes; and the im- pediment to active exercise cuts off one of the most efficient prophylactic agents. In this state of gout, then, too much should not be attempted, either by bloodletting or abstinence. Active symp- toms should be met with such certainty of prac- tice as the accompanying state of constitution may warrant. Fever should be allayed, local in- flammation abated, and general health restored as speedily as possible; but all due regard should be given to the degree of constitutional power exist- ing. In the wretched cases of extreme disorganiza- tion, broken health, and exhausted power, no one would think of employing any but palliative treat- ment ; but even this will be beneficial in propor- tion as it is guided by the principles maintained throughout this essay. So long as there is encou- ragement to employ bloodletting as part of the treatment, will benefit result from resorting to it. Tn cases in which the danger to be apprehended from its use is greater in degree than the expecta- tion of benefit, other means must be substituted ; and here colchicum is of inestimable value, sup- plying the place of more active and efficient treat- ment better than any other drug with which we are acquainted. As a healthy state of each function is the standard with which the several derangements should be compared, and which it should be the endeavour to restore, care should be taken to ascertain by direct evidences that each is actually restored to the efficient exercise of its powers. The pulse, skin, and tongue, will demonstrate with sufficient accuracy whether fever is subdued, and will thus afford evidence of the circulation being, for the time at least, restored to its healthy balance. To maintain this ground, however, assi- duous care should be devoted to the several excre- tories, all of which should perform adequately their several functions. The skin, bowels, and kidneys should be active, and their respective efficiency should be attested both by the quantity and quality of their several excretions. Each of these should receive more continued attention than is usually given to them, for if duly noticed, they would announce the advance of disease long ere depraved sensation or other prominent de- rangement indicate its approach, and would thus lead to a more timely and effective use of suitable correctives. A closer attention to them, also, during conva- lescence, would contribute much to render reco- very more perfect, and lessen the liability to re- newed attack. The skin should be active, for it is an outlet for the discharge of excrementitious matter of the highest importance. The most effectual and salu- tary means of keeping it so is active exercise. Warm bathing is a valuable assistant, and emi- nently so when but little exercise can be taken. The condition of the skin itself should be regarded. In many, large portions of its surface are hard, dry, scaly, and utterly impermeable. These should be restored by warm bathing, by such applications as soften the cuticle, and by frictions both with the hand and the flesh brush. The thorough desquamation of cuticle effected by the process of the Russian vapour-bath, would be a valuable means of restoring many an imperspirable skin to the full exercise of its functions. A freely per- spirable skin is powerful in obviating plethora both nutritive and excrementitious. The bowels should perform effectually the duty which nature assigns them, and in this respect attention is much needed, for considerable depra- vation is continually suffered to go on unchecked and unheeded. The amount and frequency of stools are too much trusted to as evidences of healthy bowels, while the only one to be relied on is the character of the matter discharged. When this, however sufficient in quantity or regular in discharge, is dark, foul, and charged with mucus, evacuant or alterative medicine is needed, how- ever free the party may be from every other symp- tom of disease. By this neglect much disease creeps in, and many a constitution is undermined where timely and judicious attention to the bowels would avert all the mischief. In like manner the urine merits attention, and more especially from the tendency which there is in gout to throw off morbid matter by this outlet. Much profitless scrutiny has been devoted to the different impregnations, the specific gravity, and other properties of gouty urine. The main fact respecting it is that it contains what ought not to find its way into it, and the most effectual way of purifying it is to cut off the morbid supplies by regulating the diet and restoring due activity to 356 GOUT, the other excretories, for it is their deficiency which throws upon the kidneys so much extraor- dinary labour. Light diet, a free skin, and active bowels will clear the urine with little aid from chemical correctives. These are, no doubt, proper as adjuvants, where high degrees of acescency or of alkalescence prevail; but they are utterly inad- equate for perfect corrections, and their use at best, if alone trusted to, is uncertain and short-lived. We have no evidence that when taken by the mouth they ever reach the bladder so as to act on the concretions deposited there. This truth the history of calculous complaints establishes. From the same source we learn that when acid calculi cease to be deposited in consequence of the free use of alkalies, if these be continued, alkaline de- positions take place, and thus the evil is changed, not removed. Both in calculus and gout our be- lief is that more may be done in correcting the morbid state of urine, by re-establishing a healthy balance in the constituents of the blood, avoiding all excess of diet or stimulants, and keeping up an active state both of cuticular and intestinal ex- cretion, than can ever be effected by neutralizing remedies. These should not be withheld, but from the circumstance before mentioned caution is required in their use, and at all events they should not, however efficient they may casually appear, be suffered to supersede the far more effectual re- lief which rectifying the fundamental errors of the constitution is capable of affording. Little more is needed to complete the discussion of gout, the principles maintained in the foregoing pages being applicable to all the forms in which the disease can present itself. It has been already stated that these complex conditions and alleged varieties are referable, not intrinsically to gout, but to the state of constitution in which it occurs ; and to the constitutional derangements should the treatment be directed, without bias from the im- puted cause. The varieties, when scrutinized, will be found to consist of gouty tendencies com- bined with visceral affections and with more or less of debility; and in treating them the object should be to restore general health, and thus re- duce whatever gout there may be to its simple and intelligible state, rather than aim at improving health by any specifics supposed to act directly on gout. The latter mode has been tried sufficiently long and by sufficient variety of means to prove its utter inefficiency, and deprive it of all confi- dence. The history of specifics and their effects would furnish a lamentable display of error and its consequences. The Portland powder appeared to cure, but the result of Dr. Cullen's inquiries was that not one of those who were so cured sur- vived three years. Some died suddenly, while others were attacked with apoplexy, palsy, asthma, hydrothorax, general dropsy, or general cachexia. In this conclusion both Dr. John Gregory and Dr. James Gregory were led by their investigations to concur. The ravages occasioned by the eau me- dicinaie are of too recent date to need more than a casual mention. According as the general health is broken, and ttie power of bearing active treatment weak, must gouty patients abate in their expectations of cure, and be content to mitigate their sufferings by such means as sound principles sanction; and by ad- hering to these much may be done even in extreme cases. In all may fever be allayed, plethora pre- vented, the bowels kept free, the skin perspirable, and contingent derangements receive their appro- priate correction. In proportion as the natural vigour is slight, or reduced by excrementitious plethora, must deple- tory treatment be cautiously applied to recurring paroxysms ; for no promptitude of relief could jus- tify the hazard incurred by even an approach to excessive evacuation. While we contend for the inflammatory nature of gout, and the decided pro- priety of combating the active disease with pro- portionally active treatment, we are far from in- culcating a rash or indiscriminate use of the lan- cet, but on the contrary would employ it with great caution, and only under those circumstances in which repeated experience had established both its safety and utility. With a full hard pulse, hot skin, and furred tongue, we would bleed, purge, and give colchicum without hesitation. Even where inflammation was less strongly marked we would employ the same means, provided the evi- dences of plethora and of febrile excitement were sufficiently discernible; and this treatment has in our own practice had perfect success in abridging the paroxysm, accelerating convalescence, restor- ing speedily the affected limbs, and greatly pro- longing the period of exemption, even in cases of long continuance, where the duration, succession, and severity of paroxysms had induced such help- lessness and decrepitude as confined the parties to the couch for two-thirds of the year. The vigour of constitution being the standard by which deple- tion should be regulated, it follows that when such vigour is deficient, measures of the same activity should not be pursued as are necessary when the habit is robust. In extreme cases, where natural languor and feebleness are confirmed and increased by the effects of excrementitious plethora, when muscular debility is great, the pulse low, soft, fal- tering, the tongue moist, clean, of a bright red colour, or scarcely whitened, the bowels invete- rately foul, the gouty effort feeble and imperfect, —in such cases wine, stimulants, and invigorating regimen must supersede every evacuation save purging. The object in such cases should be to renovate the frame by improving the bowels and giving tone to the whole system. Should the gouty effort, in consequence of such regimen, be- come more vigorous, and marked by clear evi- dences of renovated powers, then may an approach be made to the more effective treatment by which gout is so signally relieved. With respect to the nosological varieties, they may be dismissed with very few observations. Cullen has recognised them; namely, the atonic, retrocedent, and misplaced. The atonic is marked by general debility, feeble attempts to generate a paroxysm, and visceral derangements, chiefly gas- tric. Light food, regulation of bowels, and the several means suited for improving the stomach and giving tone to the general system, should be the means here resorted to. Light tonic medi- cines may be combined, but they are of little avail, and they should neither be given largely nor too long continued. The condition of the stomach is here analogous to what obtains in gastrodynia, to which head we may refer for the treatment which GOUT. 357 this derangement requires. What is generally called gout in the stomach is but a high degree of this affection; and when the spasm is intense, with prostration of strength, the strongest stimu- lants, such as brandy, ether, and laudanum, may be necessary to allay it. Immediately after, however, the stomach should be effectually cleansed of its mucous accumulations by full doses of calomel, antimony, and colocynth ; and light cordials with aperients should follow rather than direct stimu- lants or tonics. When there is great debility of stomach, chalybeates may be required, and they are best administered in the form of some natural or artificial mineral water. It is in such cases that the internal use of the Bath waters is so emi- nently serviceable, although they are valuable in most gouty cases, especially where the stomach requires some substitute for the wine and stimu- lants relinquished. In such cases the grateful stimulus of the Bath waters gives tone to the sto- mach, improves appetite, and renovates strength, thus accomplishing an unequivocal good ; not, as has been falsely imagined, by the mere establish- ment of gout in the extremities, but by the reduction of gout to its simpler and more manageable state through the amendment effected in the general health. This advantage is great, provided it be rightly understood. If the mere gouty accession be the object desired, and that on its appearance the end is considered as attained, then indeed the benefit is but slight and transitory, while the false experience thence derived serves but to confirm eiTor and perpetuate evil. But if the accession, when thus elicited by means of renovated powers, be regarded as it ought, and properly treated, the opportunity thus afforded for resorting to efficient measures is most valuable, and the Bath waters, so instrumental in procuring it, should receive the credit to which they are so justly entitled. It is curious to observe the fluctuations which take place in public opinion respecting the value of mineral springs. They become fashionable and again decline, not from any variability in their properties or medicinal effects, but from the mis- conceptions and caprices to which ignorance is prone. It is lamentable to think how great is the ignorance of the public in all that relates to the structure and functions of their own frames, and how very inconsiderable a portion the science of animal life forms even of that course of instruc- tion which our highest seminaries supply. For- merly Bath was the general resort of gouty pa- tients in all stages and degrees of the disease. The object was not to cure gout, but to excite and hasten it; and as this effect was often produced, their reputation became established. In time it was discovered that in full habits and inflamma- tory states of constitution their agency was not always limited to bringing on gout, but that other excitements less harmless were apt to ensue. The local practitioners were therefore constantly obliged, in the conscientious discharge of their duties, to withhold the internal use of the waters, however they might allow their external application ; and patients who were sent to Bath expressly to drink the waters were naturally disappointed. It came to be doubted, also, whether bringing on the pa- roxysm was to be considered an unmixed good ; and this approximation to just views gave rise to further hesitation respecting the expediency of using the Bath waters. The consequence is that though vast numbers still resort to Bath for gouty complaints, the waters are not held in that high estimation in which they were wont to be re- garded. Yet they still retain all the virtues which they ever possessed ; are still capable of rendering most valuable services to gouty constitutions, nay, of effecting, in the improvement of stomach and renovation of strength, what no course of medi- cine, nor any other mineral spring in these coun- tries, could equally accomplish ; and there is no reason, save the capricious fluctuations of opi- nions, why they should not still maintain the high character which they formerly possessed. The objects in administering them may be different, but the effect of this must be to render them only the more serviceable. Gout has been called retrocedent when the sud- den subsidence of the gouty inflammation has been followed by sudden affection of some inter- nal organ or function. Such affection is no doubt liable to occur whenever the local inflammation is repelled without the constitution being adequately relieved. Where it happens, it requires to be treated precisely as if gout were not concerned. If the substituted malady be marked by spasm and sinking powers, cordials and stimulants must be used ; if by inflammation, then must bleeding and purging be employed to the full extent which the urgency of symptoms may demand. The term misplaced gout seems to have been employed without any sufficient reason. It has been applied to any and every incidental disease occurring in a gouty habit. For the most part such disease has been inflammatory; and when it has attacked the stomach, lungs, or brain, practi- tioners, impelled by the urgent danger, have not hesitated to bleed freely, however repugnant to such practice their ordinary views of gout might be. It would be difficult to reconcile this practice with the extreme timidity which shrinks from the employment of bloodletting when the inflammation of active gout is situated in the extremities. E. Barlow. GRAVEL.—See Uhixe. [GREASE POX__See Glandehs.] GUTTA ROSEA, or ROSACEA.—Se Acne. H^MATEMESIS.—This term (derived from alpa. and e/jLco)) literally imports vomiting of blood, and is therefore properly employed to signify hemorrhage from the stomach. Some nosologists, as Pinel and Mason Good, comprise under this denomination every hemorrhage from the alimen- tary canal, whether the blood is discharged by the mouth or by the rectum. It is, however, more conformable to etymology and to general usage to restrict the name of haematemesis to gastric hemorrhage, and to denote intestinal hemorrhage by the name of Meljexa, which will, therefore, be the subject of a separate article. There is, however, much affinity between these two species of hemorrhage : and the two articles will there- fore be in some measure mutually supplementary. Haematemesis is frequently mentioned by Hip- pocrates. It is clearly described by Aretaeus, ond distinguished by him from pulmonary hemorrhage 358 HAEMATEMESIS. Among the moderns, Stahl, Hoffmann, Morgagni, Tissot, Portal, and subsequent writers, have con- tributed to its elucidation. Little has been written on the subject by British physicians. Cullen has not even included this disease in his nosological arrangement, on the ground of its being almost universally a symptomatic affection ; he has, how- ever, treated of it at some length in his " First Lines," chiefly with reference to the diagnosis and pathology. Predisposing Causes* — Women are much more subject than men to hcematemesis, and are chiefly liable to it during the menstruating period of their lives. Those of a delicate frame, of quick nervous sensibility, or subject to strong emotions, are most prone to this disease ; but the sanguine, ruddy, and plethoric are also liable to it as a con- sequence of defective menstruation. In some females it occurs during pregnancy. Men are seldom attacked by Inematemesis at an earlier age than thirty or thirty-five, and very rarely after fifty. It is in them almost invariably induced by habits of life unfavourable to health, especially by close and anxious application to business, com- bined with indulgence in the pleasures of the table, and neglect of bodily exercise. Organic disease of the stomach, liver, or spleen, and pro- bably also of the pancreas, will constitute a pre- disposition to haematemesis; and organic affections of the heart, especially valvular disease and dila- tation, by retarding the return of the blood, and hence inducing general venous congestion, are a frequent predisposing cause of this as well as of other hemorrhages. When haematemesis has once occurred in an individual, from whatever cause, a predisposition is induced to its recurrence, either spontaneously, or on exposure to some exciting cause which would not in other circumstances have given rise to it. Exciting Causes. — These may be divided into local and constitutional. The local causes are such as produce irritation or sanguineous con- gestion in the mucous membrane of the stomach, and consequent exhalation of blood; or more rarely a physical lesion of the inner surface of that organ, attended with rupture or erosion of a blood-vessel. Sauvages, Frank, and other authors, enumerate a variety of exciting causes of haema- temesis, which are confessedly of very rare occur- rence, such as the rupture of an aneurism of the aorta, or of some one of its branches, into the cavity of the stomach; the bite of a leech acci- dentally swallowed ; wounds or irritation of the stomach from swallowing a bone, needles, broken glass, &c.; larvae of insects introduced into the stomach, or generated there ; the transmission of an electric shock through the region of the sto- mach. (Sauvages, Nosol. Method. Frank, de Curand. Homin. Morbis, lib. v. part ii. p. 204. Edin. Med. Jour. vol. vii. p. 326. Percival's Es- says, vol. ii. p. 183.) Corrosive poisons are well known to induce vomiting of blood. Other acrid substances will probably have the same effect; and thus drastic purgatives and emetics are included in Frank's list of causes, but perhaps only from theoretical considerations. The effort of vomit- ing, and other violent strains and exertions, as the expulsive efforts in parturition, (Frank,) are sup- posed to have produced haematemesis. It is also a well-known effect of severe blows on the epi- gastric region. The constitutional causes are those which, by some effect, not always easy of explanation, on the sanguiferous system, produce congestion in the vessels of the mucous membrane of the sto- mach, or a tendency in the blood to escape from them. Violent, and especially strongly concen- trated mental emotions, as grief, anger, or terror, are undoubtedly exciting causes of haematemesis, though probably only in the predisposed. In some malignant fevers, in scurvy, and in purpura, haematemesis occurs as a symptom, evidently from a constitutional cause. But the most frequent in- stance of such a cause operating in the induction of haematemesis, is, where it results from the sup- pression of some natural or habitual evacuation, especially of the catamenia in females, and of the hemorrhoidal discharge in either sex. The con- nection of haematemesis with amenorrhcea has been remarked ever since the time of Hippocrates; and there appears to be no just ground for the de- nial of this connection by Dr. Hamilton, in his work on Purgative Medicines. Haematemesis very commonly supervenes on a suppression, from whatever cause, of menstruation already estab- lished, and which had hitherto observed its regular periods. In other cases it is related to have at- tended upon retention of the menses, (Frank, op. cit. p. 206,) but such instances are comparatively rare. (See Amenobiihcea.) Symptoms. — The attack of haematemesis is sometimes unattended by any premonitory signs, the vomiting of blood being the first morbid symptom which occurs. But more frequently it is preceded by symptoms similar to those which precede ordinary vomiting: anxiety, faintness, a sense of weight and distension, sometimes amount- ing to dull pain in the epigastric region ; and dis- tressing nausea. The pulse is frequent, but com- monly small and weak; and on inquiry it will be found that the bowels are costive. Sometimes there is general chilliness, with particular coldness of the extremities, vertigo, impaired vision, and ringing in the ears; but several of these symp- toms ought, perhaps, rather to be considered as indications that internal hemorrhage has actually taken place, than as precursory signs of its occur- rence ; for rejection of the effused blood by vomit- ing does not ensue, until either by its quantity or stimulus it excites the stomach and abdominal muscles to contraction. (Chomel, Dictionnaire de Medecine, tom. x. p. 555.) The blood is then brought up with considerable violence in succes- sive fluid gushes, or partly in solid coagula. Sometimes a single large coagulum is brought up, in fact a mould of the stomach. The quantity rejected by vomiting is always considerable, being seldom less than eight or ten ounces, and some- times amounting to several pounds. It is highly probable that hemorrhage from the stomach may take place in smaller quantity; but then the blood passes off by the pylorus without giving rise to vomiting. The blood is of various shades of co- lour, from a deep red to nearly black, according to the shorter or longer time that it has sojourned in the stomach, and probably from other causes. It is not to be supposed that when the blood is i dark-coloured, it is necessarily the result of venous HAEMATEMESIS. 359 hemorrhage. This was pointed out by Areteeus; and it is well known that the fluid, and especially the gaseous contents of the stomach and intes- tines, will impart a dark colour to blood which remains for any time mixed with them. When there has been a sufficient delay for separation of the constituent parts of the blood to take place in the stomach, membranaceous or polypus-like con- cretions of fibrin are occasionally brought up along with the blood. (Frank, op. cit. p. 202. Diet, de Med. loc. cit.) It is often mixed, as might be ex- pected, with alimentary matters, with bile, or with the mucous secretions of the stomach. Most commonly blood is vomited only once in the course of a single accession of hemorrhage ; but sometimes a repetition of the vomiting occurs after a short suspension. After the vomiting has subsided, the accompanying symptoms commonly cease, leaving the patient in an exhausted state, with a cold surface, pale countenance, and gene- rally considerable mental agitation and alarm, especially in a first attack. Actual syncope, as Frank has noticed, not unfrequently ensues.— Part of the effused blood usually passes the py- lorus, and after a few hours produces slight tor- mina and distension in the course of the intestines, followed by two or three dark-coloured and offen- sive stools, resembling those in melaena. This appearance of the alvine discharge will continue for twenty-four or sometimes forty-eight hours. Death has very rarely directly ensued from the loss of blood in an attack of haematemesis ; but the repeated attacks of this hemorrhage have ne- cessarily a tendency to weaken the constitution, particularly when it is not of a vicarious charac- ter. Sometimes after a single attack there will be no recurrence of hemorrhage ; but more com- monly, as we have already observed, a predisposi- tion to its return is induced, and it will after some interval reappear either spontaneously, or on the application of some exciting cause; or it will as- sume a periodical or chronic form, according to the nature of the local, constitutional, or organic cause by which it is kept up. From the above account of the causes and symptoms of haematemesis, it will appear that it has generally the character of a passive hemor- rhage. Sometimes, however, it occurs in indivi- duals of vigorous constitution, is attended with symptoms indicative of increased impetus of the circulation, and puts on the type of active hemor- rhage. This distinction is not always very clearly marked, but it is highly deserving of attention, with a view to the treatment. Haematemesis has also been divided into idio- pathic and symptomatic; but these epithets have been used by different writers in widely different senses. The most important practical distinction is that derived from the several predisposing and exciting causes, and states of the constitution which give rise to the hemorrhage. These it is always highly important to ascertain. Pathology.—As the general doctrine of hemor- rhagic diseases will be developed in another place, (see Hemorrhage,) we shall confine our present inquiry to those circumstances which are peculiar to this individual disease. Haematemesis, when unconnected with organic lesions, so very rarely proves fatal, that anatomi- cal investigation has thrown but little light on the state of the stomach and its mucous membrane in this disease. Frequently no morbid appearance whatever can be detected in patients who have died very shortly after profuse hamatemesis. In other cases, redness of the mucous membrane could alone be discovered ; but this may be the effect of simple infiltration of blood, while in other cases it may denote a congestive, or even an in- flammatory state of the mucous membrane, which has caused the haematemesis. In some of the dissections recorded by Morgagni and Portal, the stomach and other viscera, after profuse haemate- mesis, were found remarkably pale. Some ob- servers have recorded a dilatation of the venous and arterial branches supplying the stomach as a common appearance after death from haematemesis, and the veins ramified on the internal surface of that organ have been even described as in a vari- cose state; but these allegations are destitute of adequate proof. In those cases of haematemesis which are con- nected with organic affections, whether of the circulating system or of the abdominal viscera, the appearances proper to these diseases will of course be met with after death. Where the hae- matemesis has arisen from organic disease of the stomach itself, it has commonly been supposed that it was the consequence of ulceration, pro- ducing the rupture or erosion of one or more blood-vessels. Such cases, no doubt, are occa- sionally met with; but it is no less certain that scirrhus of the pylorus often proceeds to extensive ulceration without the occurrence of any haemate- mesis ; and on the other hand, as Andral from ample experience assures us, that scirrhous affec- tions of the stomach are attended with repeated haematemesis during their progress, where, on dis- section, no ulceration nor lesion of continuity in the mucous membrane or its vessels is obuervable. (Andral, Pathol. Anat. transl. vol. ii. p. 179.) Haematemesis is, then, an instance of exhala- tion of blood from a mucous surface, analogous to what happens in epistaxis and haematuria, in uterine, and many cases of pulmonary and bron- chial hemorrhage. The causes which occasion this exhalation are referred by Andral to four heads:—1, a mechanical obstacle to the return of the venous blood through the system of the vena porta;;—2, irritation of the mucous membrane of the stomach ;—3, sanguineous congestion, not re- ferrible to either of the former heads ; — and, 4, certain states of the blood itself, in which it is so changed as to have a universal tendency to escape from its vessels. (Pathol. Anat. transl. vol. ii. p. 179.) Mechanical congestion is instanced (1.) in those cases of haematemesis which depend on enlarge- ment cr induration of the liver, and sometimes also of the spleen or pancreas, in consequence of which the trunk or branches of the venae portse are more or less directly compressed, and the re- turn of the blood from the stomach impeded ; hence congestion in its vessels and haematemesis ensue. (2.) In cases depending on obstructed circulation from organic disease of the heart, and more especially from morbid alterations in itt valves, or dilatation of its cavities, in consequence of which the return of blood by the vena cava :* 3C0 H.EMATEMESIS, impeded, and general venous plethora is induced. (Ibid. vol. i. p. 64.) Such a state is now well ascertained to be a frequent cause of hemorrhage, especially from the lungs, the stomach, and the uterus; and its existence is a circumstance de- serving the most careful attention of the scientific practitioner. Irritation of the mucous membrane is the di- rect cause of the haematemesis arising from corro- sive poisons and other acrid substances. To simple congestion we must, in the present state of our knowledge, refer all those cases of haematemesis which are considered as idiopathic, including those which are vicarious, or auxiliary of suppressed or diminished menstruation, &c. " The blood," says Andral, " accumulates in some part of the mucous membrane, and escapes from its vessels, which is all that we can discover." The subject of morbid changes of the blood, will be discussed in other parts of this work. (See Blood, Purpura, Scurvy.) Andral instances, as cases where haematemesis results from this cause, "certain cases of poisoning by absorption," typhous fevers, and the black vomit in yellow fever. Diagnosis. — Haematemesis is in general easy to be recognised by the symptoms already enu- merated. It is occasionably liable to be confounded with haemoptysis. " It may be certainly known," says Cullen, «that the blood proceeds from the stomach, and not from the lungs, when it is mani- festly brought up by vomiting, and not by cough- ing ; when the vomiting has been preceded by some sense of weight, anxiety, and pain in the re- gion of the stomach ; when the blood brought up is of a dark and grumous appearance ; and when it is manifestly mixed with the contents of the stomach." (First lines, § 1017.) When, also, cough and the other local and con- stitutional symptoms of pulmonary hemorrhage are absent, we may in general safely conclude the case to be haematemesis. There are, however, se- veral circumstances which may tend to perplex the diagnosis. Cough and vomiting will materi- ally excite each other, and when they jointly oc- cur, it may not be easy to decide which is the pri- mary symptom and by means of which of them the blood is brought up. In very profuse haemop- tysis the muscles of the thorax will sometimes contract convulsively, so as to send forth the blood in successive gushes, closely resembling what takes place in true vomiting of blood ; or the blood brought up by coughing may tickle the fauces, and excite actual vomiting. On the other hand, blood brought up by vomiting may be driven back into the glottis, and excite violent cough. We must also recollect, in order to guard against all error in diagnosis, that the blood, though actually vo- mited up from the stomach, may be originally de- rived from a different quarter, as in the case of aneurism already adverted to, or where blood pro- ceeding from the fauces or posterior nostrils has been swallowed during sleep, or is transmitted from a vomica in the lung by a fistulous canal into the oesophagus, as in a remarkable case related by Dr. Mackintosh. (Practice of Physic, vol. i. p. 186.) Hemorrhage from the stomach, as has been already mentioned, does not necessarily imply the rejection of the blood by vomiting; for in the first place the. quantity of blood exhaled into the cavity of the stomach may be so inconsiderable as not u excite vomiting, and pass off by the intestines; and, secondly, in very debilitated states of the con- stitution, the relative loss of blood may be such as instantly to destroy life, before any vomiting has taken place. This chiefly occurs in cases of ul- ceration of the stomach, which organ is found al- ter death distended by an enormous coagulum. Such cases are not of very rare occurrence. The diagnosis of haematemesis is not complete for practical purposes until we have endeavoured to ascertain to what specific cause the hemorrhage is to be ascribed, and whether it be idiopathic or symptomatic, connected with organic lesion or simply with deranged function, and whether it partakes of the character of passive or active he- morrhage. Attention is therefore required to what has been pointed out on these several heads. Prognosis. — Haematemesis is always a dis- ease of formidable and alarming appearance, from the quantity of blood which is lost, and the deli- cacy and importance of the organ concerned. Ex- perience, however, instructs us that in many cases it is attended with little danger. Haematemesis which is vicarious or supplementary to menstruation is usually a very manageable complaint; though we cannot go so far as some of the older authors, who considered it as absolutely salutary, and not to be interfered with. (Salmuth, Langius, Zacu- tus Lusitanus, &c. See Diet, des Sciences Me- dicates, vol. xx. p 100.) Where, on the other hand, it is not imputable to suppressed evacua- tions; where it t-hows a tendency to assume a chronic form; where it is attended with fever or indications of organic lesion; haematemesis is a disease of considerable danger, and very difficult of cure. Treatment. — The treatment of haematemesis divides itself into three heads: — 1. prophylactic measures ; 2. those proper at the time of an at- tack; 3. those suitable in the intervals, or after the hemorrhage has subsided. 1. When warning is given of the approach of an attack of haematemesis by any of the precursory symptoms already noticed, it will be proper to have recourse to timely preventive measures, and espe- cially to prescribe rest and the antiphlogistic Tegi- men, cooling drinks, warm pediluvia or fomenta- tions to the extremities, saline or other purgatives, and, if indicated, the abstraction of blood. Small bleedings have been particularly recommended a day or two before the time at which the catamenia ought to recur, if it is apprehended that Ihey will be replaced by haematemesis. 2. The attack of haematemesis must be met by remedial measures of the same kind as those which are suited to hemorrhagic diseases in general; and their use must be modified by the character of the hemorrhage, the symptoms by which it is accom- panied, and the causes which appear to be con- cerned in its production. If there are clear indications that the hemor- rhage is of an active or inflammatory character, venesection must be promptly resorted to, and fol- lowed up by purgatives and a strict antiphlogistic regimen. If, on the contrary, the disease puts on a passive or asthenic character, and the constitu- tional powers evince a tendency to sink rapidly, we must have early recourse to the most effica- HAEMATEMESIS. 361 cious astringent remedies, and support the strength by mild but invigorating nourishment, and even cordials, given in small quantities, but frequently. In cases of an intermediate nature, the judicious combination and modification of these two plans of treatment demands the discrimination and skill of the practitioner. Thus it may be necessary to reduce local action by leeches, cupping, and mild laxatives, while proper dietetic means are resorted to to support the strength. In all cases the most perfect mental and bodily tranquillity must be enjoined, and the patient strictly confined to the horizontal posture, in a cool and well-ventilated apartment, and with as light coverings as possible. Castor oil, the neu- tral salts, or more active purgatives, are to be ad- ministered according to circumstances; or where the irritability of the stomach forbids their use, laxative clysters must be resorted to, to secure an open state of the bowels. Cold liquids, as lemon- ade, almond emulsion with nitre, or the super- acidulated infusion of roses, may be given fre- quently in small quantities, as a tea-spoonful or dessert-spoonful at a time. In cases where the hemorrhage is so profuse and violent as to threaten serious consequences, more active measures must be resorted to; and none is so deserving of confidence as the free ap- plication of cold, which is the most efficacious of all astringents, by diminishing the calibre of the blood-vessels and lessening the impetus of the cir- culation. We must, therefore, not only give the liquids just mentioned, cooled down to 32° by ice or a freezing mixture, but may with great advan- tage inject iced water into the rectum, and lay bladders filled with pounded ice on the epigastric region. A very interesting case is related by Michelotti, in the Philosophical Transactions for 1731, in which a young gentleman affected with enlarged spleen, and previously subject to epis- taxis, was cured of a second attack of profuse hae- matemesis, in the winter season, by drinking ex- cessively cold water, and taking alimentary liquids iced. The quantity of blood vomited in the space of two hours is said in this case to have amounted to twelve pounds and upwards. By means of oc- casional small bleedings, a fresh attack was averted for two years, at the end of which period the he- morrhage recurred, and was again subdued by the same means. In the remarks appended to this case, the author cautions us against resorting to this powerful remedy in asthenic or dyspeptic in- dividuals, but strongly advises its use in young ind vigorous constitutions, and in the active form of hemorrhage.* [Certain of the saline preparations, as super- sulphate of magnesia, potassa or soda, which may be formed extemporaneously, (Magnes. sulph. Jiii; Acid, sulph. dil. gtt. xxx ; Aqux f.gvj. M. Dose one quarter four times a day,) by coming in contact with the vessels that pour out the blood by rupture or transudation, arrest the hemorrhage by their stringent action, and are thus both astrin- gents and revellents; whilst by their cathartic agency they, at the same time, remove from the * Philosophical Transactions, vol. xxxvii. p. 129.— Ploucquet refers to two cases cured "gelidissimo potu ;" —1. Act. Nat. Curios, vol. iii. obs. 61; 2. Commerc. Li- ter. Noric. 1732, pp. 294, 351, 381. 2f intestinal canal any effused blood that may have passed into it from the stomach. In cases, too, of haematemesis that are dependent upon amenor- rhoea, the cathartic may act beneficially by con- tiguous sympathy, on the torpid uterus.] It is, on the contrary, in the passive kind, and in relaxed and languid subjects, or where the im- petus of the circulation has been already reduced by venesection and antiphlogistic measures, that the vegetable and mineral astringents may with safety and advantage be employed. In haemate- mesis we have the great advantage of applying these remedies directly to the seat of the hemor- rhage ; and, therefore, they may be the more relied upon. Preparations containing gallic acid, such as Ruspini's styptic, (which Dr. A. T. Thomson has ascertained to be a solution of this acid in di- luted alcohol,) are probably the most useful of the vegetable astringents. But no remedy of this class deserves so much confidence in passive he- morrhage as the acetate of lead given in combina- tion with opium, and in such large doses and at such frequent intervals as to secure its effect. (See Astringents.) Dr. Elliotson, who strongly ad- vocates the free employment of this remedy, also mentions, as one from which he has derived great benefit in haematemesis and malaena, the oil of tur- pentine, in doses of twenty drops, repealed every three hours. (Elliotson's Lectures, Medical Ga- zette, vol. ix. p. 525.) Subnitrate of bismuth, in conjunction with opium, has also been recom- mended. 3. After the hemorrhage has subsided, or in the intervals of its occurrence, we must endeavour to obviate its return by removing or weakening the exciting causes, and counteracting the predisposi- tion to the disease. A strict regulation of the diet, (passing very gradually from the mildest liquids to more nutritious food,) rest, quietness, the hori- zontal posture, cooling and astringent beverages, will be proper for several days after the hemor- rhage has ceased. The bowels must be kept pro- perly open by the gentlest and at the same time most effectual means ; and there can be no doubt that the recommendation of clysters, to clear the intestines of the blood lodged in their course, so much insisted upon by continental physicians, is a judicious and salutary practice. We cannot, however, in this country, go along with them in their unanimous and strong condemnation of pur- gatives in every case of haematemesis, at least of such as are more active than manna, cassia, and tamarinds. " Quae vi alvum movendi majore in- structs sunt, ea," says Frank, " cane pejus et angue vitanda sunt." (Op. cit. p. 221.) And other continental writers, from Hoffmann down to Pi- nel, are not less explicit in their reprobation of ac- tive, and especially aloetic purgatives. (See Diet des Sciences Med. tom. xx. pp. 120, 121.) Bri- tish practitioners, especially since the publication of Dr. Hamilton's treatise, (Observations on Pur- gative Medicines, Edinburgh, 1805,) have placed great confidence in active purging as the best mode of treatment in many cases of haematemesis, more particularly in that form of the disease which oc- curs in young and middle-aged females, and iii connected with uterine torpor and a sluggish ac- tion of the bowels. In such cases Dr. Bateman states as the result of his experience, that the sue- 362 HAEMATEMESIS. cess of Dr. Hamilton's mode of treatment is more decidedly conspicuous than in any other disease in which he has recommended it. (Reports on the Diseases of London, p. 150.) It is remarka- ble that the benefit of the purgative plan of treat- ment is not confined to sanguine and plethoric subjects ; it is not less signal in chlorotic and leu- cophlegmatic habits. It is, however, to female cases exclusively that the observations of Hamil- ton and Bateman apply; and there can be no doubt that the inconsiderate employment of active purgatives in cases of haematemesis or melaena oc- curring from wholly different causes, especially in constitutions exhausted by excess, or debilitated by the progress of organic disease, would be highly pernicious. In such cases certainly the more cau- tious procedure of our continental brethren is to be commended. With regard to the restoration of the menstrual function where its suspension gives rise to haema- temesis, the means by which this is to be accom- plished are rather such as act by removing a con- dition of the general system unfavourable to regular menstruation, than by the employment of specific emmenagogues. If, therefore, the amenorrhcea depend on vascular fulness, we resort to bleeding and suitable purgatives; if on uterine torpor and a chlorotic state, the warmer aperients and tonics, especially the preparations of iron, are to be em- ployed. (See Amenorrhea, Chlorosis, and Emmenagogues.) To complete the recovery of the convalescent from the various forms of haematemesis, tonic medicines, a suitable diet, exercise, change of air, and sometimes the use of chalybeate mineral waters, will be highly serviceable. But it is not necessary to protract this article by dwelling on these familiar topics. Freedom from care, anxiety, and causes of mental irritation, is of the highest importance in all cases, and especially where we have reason to believe or suspect the existence of organic dis- ease. In such melancholy cases the utmost that our art can aim at is to palliate suffering, to ward off the recurrence of hemorrhage, and to protract to the utmost that fatal event which the resources of medicine, however skilfully wielded, cannot hope to avert George Goldie. HAEMOPTYSIS, from alpa, blood, and nrvms, spitting.—Were it taken in the full latitude of its etymology, the word haemoptysis would embrace every discharge of blood from the mouth, without regard to the sources from whence it originally proceeds; but as the sources are various, use has annexed to the term a more limited signification, restricting it to expectoration of blood, or that which originally issues from the respiratory organs. This view of the subject has suggested to some the propriety of substituting the term pneumor- rhagia, as more definite and precise in its signifi- cation. We, however, do not recognise, in the proposed substitution, advantages sufficient to counterbalance the evil of disturbing a well-estab sputa. Still we prefer the general term haemo- ptysis taken in its conventional signification. If there be no subject within the extended field of pathology upon whose precise nature the ad- vancement of anatomical knowledge has thrown more light than hemorrhage, there is unquestion- ably no organ in the body that has derived more benefit from this circumstance than the organs subservient to respiration, which, both from their organization and from the nature of their functions, are more frequently than any other the subject of hemorrhage. The term hemorrhage, (alpotfayta, from atp.a, blood, and ptjywpi, to break,) carries upon its face evidence of the imperfect views which prevailed respecting the real nature of this morbid pheno- menon, implying rupture of a vessel to be its es- sential cause; but experience, so far from estab- lishing this as a general cause, has proved it to be of very rare occurrence, even under circumstances which we should have supposed most likely to produce such a lesion. This pathological enrol has been kept up in the application of the expres- sion " bursting a blood-vessel." Speculation and vague hypothesis filled up the imperfect measure of information upon this important pathological subject, until the invaluable labours of Bichat re- deemed it from error, and placed it in its true light In explaining the phenomenon of exhalation, he has shown that it is effected through the instru- mentality of a system of vessels which are con- tinuous with the arteries, namely, the capillaries; that these vessels enter into the composition of all our organs; that they become elements of the several tissues of the body ; and that their function consists in separating from the blood a fluid pe- culiar to the tissue of which they form part. Thus the mucous exhalants separate mucus, and the serous serum; and as long as these vessels con- tinue in the unimpaired enjoyment of their vital properties, so long they only admit the colourless fluids, and refuse entrance to the red particles of the blood ; but should these properties be so affected, either directly or sympathetically, that they are either altered or impaired, (changes to which they are especially subject from their being more under the influence of-the nervous system than any othef portion of the vascular apparatus,) they no longer retain this power of closing themselves against the entrance of red blood. In one case they as it were solicit the presence of this fluid, and in an- other yield to its forced entrance; in the formei instance giving rise to active, in the latter to passive hemorrhage. Between the first of these morbid conditions and inflammation the closest analogy exists: they recognise the same causes; occur most frequently in the same tissues; have often the same symptoms and terminations; and not unfrequently pass into each other. These considerations lead to the conclusion that the disposition of an organ to hemorrhage is in a ratio compounded of the development of the ex- halant vessels in that organ, and of their exposure to the operation of causes capable of producing lished name. Were we disposed to make any those changes in their properties upon which he- change, it would be to divide the subject into pul- morrhage, whether active or passive is found to monary hemorrhage and haemoptysis; the former depend. Applying this to the lungs, we have a expressive of the more profuse discharges of blood, ready and satisfactory explanation of the frequency *he latter of the smaller quantities discharged as ( of pulmonary hemorrhage. These organs com- HAEMOPTYSIS. 383 bine in themselves every condition favourable to the production of this morbid phenomenon, both in its active and passive form : 1. a considerable extent of mucous membrane, the tissue the most richly furnished with exhalant vessels of any in the animal economy ; 2. the constant and imme- diate relation of this tissue with the atmosphere,— a source of irritation not only from the variations of temperature of which it is so susceptible, but also from the different impregnations with which it is continually charged; 3. a loose spongy pa- renchyma traversed by numerous blood-vessels of every dimension, freely communicating with each other; 4. the proximity of these organs to the heart, and consequent exposure to the effects of every irregular motion of this organ; 5. the con- tinued motion which the exercise of their own functions entails upon them. In order to appreciate the disposition of the lungs to hemorrhage still further, we shall briefly glance at the two systems of blood-vessels which traverse them, viz. the bronchial or proper nutrient vessels of the organs, and the pulmonary vessels, whose office consists in the transmission of the blood through the lungs, for the purpose of its undergoing the proper chemical changes to fit it for its several uses. The bronchial arteries are distributed to all parts of the lungs. Their trunks follow the course of the bronchi, and, sending off twigs to all the branches given off from the bronchial tube, accom- pany them to their ultimate termination. These nu- merous blood-vessels, after embracing the bronchi, penetrate their coats, and are spread out upon their mucous surface into an incredible number of capil- laries. In addition to these branches supplying the bronchi, the bronchial arteries send lateral branches to all other parts of the lungs, which, passing into the tissue of the organ in connection with numerous branches of the pulmonary artery and pulmonary vein, constitute a fine network made up of innumerable capillaries freely anastomosing with each other. The pulmonary artery, after it has pursued the bronchi to their termination, sends branches to each vesicle; and these branches, anastomosing on all sides, are spread out upon the vesicles. This artery gives off vessels which, pursuing a tortuous course between the air-cells, proceed to take their share in the composition of that net- work of vessels to which we have before adverted as made up of the ultimate ramifications of the bronchial and pulmonary arteries and pulmonary vein. Through the medium of these vessels, an injection thrown into the bronchial artery fills the pulmonary artery also, though its passage from the latter into the former is much more easy. The pulmonary veins, made up of branches collected from all points to which the bronchial and pulmonary arteries carry the blood, conduct this fluid back to the heart, pursuing their course along the bronchi and their branches in the same way as the pulmonary artery. These anatomical details explain to us, so to speak, the machinery of pulmonary hemorrhage, and enable us to understand the mode of opera- tion of the many and different causes which pro- duce this morbid phenomenon. They exhibit to us such a freedom of communication existing be- tween all the blood-vessels of the lungs, that any derangement of either the general or pulmonic circulation is competent to give rise to it. In cer- tain excitements of the general circulation the blood will be impelled through the bronchial ar- tery, proceeding from the aorta, into the smaller vessels which are spread upon the bronchial mu- cous surface, and from them into the bronchial tubes. Should the derangement be more particu- larly confined to the pulmonary circulation, as in case of hypertrophy of the right ventricle of the heart, the blood will then be driven into the sinall branches of the pulmonary artery which are dis- tributed to the parenchyma of the lung, and being exhausted there, will constitute hemorrhagic en- gorgement or pulmonary apoplexy; and, should the impetus be considerable, its effects will be ex- tended to the communicating bronchial branches, from whence the blood will be poured into the bronchial tubes, giving rise to bronchial hemor- rhage.—See Apoplexy, Pulmonary. We are now prepared to understand a circum- stance to which we shall have occasion to advert when we come to speak more particularly on the subject of pulmonary apoplexy. Although this affection generally consists in the extravasation of blood into the parenchyma of the organ, and of haemoptysis more or less extensive at the same time; still this latter phenomenon may be altoge- ther absent, and the hemorrhagic engorgement (which is really the essence of the disease) alone be present. In fact, we regard the addition of the haemoptysis as a mere accident, though a measure of the intensity of the cause which has given rise to the hemorrhagic engorgement; and we readily account for its frequency by the facility with which an injection is found to pass from the pulmonary into the bronchial artery. The communication which we observed to exist betweeri the pulmonary vein and pulmonary and bronchial arteries, fur- nishes us with the rationale of haemoptysis de- pendent upon particular lesions affecting the left side of the heart. Thus, from a narrowing of the communication between the left auricle and ven- tricle, the pulmonary vein is prevented emptying its blood into the auricle; and as it is the channel into which the pulmonary and bronchial arteries empty their contents, the effects of its congestion are necessarily felt in these arteries. Besides, the remora of the blood in the lungs opposes a resist- ance to the efforts of the right ventricle to drive its blood through the pulmonary artery and lungs, and demanding increased efforts of this ventricle, occasions its contents to be thrown with unusual force into the minuter vessels of the pulmonary artery, and the communicating minute branches of the bronchial artery : it is in this way that wo explain the frequent haemoptysis in this particular lesion of the heart. From the foregoing observa tions it is obvious that the blood-vessels of tho lungs font! a circle; and that haemoptysis may le- sult from derangement of the circulation affecting any part of it. Though there is no period of life which can be strictly said to be exempt from haemoptysis, still it is so much more frequent from the age of fifteen to thirty-five, that this has been considered its proper season. This is the period when the energies of the system seem to converge towards the orgau.« 364 HAEMOPTYSIS. of respiration; and when are developed between them and distant organs those sympathies upon which their susceptibility to certain diseases would seem to depend. This is the period when phthisis strikes its victim; and when we come to speak more in detail of the particular lesions of the lungs which give rise to haemoptysis, we shall see how often it occurs as a symptom of this disease. Haemoptysis sometimes comes on quite sud- denly, and without any premonitory announce- ment. It is, however, in general preceded by chilliness of the skin, lassitude, alternating pale- ness and flushing of the face, headach, palpitation of the heart, and strong vibrating pulse. To these may be added what we may term the local symp- toms, consisting of a painful sensation of weight and tension, and of heat and itching in all or in some part of the chest, with dyspnoea, and a sense of anxiety about the praecordia: these symptoms are due to the congestion which immediately pre- cedes the effusion of blood. Other symptoms are enumerated, which are in reality owing to the blood already effused into the parenchyma of the organ, and into the bronchial tubes. Among these the most remarkable are a sense of ebullition in the chest, (a feeling produced by the mixture of blood and air from the successive movements of inspiration and expiration,) and a great increase of dyspnoea. When blood is effused into the air-passages, the irritation it produces causes cough, which de- termines its expulsion ; and when the effusion is considerable, (which it is sometimes, to the degree of producing an urgent sense of suffocation,) the muscles of expiration contract almost convulsively, the lungs are compressed, and the blood is expelled with violence through the mouth and nose. Some- times some of it, passing into the stomach, excites vomiting and is rejected with the contents of this organ ; a circumstance which may embarrass our diagnosis as to the original source of the hemor- rhage. Haemoptysis varies considerably in the quantity of blood discharged. Its extent is sometimes so great that we wonder how it can take place, and not extinguish life ; still we see the same quantity discharged again and again at intervals not very long distant, and this go on for months, nay for years, and the subject of it ultimately restored to the enjoyment of perfect health. At other times, we regard with alarm even the appearance of ex- pectorated blood, when we have reason to look upon it as the index of deeper mischief latent; a single sputum tinged witn blood will then bespeak more danger than a loss, frightful in quantity, under different circumstances. From this we may conclude that the extent of the haemoptysis is not in all cases an exact measure of the amount of danger; and that in general its importance is derived from the circumstances under which it takes place. We should be acquainted with the appearances present*™ ny expectorated blood, as a circumstance to guide our diagnosis. When it is not in consi- derable quantity, it is generally frothy or mixed with air, and of a vermilion or arterial colour; if it be considerable, it is not frothy, but has the arterial colour. These appearances, however, are not sufficiently constant to enable us to rest our judgment on them alone; we must have recourse to other signs and symptoms, both positive and negative, before we deliver our opinion in doubtful cases. Among the constitutional symptoms of haemop- tysis, some depend upon the actual loss of blood; others are due to tht alarm or nervous shock pro- duced by this phenomenon, which is so often associated with circumstances of danger. In this way alone can we explain the exanguious appear- ance, the tremour, the hurry of the circulation, the irregular action of the heart, the fainting which we find so often to follow the loss of even a mo- derate quantity of expectorated blood. We con- stantly observe a loss of blood apparently trifling produce more disturbance in a nervous delicate person, than a very considerable loss will do in one of a strong vigorous constitution : in fact, fright and hemorrhage have precisely the same physiological operation, and give rise to the same phenomena. Haemoptysis is the consequence either of con- gestion of the lungs, (whether caused by the blood thrown upon these organs with unusual force, or by its remora in them,) or of some lesion of those organs: we shall therefore consider it under these circumstances respectively. When we reflect upon the organization of the lungs, we cannot wonder that they should often be the organ through which nature relieves her- self from a state of morbid plethora; especially should that state depend upon the suppression of a hemorrhage which ordinarily takes place from an organ between which and the lungs a sympathy is known to exist. Physiology has ever recognised a remarkable sympathetic relation to exist between the organs of respiration and the uterine system; in virtue of which the lungs (especially when possessed of any particular susceptibility of disease whether natural or acquired) seldom remain long unaffected, should there be any interruption to the development or regularity of the functions of the uterus. This is the most fertile source of haemop- tysis, independent of organic lesion of the lungs. In some of these cases we find the htEmoptysis anticipating the period of the establishment of the menstrual discharge, and entirely ceasing when this discharge has been fully established. In other cases we find the haemoptysis altogether super- seding this discharge, usurping its regular periodi- cal appearance, and establishing itself into a func- tion, so connected with the health of the system as to require much caution to be observed in in- terfering with it. Again,—and which is the most common case,—the haemoptysis is a supplementary discharge, making up for the deficiency of the menses : in these instances nature seems to make an effort to establish the due order of her func- tions ; pains in the back and loins are felt at the same time as a sense of weight and tightness in the chest, with oppressed breathing; upon these follow a mere appearance of the menstrual dis- charge, and a more profuse discharge of blood from the chest. This state of things will some- times continue till the period of life when the menses usually cease, with no more inconvenience than the occasional oppression caused by the con- gestion which precedes the haemoptysis. Hoff- HAEMOPTYSIS. 365 mann mentions a remarkable case in which the haemoptysis usurped the place of the menses : the subject of it became pregnant, the haemoptysis was then suspended, and reappeared after deli- very, and continued for many years. Suppression of the hemorrhoidal discharge will give rise to haemoptysis. Between this and the haemoptysis connected with suppressed menses, Laennec makes the distinction that the former occurs as pulmonary apoplexy, and the latter as bronchial hemorrhage. This hemorrhage exhibits the same tendency to return as the discharge which it has superseded. Masson (Dissertation sur FHemoptysie) records a remarkable case where the haemoptysis, which succeeded a sus- pended hemorrhoidal discharge, returned regularly every month for a year, although the original dis- charge had not observed the same periodical regu- larity. Haemoptysis occurs sometimes, though rarely, as a critical discharge. Nature, in directing her critical efforts to other organs in preference to the lungs, would seem as if she respected these organs in consideration of their importance, and of the danger that might result from their being the sub- ject of hemorrhagic congestion. Any circumstance, which, by interrupting the balance of the circulation, throws an unusual quantity of blood upon the lungs, may act as a cause of haemoptysis. It is thus that the bent position of the body, which certain trades require, acts. Tailors are, for this reason, much subject to this affection: their constant sitting posture, with the body bent and head leaned forward, and with the abdominal viscera so compressed as to admit a less than natural quantity of blood into them, favours an unequal distribution of this fluid, which is directed in an undue proportion towards the lungs, and produces in them a local plethora, a frequent result of which is haemoptysis. Malformation of the thorax, by compressing the lungs, and thus interfering with the free exercise of their functions, often causes haemoptysis; a fact already noticed by Morton. Prolonged pressure upon the abdomen by tu- mours, whether solid, fluid, or gaseous, produces haemoptysis, by diminishing the quantity of blood sent to this region, and increasing that which is carried to the chest. In advanced pregnancy haemoptysis is sometimes so considerable as to demand instant delivery. Stoll mentions a case in which haemoptysis came on during ascites : it ceased on tapping, and reappeared on the fluid accumulating again. Tympanitis has been known to be attended with a similar result. Haemoptysis is often caused by a paroxysm of some of the diseases classed under the head of neuroses. Bohn mentions a case of epilepsy, each attack of which brought on a profuse haemoptysis. We have often had occasion to observe the same in paroxysms of hysteria. M. Fougnet, Professor at Montpellier, treated successfully with bark a tertian which was always ushered in by an haemoptysis so considerable that the patient seemed to vomit blood. Low, asthenic fevers, accompanied with pete- chiae, often exhibit this phenomenon. It was much more common in crupftve fevers before Sydenham improved the practice in this class of diseases. 2f* Halter observed, in an epidemic small-pox, that all who were treated upon the cordial heating plan were covered with livid spots, the appearance of which was preceded by pains in the back and chest, and by haemoptysis. Diemerbroeck, in his description of the plague which ravaged Belgium and Germany in the middle of the seventeenth century, mentions the hemorrhagic flux from the nose, uterus, urinary passages, and lungs. Fra- castorius makes the same observation respecting the plague of the fourteenth century. Besides this accidental complication of fever and hemorrhage, authors admit a hemorrhagic fever, in which the fever is as essentially connected with the hemorrhage, as the fever preceding and accompany- ing small-pox is part of that disease. This fever may be either sthenic or asthenic in its type, and the accompanying hemorrhage either active or passive in its character. The most striking feature of sthenic hemorrhagic fever is the full, bounding, vibrating pulse, so characteristic of this morbid condition that by it alone we can almost predict an impending hemorrhage. We have already anticipated our observations upon haemoptysis resulting from congestion of the lungs, the effect of disease of the heart, and ex- plained its frequency in that particular lesion which consists in a narrowing of the communication be- tween the left auricle and ventricle. The following case will illustrate this point. We had under our care, for three years, a young female who laboured under most distressing palpitation, greatly increased by the slightest exertion or motion: the pheno- mena of auscultation left no doubt that the lesion consisted in a narrowing of the left auriculo-ven- tricular opening of the heart. She had repeated haemoptysis, which became more frequent and pro- fuse as she approached death. Examination of the body after death exhibited both lungs gorged with blood ; even the minutest capillaries under the pleura were injected; and there were numerous ecchymosed patches in the cellular tissue subjacent to this membrane. The heart did not exceed the natural size; its right ventricle was both in a state of hypertrophy and dilatation; the left ventricle was smaller than natural; the capacity and mus- cular structure of the left auricle were unusually developed; the communication between the left auricle and ventricle would scarcely admit the introduction of a crow-quill. The pulmonary artery exceeded its natural size; the calibre of the aorta scarcely equalled that of the common carotid. This is the lesion which we shall find to be most frequently the cause of pulmonary apoplexy; a form of hemorrhage to which we shall have occa- sion to advert when we come to speak of the morbid conditions of the lungs which give rise to this phenomenon. Haemoptysis arises no less from moral than from physical causes. Moral causes operate principally in the production of haemoptysis through the me- dium of the heart; in fact, the lungs and heart have such an intimate sympathetic relation, that one cannot be affected without involving the other; so that it is not always easy to determine which has preceded in the order of their derangement There is no organ in the body more subject to dis- turbance of its function from the irregular play of passion than the heart; and whether that passion 366 HAEMOPTYSIS. be of the exciting or depressing character, it is equally capable of producing haemopts sis. These two orders of moral affections act upon the heart as stimulant and sedative agents do ; the former throwing an unusual quantity of blood upon the lungs; the latter, by weakening the impelling power of the heart, giving rise to a stagnation of blood in them. In addition to haemoptysis pro- ceeding from these palpable causes, we sometimes meet with it under circumstances in which we cannot fathom its etiology; when, perhaps, it de- pends upon some particular state of the capillaries, which our imperfect knowledge of this portion of the vascular system prevents our appreciating. One of these mysterious cases is that remarked by Dr. Cheyne in the fifth volume of the Dublin Hospital Reports: the subject of it has had, since 1807, frequent attacks of haemoptysis coming on at variable intervals, but nearer to each other in spring. We have had recent communication with this in- dividual on the subject of his disease, and have been informed that it comes on without any provo- cation, and when at its height returns three or four times in the course of the day : it is not influenced either by rest or by exercise, and does not seem to yield to remedies, but subsides spontaneously. Previous to the attack a sense of constriction is felt in the chest; there is no fever, the pulse not exceeding eighty-four beats in the minute. A system of small bleedings from the arm, adopted at the suggestion of Dr. Cheyne, gave the first check to his disease, and by following it up he is now enabled to engage in the active duties of his profession as a clergyman, and feels no inconve- nience from an unsparing exercise of his voice. We now come to consider haemoptysis in con- nection with actual lesion of the lungs. Unquestionably the morbid condition of the lungs with which haemoptysis is most frequently associated is the development of tubercles : this is a pathological fact universally admitted, though the question whether the haemoptysis, which so often ushers in phthisis pulmonalis, be the harbinger of tubercles, or the index of their actual existence in the lungs, is still sub judice, each opinion reckon- ing among its advocates the highest pathological authorities. Laennec is of opinion that the forma- tion of tubercles precedes the haemoptysis, and that the contrary opinion is founded upon the hasty application of the axiom, post hoc, ergo propter hoc; that though the haemoptysis is the first symp- tom of the disease which attracts notice, still, if the chest be examined before its appearance, there will be evidence of the existence of tubercles; and as haemoptysis often recurs in the progress of the disease, we may conclude that the presence of tubercles is its most frequent occasional cause. He further adds that the mode of their operation in the production of this effect is easily understood, when we consider that they are foreign bodies, which in their development press upon and irritate the parenchyma of the organ ; that, on the other hand, we want a positive fact to prove that haemo- ptysis alone can produce tubercles; nor can we conceive, anatomically, how that can be the case; for if it were so, we should see hemorrhagic en- gorgement transformed into miliary tubercles, a circumstance which he had never observed. Be- tides, he observes, haemoptysis resulting from vio- lence is nothing more than a mere accident, unat- tended by any unpleasant sequelae if properly treated; whereas tubercular phthisis, long latent, often manifests itself immediately after an haemo- ptysis coming on without any appreciable cause, and which has no other cause than the presence of tubercles in the lungs. Andral, in advocating the opinion of the hae- moptysis preceding the formation of tubercles, and being their actual cause, says he has more diffi- culty in conceiving how tubercles, which, accord- ing to those who espouse the former opinion, have the power of irritating the pulmonary parenchyma to the degree of producing abundant haemoptysis, can exist for a long time without causing even a slight cough, than that under causes more or less appreciable some portions of the lungs should be- come the seat of sanguineous congestion, and give rise to haemoptysis. If this congestion exist in one or more points of the lung, and if at the same time the subject be predisposed to tubercles, these bodies may arise easily, and multiply rapidly, in the midst of a part whose nutrition is modified in consequence of the new state in which it is: it is thus that he would explain phthisical symptoms so often following haemoptysis, although well-di- rected treatment will often avert the mischief. Louis thinks that haemoptysis, unless connected with irregular menstruation, or dependent upon external violence, furnishes strong presumptive evidence in favour of the existence of tubercles in the lungs; an opinion sustained by actual obser- vation and the analogy of other organs, in which, when hemorrhage occurs, it is the index of some serious alteration in their structure ; besides, it is natural to suppose that the same cause which pro- duces haemoptysis in the progress of the disease, produced it also in the beginning. We may infer that Broussais is of opinion that haemoptysis precedes the formation of tubercles, from his observation that the loss of blood is not to be considered the direct cause of consumption, but as one of the inflammatory movements which are the sole cause of phthisis. Amidst these conflicting opinions, we hesitate to express a decided judgment, while we admit a bias in favour of that which considers the forma- tion of tubercles to precede the haemoptysis. In the examination of those who have died of hae- moptysis, we have found tubercles, the existence of which was not suspected during life; and we have ever regarded the mode of operation of tu- bercles in the lungs to be precisely similar to that of foreign substances in other parts of the body, each tubercle or cluster of tubercles acting as a nucleus or centre of irritation, and soliciting to the part an unusual flow of blood. In admitting the difficulty of deciding between these opposite opinions, it happens fortunately that the difference carries with it no practical in- convenience, as whichever view be adopted, it in- volves no difference of treatment So frequent an accompaniment of phthisis is haemoptysis, that Louis found it to exist in two-thirds of the cases which fell under his care. Andral observed, that among those that die of consumption, a sixth have never spit blood ; three- sixths or a half never spit blood till pulmonary tu- bercles had given unequivocal evidence of theh Haemoptysis. 367 existence; and in the remaining two-sixths the hemoptysis seemed to precede and be the actual cause of the tubercles. There are three principal sources from whence the blood expectorated in these cases may be de- rived ; either from the mucous membrane of the bronchi, or from a tubercular cavity, or from the parenchyma of the lung. Death is sometimes caused by haemoptysis, when examination can de- tect no other source of it than the bronchial mucous membrane, which, in this case, only exhibits a slight blush, or is even paler than natural. As haemoptysis is found to be more frequent when tu- bercles are in their crude or nascent state, we may account for the repetition of this phenomenon by the successive development of these bodies through the course of the disease, on the physiological principle above noticed, ubi stimulus ibi fluxus. We may perhaps ascribe the frequency of hae- moptysis at this stage of the disease to the ob- struction to the pulmonary circulation caused by the extensive tubercular development in the lungs; this obstruction demands an increased energy of the right ventricle, whereby the blood is thrown with unusual force into the lungs, and hemorrhage is thus produced. This we may expect to be most frequently the case when the tubercles have formed rapidly, and not allowed time for the heart to accommodate itself to this sudden encroach- ment upon the sphere of its operation ; and it would be a more frequent occurrence if the strength of the heart were not weakened by this organ sharing in the muscular atrophy incidental to the disease. The next source of haemoptysis is a tubercular excavation. In several phthisical patients who have died of haemoptysis, there have been found large excavations hollowed out in the lungs, and filled with blood either fluid or clotted : in this case the blood is also found in the bronchi and trachea, and the individual seems to have died of suffocation. It is very common to find the puru- lent matter contained in a cavity tinged with blood. It sometimes happens, though rarely, that the blood in these cavities is poured out from a vessel traversing their sides, in those transverse bands which Laennec has not unaptly compared to the carneae columnae of the heart: these bands consist of an artery, vein, and bronchial tube mat- ted together. The canal of the artery is gene- rally obstructed, although an unhealthy inflamma- tion pervading the pulmonary tissue will interrupt this provision of nature; and the arterial struc- ture, which might almost be said to enjoy an immunity from the effects of inflammation under its ordinary circumstances, will here yield, and admit of an extravasation of blood. The next reputed source of haemoptysis is the parenchyma of the lung. The lesion upon which this depends has, from its analogy with cerebral apoplexy, been designated pulmonary apoplexy. It is thought to depend upon a sanguineous exha- lation into the pulmonary parenchyma, that is, into the air-cells, whose form is represented by the granulir aspect of the surface of a section of a portion of lung affected with this modification of disease. This lesion, consisting of a circumscrib- ed hardening of the pulmonary tissue, is consid- ered oy Laennec, who first noticed the subject, to be the frequent source of these alarming discharges of blood from the lungs which we sometimes meet with. The density of the affected portion of the lung is greater than that which constitutes hepa- tization. The hardened portion, different from that affected with hepatization, presents no trace of the pulmonary tissue, but is of a homogeneous aspect and of a deep black colour, resembling a clot of venous blood. Pulmonary apoplexy would seem to consist in a double lesion, viz. hemorrhagic engorgement and haemoptysis : this latter, though the most striking feature of the disease, is less essential than the other, and may be absent with- out changing the character of the lesion. Expe- rience has established this fact, auscultation recog- nising the engorgement which had not been announced by the ordinarily accompanying hae- moptysis. Nor indeed have we much difficulty in explaining this, if we revert to the observations we made upon the freedom of communication between the pulmonary and bronchial vessels. It is found to occur most commonly from hyper- trophy of the right ventricle ; the effect of which lesion is to throw the blood with unusual force into the capillary vessels of the pulmonary artery. Should that force be considerable, the blood will not only pass into the bronchial capillaries, and thus into the bronchial tubes, giving rise to hae- moptysis in the common form, but may lacerate not only the tissue of the lung, but also its invest- ing membrane, and be extravasated into the cavity of the chest. We can likewise understand how the blood may be impelled with a force only sufficient to fill the capillaries of the pulmonary artery, without that force carrying it on to the bronchial capillaries; in which case we shall only have so much of the lesion as consists in the hemorrhagic engorgement without the haemop- tysis ; whereas, should the influence of this force extend to the bronchial capillaries, ordinary hae- moptysis will be superadded. The external hemor- rhage, then, we do not regard as a consequence of the hemorrhagic engorgement, but as a concur- rent effect of the same cause. There is a species of pulmonary apoplexy in which the extravasated blood forms a coagulum in a cavity hollowed out in the substance of the lung. This is the only lesion which in strictness seems entitled to the designation of pulmonary apoplexy, as being that which alone is analogous to the condition of the brain in the true apoplexy of this organ. In this lesion the pulmonary tissue is lacerated by the blood issuing from its vessels, in the same way as the cerebral tissue is lacerated under similar circumstances. A case of this na- ture fell under our notice not very long since ; the subject of it died of a profuse expectoration of putrid blood; and on examination after death a consider- able quantity of blood in the same state was found in a cavity occupying the entire extent of the right lung. The attack arose from exposure to cold when the individual was in a state of intoxication. The modification of pulmonary disease which Bayle has designated ulcerous phthisis (phthisic ulcereuse), and which is now recognised as gan- grene of the lungs, from the fetor of the breath and expectoration which accompanies it, often gives rise to haemoptysis to such a degree as to cause death. Though this form of disease is some- 368 Haemoptysis, times, nay often, complicated with tubercular developments, the latter are not essential to it; it is, in fact, an unhealthy inflammation of the pul- monary parenchyma, which generally takes place in a bad habit of body, and in its destructive operation respects no tissue. This is the case in which nature seems to neglect her usual precau- tionary measure of obliterating the canal of the arteries, to provide against hemorrhage; these vessels remaining pervious, anu giving way to the disorganizing ulceration, furnishes one of the few instances of hemorrhage arising from actual lesion of the containing canals. A profuse haemoptysis is often one of the first symptoms that ushers in this disease; but in general the patient for some time previously has had a pain in the side, and a teasing irritating cough, his general health much deranged, languor and lassitude, loss of appetite, &c. Amidst these symptoms he is sometimes suddenly seized with haemoptysis so extensive as to extinguish life at the moment; an instance of which is related by Bayle in the first case which he gives of this modification of disease. (Obser- vation 25.) In some cases the haemoptysis has the effect of relieving the system, as it were, from an oppressive load, and the patient feels himself much better after it; but fetid expectoration soon succeeds, and the haemoptysis is repeated at varia- ble intervals, but with the same feelings of mo- mentary relief. This state of things sometimes continues through this often protracted form of disease. Examination after death exhibits the several tissues of the lung indiscriminately in- volved in one general sloughy mass emitting an intolerable fetor. Haemoptysis has no necessary connection with pneumonia; the prune-juice sputa, however, which Andral regards as characteristic of the third stage of pneumonia, owe their colour to the blood, which is mixed with the other matter of expectoration. Bronchitis, especially when it occurs as an epi- demic, is sometimes attended with abundant hae- moptysis. This form of disease seems to differ much from ordinary bronchitis, and to bear some analogy to dysentery ; for as this latter often de- generates into diarrhcea, so the former terminates in an analogous form of disease, consisting in a thin, frothy, abundant expectoration. When bron- chitis thus occurs as an epidemic, it is accompa- nied with a small feeble pulse, great prostration of strength, loss of appetite, languor, lassitude, loaded tongue, and high-coloured urine, &c. It is of the last importance that we be acquainted with the form of disease, and be enabled to recog- nise the haemoptysis as a symptom connected with and dependent upon a serious constitutional de- rangement, and whose treatment merges into that of the constitutional disorder. We have known death to follow a mode of treatment which only contemplated the haemoptysis, and left out of sight iLe more important cause upon which it depended; this seems to be the disease which Stoll designated bilious haemoptysis, and which he treated so suc- cessfully with emetics. Independently of organic lesion of the lungs, haemoptysis may arise from lesion of either the larynx or trachea, and is met with in persons whose profession requires a continued exercise of voice. Haemoptysis, however, from this source has been admitted more from analogy than from actual observation, and seems to rest more upon negative than upon positive evidence ; more upon the absence of the signs of pulmonary haemor- rhage, than upon any unequivocal proof that the blood comes from the larynx or trachea. External injury often produces aggravated hae- moptysis ; thus, violence directly applied to the chest will sometimes be followed by an immediate and abundant expectoration of blood, an effect which is often attributed to an opening of some vessel produced by a fractured bone, which is sometimes one of the consequences of this vio- lence ; but as in many cases the haemoptysis comes on independently of any fractured bone, it must be ascribed to the commotion of the system pro- duced by the violence. The assassin's poniard is the frequent source of fatal haemoptysis. Henry the Fourth of France received two strokes of a knife from the hand of the traitor Ravaillac; he uttered a few words, threw up some blood, and immediately expired. Examination after death discovered two wounds : one, in the left side of the chest, did not penetrate; another, between the fifth and sixth rihs of the same side, penetrated the left lung, and made an opening to the pulmo- nary vein, capable of receiving the point of the little finger : the lungs were black and gorged with blood, and there was much blood effused into the cavity of the chest. Treatment. — Having considered the impor- tant phenomenon of haemoptysis under its different phases, and under the different circumstances both of the constitution and of the organs with which it is connected, we next come to the interesting subject of its treatment; upon which were we to enter as fully as its importance deserves, we should extend this article beyond its legitimate limits, and encroach upon other articles which have to deal with this phenomenon in the relation of a symp- tom of many morbid conditions both of the con- stitution and of the organs from whence the blood proceeds. To the several specific articles upon these morbid conditions we would refer for more detailed information upon this important subject, while our observations partake more of a general character. We have seen that haemoptysis gene- rally occurs either in consequence of congestion of the lungs, or of lesion of these organs : what we shall have to observe upon its treatment will contemplate it under these two modifications of circumstances. Congestion of an organ so important as the lungs must ever be regarded with alarm, and for this reason Hoffmann observes that of all morbid hemorrhages haemoptysis is that which is accom- panied with most danger. Even when it is con- nected with suppression of some habitual dis- charge, and seems to make amends to the consti- tution for the derangement of its functions, it cannot with safety be permitted to continue, but must be met with an uncompromising hand. The treatment of haemoptysis resolves itself into that which is to be employed during an at- tack, and that which is to be pursued in the inter- vals of the attacks, with a view to prevent their return. The character of the hemorrhage, as to its active or passive nature, is the point upon which the treatment hinges. In an attack of ac- Haemoptysis. 369 live haemoptysis, general bleeding, proportionate to the vascular orgasm and to the strength of the individual, must be employed, and leeches should be applied to the chest, or in the neighbourhood of the organ which is the usual vent of the hemor- rhage upon whose suppression the haemoptysis may depend. The auxiliaries to bleeding are de- rivatives or counter-irritants, either internal or ex- ternal. The first include purgatives, emetics, sudorifics, and diuretics ; in fact, all those medi- cines which, exhibited internally, produce a deri- vation to counterbalance the original hemorrhagic movements. The external counter-irritants con- sist of blisters, mustard cataplasms, frictions, ru- befacients, &c. Among the internal derivatives, purgatives of the saline class hold a foremost place; while they determine to the mucous mem- brane of the intestinal canal, they reduce the mass of the circulating fluid. Emetics present the threefold advantage of causing a revulsion, of producing a sedative effect upon the heart, and of determining to the skin. Sudorifics and diuretics also produce a derivative effect (though in a milder degree) by.their action upon organs different from that which is the source of the hemorrhage. Nitre, from its refrigerating properties, has been long regarded as a most valuable medicine in ac- tive hemorrhage: it has been reputed to produce an actual change in the inflammatory character of the blood. Digitalis and acetate of lead pow- erfully co-operate to restrain the violence of the heart's action by their sedative effect upon this organ. Muriate of soda is a popular remedy for haemoptysis, and one whose efficacy we have often witnessed. Acidulated drinks are valuable adju- vants. [In this country, it is very common, during the flow, for the patient to be directed to take common salt into his mouth, under the idea that it pos- sesses haemastatic virtues; but the writer, as he has remarked elsewhere (Practice of Medicine, 2d edit. i. 290, Philad. 1844,) has never had the slightest reason for believing that it has been pro- ductive of any advantage; nor can he see on what principle it has been recommended. After a time, longer or shorter, according to circumstances, the hemorrhage ceases, whether salt has been employed or not; and hence it has probably happened that the result has been ascribed to the salt, when it may have exerted no agency. By M. Andral (Cours de Pathologie Interne) it is referred to as a remedy employed in Philadelphia. It is important, however, not to allow much fluid of any kind; but to allay thirst in active haemoptysis, small pieces of ice may be taken into the mouth, or iced lemonade may be sucked through a rag.] Much difference of opinion prevails as to the place where external counter-irritants may be applied with most advantage; some recommend- ing the nearest point to the seat of the congestion as the fit place for their application; while others prefer a distant point, a preference to which we subscribe, both from reason and experience. The nervous agitation which generally accompanies hemorrhage suggests to us the absolute necessity of repose of both mind and body. There should be a free circulation of cool air around the patient, but not so cold as to cause constriction of the Vol. II. —4? skin, and thus determine to the internal organs. The diet should be conducted upon the most rigid principle of abstinence from every thing capable of producing the least excitement of the system. It will sometimes happen that the hemorrhage will reduce the powers of life so low that we shall be obliged to administer stimulants. The proper management of a patient under these circum stances is one of the nicest points in the practice of medicine, as we have to determine the extent to which we can safely employ stimulants without running the risk of exciting the system, and awakening the orgasm which has produced the effect which we seek to redress. In many of these cases there is no proportion between the loss of blood and the constitutional disturbance, the lattei being much greater than can be accounted for by the actual hemorrhage, which is sometimes very inconsiderable : the nervous irritability of the indi- vidual can alone account for it: here we may advantageously employ antispasmodics, viz., cam- phor, ether, &c. to calm the flurry and agitation of the nervous system. If the haemoptysis ah initio, partake more of a passive character, we shall find our most valuable remedies to consist of the mineral acids, conserve of roses, infusion of roses acidulated with sulphu- ric acid, turpentine, muriated tincture of iron, [tannic acid, creasote,] &c, and sponging the chest with cold vinegar and water. To these cases much advantage is derived from blisters applied to the chest; they restore the tone of the capillary vessels, upon whose weak condition the haemoptysis depends. A free circulation of refresh- ing air is no less beneficial in passive than in active haemoptysis : we have known it to give an immediate check to this affection. We are not obliged to observe the same strictness in diet in this form of haemoptysis, and may gradually come to that of a more nourishing character, with a moderate use of port wine and water. We are next to consider the treatment and management of haemoptysis in the interval of the attacks, with a view to prevent their recurrence. If we can connect the haemoptysis with the sus- pension of an habitual hemorrhage, the obvious indication is to restore that hemorrhage. Should a suppression of the hemorrhoidal discharge be the cause, aloetic purgatives, and leeches applied circa anum, are the means to be employed. If the suspended menstrual discharge seem to be the cause of the haemoptysis, we must endeavour, though with caution and without forcing the sys- tem, to restore the due order of the functions; and with this view we try to assist the abortive efforts of nature at the ordinary period of the menstrual discharge, by determining to the uterus by means of aloetic purgatives, by leeches applied to the interior of the thighs, and by the hip-bath: but our treatment will especially consist in imparting a degree of vigour and tone to the constitution, upon a deficiency of which this derangement of function often depends. In this case chalybeate tonics furnish us with a valuable resource: sea bathing, horse exercise, &c. also assist the object we have in view. (See Amenorrhea, Chlo rosis, Emmenagogues.) In some cases we meet with this morbid pheno 370 H aE M O P T Y SI S. aon in a condition of the system precisely oppo- site to that which we have just described, and in which we have to adopt a mode of treatment and management as opposite. In this latter instance our object is to reduce the fulness and plethora of the system by medicine and diet. Should the cause of the haemoptysis be less obvious, the frequency of its association with phthisis, and its being so often the precursor of this fatal malady, must make us ever regard it with alarm. We before remarked that the adjust- ment of the question as to tubercles being the cause or consequence of haemoptysis was a matter of indifference as regarded the treatment to be adopted to combat this affection ; for, as Laennec has observed, it must be met by bleeding carried to the very limits of possibility. The question, however, assumes an aspect of greater importance when we come to consider the treatment suited to the intervals of the attacks of haemoptysis: we then feel that it involves a consideration of the most vital moment, how far we can with safety pursue a depletory mode of practice, which may have the effect of indirectly generating tubercles, by producing a habit of body favourable to their development. The formation of tubercles seems to us to be, in most cases, the result of a deteriorated constitution taking on an action infra se. We meet them either in persons imperfectly nourished, or in those who have been wasted by previous disease, as by long-protracted fever. We have observed in phthisical patients a disposition to generate worms and vermin, even in those who, to the latest moment of their existence, bestowed the utmost pains on the cleanliness of their person. The inference we deduce from this is, that these parasitical animals, like tubercles, indicate a dege- neracy of habit, or, so to speak, a descending in the scale of the animal being. These points, however, more properly belong to the articles Tubercles and Phthisis, to which we refer for more detailed information upon them. We would only observe that the causes which call a tuber- cular diathesis into active operation are such as have the effect, either directly or indirectly, of debilitating the energies of the constitution; and that therefore, though haemoptysis be a complica- tion with which we cannot tamper, but which we Inust meet with decision, we cannot but regret the dilemma in which we are placed by a symp- tom requiring a mode of treatment which we have reason to apprehend may have the effect of in- creasing that condition of the system which has given rise to the original disease. We would convey our opinion respecting bleeding in phthisis in the words of Laennec, who observes that as bleeding can neither prevent the development of tubercles, nor cure them when they are formed, it staould not be employed in the treatment of phthi- sis, except with a view to subdue an inflammatory complication or acute sanguineous congestion ; beyond this it is a gratuitous waste of the patient's strength, and may be superseded by medicines, which have the effect of reducing the powers of the circulation without producing permanent pros- tiation, such as digitalis, tartar-emetic, &c. We would here express our decided conviction that phthisis, of which haemoptysis is so frequent a symptom, would be treated with much more suc- cess if physicians were not continually haunted with the apprehension of exciting or keeping up inflammation; a feeling which, within due limits, should ever be present, but still when pushed too far, and acted upon too rigorously, it deprives the system of its remaining stamina, and unfits it for bearing the exhausting effects of a wasting dis- ease. A gentleman in Scotland (Dr. Stewart), who has now ceased to be a member of the medi- cal profession, long since ventured to deviate from the routine of practice in this disease, and pur- sued a mode of treatment which has had most encouraging success: the principle of this treat- ment was to strengthen the constitution. He argued, that when the tubercles softened and tht expectoration became purulent, the treatment should be the same as that required by the forma- tion of matter in other parts of the body, when we have no other view than that of supporting the system. To fulfil this intention he treated the disease with tonic medicines cautiously exhibited, but placed his chief reliance upon cold bathing, exercise, and nourishing diet. His plan with respect to cold bathing consisted in making the patient sponge the entire body in the morning, and the neck, chest, and shoulders at night, with tepid vinegar and water, whose temperature was reduced each day till it was quite cold : this spong- ing was followed by rubbing for half an hour with flannels, and then with a flesh-brush. By degrees, as the feverishness subsided, the vinegar was laid aside. This was a preparation for cold bathing, and afterwards for sea-bathing. We do not mean to affirm that tubercles do not often form in an inflammatory habit, and that bleeding is not often required in such a habit: we only question its propriety as a preventive measure. The slighter haemoptysis, which comes on in the progress of consumption, seldom demands constitutional bleeding; it will in general be checked by acetate of lead, nitre, digitalis, con- serve of roses, acidulated drinks, &c. When the frequency of haemoptysis in an indi- vidual not naturally predisposed to phthisis leads us to connect its cause with some obscure condi- tion of the capillary vessels of the organ exhibit- ing itself in either active or passive hemorrhage, we have to treat it as an idiopathic disease, and not, as before, as a symptom whose treatment was modified by that of the disease upon which it depended The character of the hemorrhage, whether active or passive, alone regulates our attention: we are, therefore, relieved from the caution with respect to bleeding which tied up our hands in the management of this morbid phe- nomenon in phthisis. It was this kind of habi- tual haemoptysis to which we before alluded, as deriving so much benefit from small bleedings often repeated; a practice which seems to us enti- tled to a decided preference over large bleedings which cannot be repeated : for the efficacy of bleeding in these cases depends not so much upon the quantity of blood drawn, as upon the revulsive effect of the operation; the opening in the vein solicits the blood to it, and so diverts it from the source of the haemoptysis. The older physicians appreciated this point of practice, and accom- plished it by closing the opening during the opera- HEADACH. 371 tion. When we reflect how comparatively inde- pendent of the general circulation the capillary system is, we see reason to expect more advan- tage from means which have more of a local operation, as cupping, leeching the chest, &c. We shall find nothing to exercise such a salutary con- trol over this kind of haemoptysis as change of air, adapting the temperature to the character of the discharge; if it be active, removing to a warmer climate; if passive, to a colder and more bracing. This hemorrhage is much influenced by moral causes; moral management constitutes an import- ant part of its treatment: the writer has known it to cease immediately upon hearing agreeable news. Pulmonary apoplexy demands full depletion. Bleeding should be carried to the extent of pro- ducing fainting, and should the haemoptysis still continue, we must adopt every other means cal- culated either directly or indirectly to lower the energies of the circulation. For this purpose we would employ small doses of ipecacuanha often repeated, so as to keep up a continual nausea. Purgatives are a valuable resource. Laennec has not found tartar-emetic as beneficial in this form of disease as in inflammation. Astringents should not anticipate the chronic stage of the disease. Haemoptysis dependent upon gangrene of the lungs requires a mode of treatment adapted to the vitiated constitution in' which it occurs. Tonics constitute our principal remedial agents, while we seek to allay the irritation of the cough by opium, hyoscyamus, conium, &c. When haemoptysis proceeds from the larynx or trachea, and seems to be produced by an excessive exercise of voice, the first thing required is the repose of the organ ; nor, in general, is this enough; as the local affec- tion is merely the index of constitutional relaxa- tion, the object of the means we employ must be to restore the tone of the system by exercise, shower-baths, sulphate of quinine, &c. To this we would add sponging the throat with vinegar and water. For further information on this sub- ject we would refer to the articles Apoplexy, Pulmoxary; Phthisis Pulmonalis ; Lungs, Gancjhene of the, &c. &c. Robert Law. HEADACH.— Cephalalgia, from KtfaXr), the head, and a\yoc, pain. From a very early period the term cephalalgia has been employed to desig- nate various kinds and degrees of pain affecting the head. Some authors, indeed, have confined its use to headachs of the more obtuse and tran- sient character; including pain of a more severe, tensive, and continued kind under the term ce- phalxa. But the words are too nearly alike ever to preserve a separate and distinctive mean- ing. For all practical purposes it will be more eligible to adopt exclusively the term cephalalgia, as answering to our English word headach, ar- ranging under it the more marked distinctions of headach as species and varieties. From the intimate connection which subsists between the sensorium and every other part of the system, it is not surprising that the head should participate in the morbid affections of those parts. Disorders of the stomach, liver, intestines, and ute- rus, especially, have long been observed to pro- duce pains of the head. Nosologists have accord ingly specified many kinds of sympathetic cephalal- gia ; but they have not been equally successful in pointing out the kinds of pain which arise from the diseases of the head itself. In truth, the diffi- culty of such an undertaking seems to have de- terred them from making the attempt. They have too readily acquiesced in the opinion that, with the exception of some organic lesions of the brain, pain of the head almost always arose from morbid affections of other organs. Even the philosophic Cullen has given cephalalgia no place in his noso- logical system. Yet it would be truly astonishing if the head, itself so susceptible of impression from disorders of other parts of the system, should not suffer pain from some of its own. Many serious structural changes may indeed take place within the head unaccompanied by pain; but it is impos- sible to deny that numerous other morbid condi- tions of the brain and its meninges, as well as of the cranium and its coverings, do produce head- achs of various a id distinctive characters, and re- quiring a corresponding variety in the treatment. One of the difficulties connected with the inves- tigation of headach arises from the gradual and almost imperceptible conversion of pain, originally sympathetic, into an independent affection, which may remain long after the primary disease has been removed. Thus dyspeptic headachs not un- frequently induce permanent disorder in the head, remaining perhaps for months or years as the ha- bitual malady, although the original symptoms of indigestion may have been entirely lost. Another source of obscurity may be traced to the frequent coexistence of disease in the head and in some other organ with which the head pe- culiarly sympathizes ; each disease serving to in- fluence and aggravate the other. Under such cir- cumstances it is sometimes difficult to determine which was the original malady. Allied to this difficulty is a third, arising from the simultaneous operation of several of the more powerful exciting causes of headach; such, for ex- ample, as immoderate mental excitement and sti- mulating potations, both upon the head and upon the stomach. Thus, intense application of mind may not only excite headach by its direct action upon the brain, but may at the same time produce evident disorder of the digestive organs. With- out careful discrimination, such a headach would probably be ascribed solely to dyspepsia, to the neglect of the actual state of the brain; whereas the derangement of both head and stomach may be alike dependent on the undue excitement of the sensorium. In no disease, perhaps, does the subject of pre- disposition require to be more attentively con- sidered than in cephalalgia. Of the circumstances which especially predispose to headach we may enumerate the following : — 1. Original malformation of the head. 2. A highly susceptible state of the nervous system. J Debility, however induced. 4. General or local plethora. 5. The previous occurrence of conges tive or inflammatory disease. 6. Habitual or fre- quent excess in wine, spirits, and other powerful stimulants. 7. Injuries of the head from blows, falls, &c. 8. Continued mental excitement. The occasional or exciting causes of headach 372 HEADACH. are very numerous. Some of them would pro- duce the disease in almost any individual, even under ordinary circumstances; but .the greater number only excite pain of head in persons already predisposed to the malady. Hence the great im- portance of estimating the degree of predisposition. Of the more frequent occasional causes we may specify: — 1. Rheumatic affection of the pericranium. 2. Inflammation, or a more chronic morbid condition, of the pericranium. 3. Inflammation of the mu- cous lining of the frontal sinuses, or foreign bodies within the sinuses. 4. Intense mental excitement 5. Strong impressions on the external senses. 6. Excessive impetus of blood to the head. 7. Im- peded return of blood from the head. 8. Con- gestion within the head. 9. Suppression of ac- customed evacuations. 10. Inflammation of he brain or its membranes. 11. Tumours, or other morbid changes of structure within the head. 12. Morbid affections of the stomach : — as from over- excitation or distension ; from irritating ingesta; from imperfect digestion ; the presence of bile in the stomach, &c. 13. Costiveness. 14. Narco- tics. 15. Worms. 16. Diminished pressure of the atmosphere. 17. A heated, humid, or deteri- orated atmosphere. 18. Sudden changes of tem- perature. 19. Exposure to a current of air, or to a cold wind, especially from the east. This enumeration will sufficiently show the im- possibility of treating separately every variety of headach in a work like the present. Some lead- ing distinctions of cephalalgia can alone be at- tempted ; and such, we apprehend, may be satis- factorily comprised in the following species : — Cephalalgia muscularis. periosteosa. -----congestiva. ----- organica. -----dyspeptica. -----periodica. Of these we shall now proceed to treat separately. I. Cephalalgia Muscularis. — This kind of pain is essentially of a rheumatic character, and particularly affects the occipito-frontalis and tem- poral muscles. The pain is tensive and remitting, sometimes diffused over the greater part of the head ; at other times, varying its situation from the forehead to the vertex or the occiput, or from one side of the head to the other. In some cases, also, the pain extends to the face and teeth. Not unfrequently, the muscles of the neck and shoul- ders are at the same time affected with fugitive pains. The action of the affected muscles remark- ably increases the pain and tension, as does also even slight pressure upon the scalp. The attack may be usually traced to some partial exposure to cold or humidity, as by sitting near an open win- dow, or standing in a current of air after being heated by exercise. It is often preceded by a sense of coldness over the head and along the sides of the face. Some disturbance of stomach usually attends it for the first day or two, accom- panied sometimes with slight febrile excitement of the system. These symptoms generally soon sub- side, even without medical treatment; leaving, however, an increased susceptibility in the parts to a renewal of the complaint from very slight causes. A dose of calomel and antimony, aided by a pediluvium, at night, and followed by a brisk aperient dose in the morning, considerably expe- dites the departure of the pain. In some cases of peculiar severity, diaphoretic remedies are re- quired ; and if the pain be very acute, leeches to the temples will afford considerable mitigation. But the principal aim of the practitioner should be to prevent a recurrence of the attack, by direct- ing the patient to be much in the open air; to use a shower-bath daily, or, in its stead, the free affu- sion of cold water over the head ; and every other practicable method of restoring the tone of the af- fected parts, and thus enabling them to resist the influence of cold and humidity. II. Cephalalgia Periosteosa. — Tnis is an unusual form of headach, and has not, we believe, been hitherto described by authors. The writer of this article first pointed out its nature in a pa- per read before the Westminster Medical Society in the year 1825. In many particulars, the peri- osteal headach resembles the muscular. As in that species of cephalalgia, the pain is diffused, tensive, and remitting, increased by pressure and by the action of the occipito-frontalis and tempo- ral muscles. It may also be generally traced to the same exciting causes, humidity and sudden changes of temperature. The very parts affected in the merely muscular headach are equally in- volved in this; but, in addition, the periosteum is also affected, and the sensorium suffers more ex- citement. The pain itself is more deeply seated and intense, and is attended with an augmented action of the external arteries of the head, as well as with more gastric and general febrile disturb- ance. The attack, moreover, does not so speedily subside; for although after a few days the muscu- lar covering of the head can be moved without pain, and slight pressure no longer produces unea- siness, yet the periosteal pain and tenderness re- main. Firm and deep pressure is still painful, and excites a sensation of distressing tension over the greater part of the head and face. The same kind of constrictive pain is produced almost inva- riably by going out of a warm into a cold room, or by taking off the usual covering of the head. The whole periosteum, indeed, of both the head proper and the face is implicated in the disease, although those parts of the membrane suffer most which are but slightly covered. Hence, the upper portion of the nose and the alveolar processes are particularly affected. We may here remark, as a striking proof of the periosteum itself being the immediate seat of the malady, that the pain is fre- quently transferred for a time from the head to the face, soon, however, returning to its more accus- tomed seat around the head. It is not less re- markable that an increased feeling of tension may be induced over the whole or the greater part of the head and face by firm pressure upon any one point of the periosteum, whether of the head or of the face. Hence we may conclude that the struc- ture affected is one common to both head and face. It may, perhaps, be supposed that the periosteal cephalalgia now described is only an aggravated form of rheumatic headach. It is, however, a far more complicated and intractable malady, and oc- curs, we believe, only to those who have previ- ously suffered from continued cerebral excitement In truth, a two-fold predisposition appears to be HEADACH. 3/3 essential to its production :—first, a highly sus- ceptible, if not also preternaturally vascular con- dition of the brain or its membranes, such as is often induced by long-continued study, or high mental excitement, as well as by the frequent oc- currence of sympathetic headach arising from gas- tric or hepatic disorder: and secondly, a state of debility and exhaustion supervening upon that ex- cited condition of head, whether occurring spon- taneously, or as the result of the depletory mea- sures employed for the removal of the previous cerebral excitement. If an individual, under these concurring circumstances, be exposed to a power- ful exciting cause, such as a sudden diminution of temperature, especially if accompanied by hu- midity, he may have the periosteal cephalalgia in- duced,— a disease of a singularly obstinate cha- racter, and apparently maintained by that condi- tion of the brain or its membranes, which existed prior to the supervention of the external malady. On the other hand, the pain and irritation con- nected with the external malady tends, in its turn, to perpetuate the morbidly excitable state of the brain. The following case may serve as an illus- tration. A gentleman of a susceptible constitution, who had long been subject to occasional attacks of dys- peptic headach, and had frequently suffered from mental application during a long and laborious course of study, was thrown at once into the one- rous duties of a large public institution. Much pain and excitement of head ensued. General and local bleeding, mercurial purgatives, antimony, low diet, &c, were considered necessary. The symp- toms subsided considerably, but the brain and nervous system remained in a state of extreme susceptibility. On some recurrence of pain, it was judged needful to shave the head, which happened to be done under circumstances of great exhaustion on a cold wet evening. The ordinary covering of a thin night-cap was alone worn during the night. On awaking from sleep, a severe constrictive pain was felt over the whole head, attended with heat and tenderness of the scalp, throbbing of the tem- poral arteries, considerable cerebral excitement, and vomiting. In truth, an external periosteal disease was thus engrafted upon a head previously suffer- ing from high and continued excitement. After a few days, the more superficial tenderness subsided, but the periosteal affection proved exceedingly in- tractable. In this case it seems probable that the frequent occurrence of sympathetic headach, aided by the excitement attendant on long-continued study, had induced an undue degree of vascularity and of nervous susceptibility in the head generally ; while the remarkable prostration of vital power consequent upon the depletory measures employed, served to increase the nervous susceptibility, and thus concurred to form that two-fold predisposition of which we have before spoken, and without which, we apprehend, the subsequent exposure to cold and humidity would have been insufficient to excite this peculiar periosteal cephalalgia,although it might have produced an ordinary rheumatic affection of the scalp. So exquisitely sensitive does the pericranium remain in these cases, so readily affected by every exposure to humidity or sudden reduction of temperature, and so apt to participate in every occasional excitement of the brain, that 2» one attack of the complaint has scarcely time to subside before some fresh exposure gives rise to a decided augmentation of disease. In the treatment of periosteal headach the first object must be to lessen the general cerebral excite- ment, as well as the inflammatory tendency and morbid sensitiveness of the affected membrane. Local bleeding, mercurial purgatives, antimonials, the acetate or citrate of ammonia, and similar means, are best adapted to fulfil these indications. Opiates are of doubtful efficacy. Should much nausea occur at the commencement of the attack, an emetic would be advisable; after which a dose of calomel and antimony, followed by a saline purgative, will generally be found very advanta- geous. The utmost quietude of mind should be preserved. After the acute symptoms have been subdued, vigilant attention will be necessary to guard against a relapse. The susceptibility of the pericranium may be moderated by the gradual use of cold washing, followed by gentle friction of the head, as well as by a free though prudent exposure to the open air in the way of carriage, horse, and walking exercise. A residence in a dry and some- what elevated situation will materially conduce to the patient's recovery. But it must also be re- membered that the morbid condition of the mem- brane may be maintained by undue cerebral ex- citement, and that therefore the discipline of the mind, the avoidance of intense or long-continued study, and every engagement and pursuit which may tend to perpetuate that excitement, are abso- lutely essential to a permanent cure. Under the division of periosteal headach it may be proper to describe that affection of the peri- cranium which has been called by Mr. Crampton periostitis. (Dublin Hospital Reports, vol. i.) Cases in some respects similar had been previously published by Sir Everard Home, (Trans, of the Soc. for the Improvement of Med. and Chir. Knowledge, vol. iii.) and some important illustra- tions of the same subject have been recently added by that accurate and distinguished pathologist, Dr. Abercrombie. (On Diseases of the Brain and Spinal Chord.) Fixed pain of the head and tenderness of some portion of the scalp, with a degree of thickening and swelling of the integu- ments, were the characteristic symptoms. The periosteum was generally found thickened, and, in some cases, the bone itself diseased. In the ma- jority of instances, some affection of the brain co- existed with the periosteal disease. It would seem probable, however, that the periosteum was pri- marily affected in several of the cases adduced; in those, particularly, in which complete and perma- nent relief followed the division of the pericranium and the keeping open of the wound for a considerable time. Yet it must be allowed that even pains of head, apparently connected with internal as well as external disease, have been essentially relieved by such an operation. Mr. Brodie and the late Mr. Pearson have repeatedly cut down to the bone in cases of fixed and obstinate pain confined to a limited part of the head, maintaining afterwards a free discharge from the part, and with very decided success. We might here without impropriety have intro- duced another kind of headach—that depending 374 HEAD ACH. on a diseased state of the bones of the cranium, and attended with constant pain and tenderness at some particular spot; but as such cases are com- paratively rare, we are unwilling to present it as a distinct species. III. Cephalalgia Congestiva.—This species is characterized by an obtuse pain affecting the whole or a part of the head, particularly the fore- head and occiput, and is frequently attended with a feeling of general oppression and torpor. It may be observed in three different states of constitution : —in the plethoric; in the delicate and irritable ; and in the weak and leucophlegmatic. 1. The congestive headach frequently attacks persons of a plethoric habit, who have passed the middle period of life, have lived freely, and have used but little bodily exercise. In such the counte- nance is often bloated, the eyes are full and red, the veins of the face distended, and the general expression dull and inanimate. It is more especially observed in those who have suffered from gout or from chronic diseases of the liver, and after the cessation of the catamenia. In such it must always be regarded with vigilant attention, as indicative of an apoplectic or paralytic tendency. 2. The congestive cephalalgia also affects the delicate and irritable, especially those whose minds have been injudiciously cultivated at the expense of their bodily health and vigour. Hence it is most frequently observed in the female sex. In persons of this temperament the sanguineous cir- culation is so nicely balanced as to be disturbed on very slight occasions. A vivid emotion of mind, earnest or continued conversation, an unusual de- gree of bodily exercise, or some irregularity in diet or in the action of the bowels, will occasion in such habits an increased impetus of blood to the head, which, though only producing at the time a sense of heat and excitement, is generally followed by coldness of the legs and feet, and by the dull, oppressive headach of which we are now treating. In some cases the pain is attended with flashes of light or with little floating specks before the eyes, as well as by noises in the ears. This species of headach is particularly observable in delicate fe- males of an irritable temperament, both before and for a day or two after each menstrual period. 3. The congestive headach also attacks the weak and leucophlegmatic. It may be recognised in persons who have been reduced by acute diseases, by hemorrhages, leucorrhcea, &c. It is also seen in chlorosis and in various other asthenic condi- tions of the system. There is usually a slow and languid pulse, a pale, sallow, or even semi-trans- parent appearance of the skin, and a peculiarly heavy expression of countenance. The lips are generally pale, or of a slightly blue tint; the feet are apt to swell in hot weather or after exercise; and every muscular exertion becomes laborious and formidable. In this variety of congestive head- ach, the pain is most commonly in the forehead, although in some cases the occiput is chiefly affected. The treatment of congestive cephalalgia must necessarily be adapted to the circumstances of each individual case. We may remark that, in the first variety, that which is incident to the plethoric habit, venesection or cupping, brisk purgatives, a mode- rate diet, the affusion of cold water upon the head, and stimulating pediluvia, are usually required. When the attack has been subdued, the patient should be directed to avoid much mental applica- tion ; to observe regular habits of exercise in the open air, as well as great moderation in diet, and a careful attention to the state of the bowels. The shower-bath should also be daily employed. In the congestive headach of the weak and irri- table, it may be sometimes necessary to have re- course to topical bleeding: but, generally quietude of mind, a stomachic aperient, the application of cold to the head, either by the affusion of water or by evaporating lotions, stimulating pediluvia, and the exhibition of camphor and ammonia or other diffusible stimulants, will prove adequate to the removal of the attack. Every precaution should be used to prevent a recurrence of the complaint by increasing the tone of the system, and thus counteracting the undue susceptibility of impression and the irregular distribution of blood, with which the malady is peculiarly connected. The third variety of congestive headach, that occurring in the weak and leucophlegmatic, re- quires nearly the same management as the last. In this, however, the loss of blood can scarcely ever be necessary, although blisters are sometimes indicated. Warm and cordial aperients, the mode- rate use of wine, camphor, valerian, or ammonia, aided by a mustard or other stimulating bath for the feet, are well adapted to remove the immediate pain; while good air, gentle exercise, a nutritive diet, cheerful society, with the assistance of tonic remedies, more particularly the lighter preparations of steel, are not less calculated to invigorate the constitution, and thus preserve it from future at- tacks of the complaint. We now proceed to a very important division of our subject, viz. headach arising from organic disease within the cranium: this we have ventured to name, although the term is not unexceptionable. IV. Cephalalgia Organica.—So numerous and complicated are those morbid changes of the brain and its membranes which have been found to pro- duce headach, that we must content ourselves with a reference to the most frequent of them; endea- vouring chiefly to point out the principal symp- toms which distinguish the organic headach from cephalalgia arising from other causes. Among the structural changes productive of headach, tumours are undoubtedly the most frequent These may be either imbedded in the substance of the brain, or attached to its surface, or to the membranes surrounding it. Such tumours may be of a pulpy, adipose, albuminous, cartilaginous, scirrhous, or even bony consistence. Hydatids are another cause of headach, as are also spiculae of hone attached to the dura mater, or growing from the inner table of the skull. In a case which occurred to the writer a few weeks ago, one of the clinoid processes of the sphenoid bone was found unusu- ally long and formed into a thorny point, so sharp and strong as to pierce the finger when pressed against it. A similar, though not equally long point, was found to have grown from the squamous portion of the temporal bone. In some instances the membranes of the brain have been found thickened and partially disorganized ; in others a portion of the brain has exhibited a softening or degeneration of its structure, or one or more ab- scesses imbedded within its substance. HEADACH. 375 fn many of these diseased conditions, the pain of head may remain, during a considerable period, unattended by any other prominent symptoms : at length, however, some decisive indication of in- flammatory action or of cerebral pressure occurs ; the sight or hearing, for example, becomes affected, or the powers of the mind become enfeebled, or simple convulsion, epilepsy, or paralysis announces the extension of disease. The diagnosis of cephalalgia organica is often difficult at an early period, while the pain is un- attcnded by any morbid affection of the senses or of the moving powers. In general, however, we may remark that the pain itself is more fixed, deep-seated, and habitual than in other kinds of headach ; more independent of the state of the sto- mach ; more obviously increased by mental appli- cation, by close or heated rooms, by stooping, and sometimes even by the horizontal posture. The same degree of cheerful conversation which would chase away, or at least suspend the feeling of or- dinary headach, often becomes laborious and almost insupportable in organic cephalalgia. Nor is the effect of stimulants received into the stomach less remarkable. Wine and other fermented liquors produce an immediate aggravation of pain. When the disease has considerably advanced, even a slight.motion of the head will sometimes give rise to extreme suffering, and also to vomiting. It is proper to add that the disturbance of stomach which is sometimes present in this species of head- ach may occur without any apparent disorder of the stomach itself, and in this respect, as well as in others, differs materially from the sickness inci- dent to dyspeptic headach. Moreover, the pain in organic cephalalgia equally remains when the sickness ceases. We have said that the pain in organic headach is fixed and habitual. There are, however, exceptions to this general rule. Sometimes the pain is of an intermitting character, although serious structural mischief may be stead- ily advancing. In such cases, the most vigilant attention to the collateral symptoms will be re- quired before the real nature of the case can with any reasonable probability be determined. V. Cephalalgia Dyspeptica.—This may be regarded as the most frequent kind of headach. In many individuals it is induced by very slight errors in diet, or even by remaining somewhat longer than usual without food. It may occur without any remarkable or at least very obvious degree of susceptibility in the brain. We see it, for example, in persons who can bear close appli- cation to study without any apparent inconveni- ence to the head itself, while yet very liable to headach from taking certain articles of food, or mingling them in too great a variety. Yet, in the majority of instances, it must be allowed that dys- peptic headach is most frequently found in those persons who also suffer from much mental excite- ment, and in whom the gastric disturbance is only one,effect of that excitement. In such, the sto- mach may become either morbidly irritable or in the opposite state of atony, being, in either case, equally unfit for the due performance of the diges- tive functions, and therefore liable to be still fur- ther deranged by any irregularities in diet. The dyspeptic or stomach headach, when severe, more particularly affects the left temple, extending some- times over the same side of the forehead, and pro- ducing tenderness in the corresponding ball of the eye. In other instances, the whole forehead, or even the greater part of the head, becomes painful. The pain may be either dull and oppressive, or of a more acute character, and in both cases renders mental exertion difficult and irksome. It is not unfrequently attended with some tenderness of the scalp, and an increased pulsation of the tem- poral arteries. The paroxysm of dyspeptic cepha- lalgia usually commences when the patient first awakes in the morning from a heavy sleep. The pain, at first diffused and oppressive, gradually concentrates itself upon one or other temple, gen- erally the left, and becomes more and more acute. A degree of nausea often supervenes, sometimes increasing to sickness and vomiting. If the latter occur, the remains of an undigested meal, or merely an insipid fluid mixed with frothy mucus, is perhaps first ejected ; but if the action of vomit- ing continue long, some admixture of bile usually follows. In some instances the stomach throws off, on the first attempt, green or yellow bile, or a fluid extremely acid and irritating; in which case, the pain of head is sometimes immediately relieved. if neither vomiting nor aperient medicine be employed to check the ordinary progress of the paroxysm, the pain generally becomes more se- vere as the day advances, until it is lost in sleep. Occasionally, it remains during the greater part of the second day. When, however, an active dose of purgative medicine has been taken, the headach often becomes less in two or three hours, and ceases altogether in six or eight. It is re- markable that the beneficial effect of a stomachic and antacid purgative is frequently felt long be- fore the offending matters are expelled from the bowels, clearly indicating that the sources of irri- tation were either in the stomach itself, or in the upper portion of the intestines. Such is the usual course of a sick headach when occurring as a distinct paroxysm. The dyspeptic cephalalgia may, however, exist in a more chronic and habitual form, and in every possible degree. It may also be very transient in its duration. Many individuals suffer more or less inconvenience after every principal meal, un- less they limit themselves, with the utmost pru- dence, in respect to the kind and quantity of food; but after two or three hours, the pain of head spontaneously ceases. When the stomach itself suffers from irritating ingesta, drowsiness or head- ach rather quickly succeeds, attended sometimes with confusion of thought and dimness of sight. In such cases, a mild emetic affords immediate re- lief. In many instances, however, the pain is not felt until several hours have elapsed, and is then accompanied with a sense of tightness and dis- tension of the scalp and stiffness of the eye-balls. Sometimes the patient sees a mist before his eyes, or even luminous and coloured appearances, be- fore the headach comes on. Under these circum- stances, there is reason to believe that the duode num is principally irritated ; an opinion which is rendered probable by the sense of distension ana uneasiness which is often felt in the exact situa- tion of that bowel. It is sometimes, indeed, fully confirmed by the fact that an emetic under such circumstances does not afford relief, nor even 37fi HEADACH. evacuate any thing material from the stomach; while, on the contrary, a dose of magnesia, either alone or combined with rhubarb or epsom salt, will in two or three hours relieve both the head- ach and the uneasiness existing along the course of the duodenum. Yet it is proper to add, that when the irritating cause is considerable, both the stomach and duodenum remain in a state of disturbance during several hours. In a very able paper on headach, inserted in the fourth volume of the Medical Transactions of the Royal College of Physicians, Dr. Warren main- tains that the headach arising from irritation of stomach differs considerably from that which is produced by disturbance in the duodenum; that the former " is attended more with confusion than pain," while the latter is characterized by a dull aching of some parts of the head, " coldness and tightness of the scalp, slight giddiness, weight, pain, distension and stiffness of the eye-balls," and sometimes temporary numbness and tingling of the fingers and hand. Although feeling the greatest confidence in Dr. Warren's accuracy of observation, we have not been able satisfactorily to determine that the latter symptoms may not also occur from irritation of the stomach itself as well as of the duodenum; nor are we convinced that the duodenum can be irritated to such an extent, by matters which have lately been propelled from the stomach, as to produce a high degree of cepha- lic irritation, without its contiguous organ, the stomach, being at the same time somewhat impli- cated in the disturbance. The exciting or immediate causes of dyspeptic cephalalgia are sufficiently obvious : long fasting; excess in wine or other powerful stimulants; or in the quantity, quality, or variety of solid food, are among the principal. Particular articles of food, likewise, which are innoxious to most per- sons, become irritating to certain individuals. But it must not be forgotten' that the efficiency of the exciting cause bears an important relation to the amount of predisposition; an article of food, for example, may produce headach to-day, if the sto- mach or the brain, or both, be unusually excitable, which would not have produced it yesterday when those organs were less susceptible of irritation. Hence the importance of particular investigation with respect to the previous state of the head, as well as of the digestive organs. In many in- stances it will be found that sedentary habits, ex- cessive mental application, anxiety, the hurry of business, and similar causes, have gradually in- duced a strong predisposition to headach, although the tendency may not have been developed until some error in diet, acting as the exciting cause, gave rise to gastric disturbance, and thence to sympathetic pain in the head. In truth, a two- fold predisposition may be often said to exist, in- volving both the head and the stomach. In some cases mental excitement would seem to precede the morbid affection of the stomach. In persons of great susceptibility, a very high degree of cere- bral excitation appears to be inconsistent with an adequate supply of nervous energy to the digestive organs; as if there were but a certain portion of vigour to be shared by the different parts of the system, and, consequently, that an undue propor- 'ion allotted to one occasioned a corresponding deficiency in the rest. The fact, however, is in- controvertible, that in many susceptible individu- als, intense engagement of mind induces a power less state of stomach and duodenum, giving rise to dyspepsia and the headach arising from it. Not uncommonly cerebral excitement occasions a rapid and profuse secretion of bile, which, in its turn, produces a sick or bilious headach in its se- verest form. We have repeatedly seen the same effect follow an unusual degree of bodily exercise; in which case, it is sometimes attended with both vomiting and purging of a highly bilious cha- racter. The dyspeptic cephalalgia chiefly occurs in early or in middle life, becoming less and less severe as the irritability of the system gradually declines. Sometimes, however, as life advances, there is an apparent transfer of irritability from the stomach to the bowels. Frequent diarrhcea takes the place of bilious headach, being excited by the same cir- cumstances. The treatment of dyspeptic headach requires a careful adaptation to the peculiarities of each case. An ordinary paroxysm of the pain, if at- tended with much nausea, may be considerably shortened by an ipecacuanha emetic, afterwards allowing to the stomach and to the head an inter- val of entire repose. After an hour or two, twenty or thirty grains of magnesia combined with rhu- barb, or the sulphate of magnesia and an aromatic, may be given, and followed, after some hours, by a little bland farinaceous nourishment. Where no particular nausea is felt, the antacid aperient may be given at the first. A few grains of the subcarbonate of ammonia, or thirty or forty min- ims of the aromatic spirit of ammonia may be added with advantage, when the stomach is pecu- liarly irritable. In the milder and more chronic forms of dys- peptic headach, much will depend on the discipline of the mind and the regulation of the table. Every individual may be able, by proper attention, to ascertain what kinds of food and what quantity of food he can comfortably digest; and under what particular circumstances the symptoms of indigestion and headach have generally arisen. A little observation will also discover the con- nection which subsists between that state of tone and vigour of the whole system which regular bodily exercise induces, and the power of the sto- mach itself. Thus it will be found that the same kinds and quantity of food which perfectly agree while the individual takes his daily walk in the open air, and employs his brain within moderate bounds, become sources of indigestion and headach when the head is allowed too much duty and the feet too little. The daily management of the bowels is an ob- ject of great importance in this kind of headach. When diet and exercise prove insufficient to se- cure a daily motion, a mild stomachic aperient, combined, perhaps, with an alkali, may be given every night, or on alternate nights, until the ten- dency to constipation and headach be overcome. When, however, there appears to be much duo- denal indigestion, a few grains of rhubarb, or a grain or two of aloes, taken before dinner, will be a preferable mode of increasing the propulsatory power of the intestines. We cannot, however, HEADaJH —HEART, (DISEASES OF THE) 37; recommend this as a general mode of regulating the bowels; being convinced that it often accek- rates. in an injurious degree, the peristaltic action, and deprives the system of a part of the nourish- ment which would otherwise be received by ab- sorption. Persons have been found to become manifestly thinner under such a plan. When, as indeed often happens, the biliary secretion is irre- gular or defective, a mild mercurial preparation may be given for a few successive or alternate nights. Occasionally some aromatic bitter, either with or without soda or ammonia, may be em- ployed with advantage. Horse-exercise, if it be not used to the exclusion of walking, is often ex- tremely beneficial. The shower-bath, or cold sponging, aided by friction of the skin and mo- derately warm clothing, are also powerful aux- iliaries. VI. Cephalalgia Periodica. — This kind of headach is said to be sometimes hereditary. It may have regular or irregular accessions, and may occur in a quotidian, tertian, or quartan fcrm. It has returned periodically at the regular intervals of several weeks or even months. Most com- monly it observes daily accessions, returning either in the morning or at noon. Sometimes a very limited portion of the head, a small spot, is alone affected. Not unfrequently the pain commences at the inner angle of the orbit, producing pain, redness, and tenderness of the eye, and extending towards the nose. This has been popularly called megrim. In other instances, one entire half of the head and face is affected, constituting the hemicrania of authors. The pain is sometimes so acute as to resemble that of tic douloureux; but it may generally be distinguished from the latter by its more regular periodical accessions, by the longer duration of each paroxysm, and by the more complete and protracted intermissions. In many cases, too, the periodic cephalalgia is obvi- ously connected with existing rheumatism or ca- tarrh. The pain of tic douloureux, on the other hand, is generally very sudden in its attack, and quite excruciating in its degree, but lasts only for a few seconds. It returns at indefinite periods, being readily excited by the slightest exposure to a current of air, or by the motion of the jaws in eating or speaking. The cephalalgia periodica also bears some resemblance to the ' muscular or simply rheumatic headach ; from which, however, it may generally be distinguished by the greater regularity of its accessions; by its usually affect- ing a circumscribed portion, or, at most, one side of the head and face ; and more particularly, by its frequent connection with intermittent fever. Sometimes, indeed, it appears to be the direct effect of an exposure to malaria, although unat- tended with the ordinary phenomena of fever. In other instances, a carious tooth or some lesion of the antrum highmorianum has appeared to produce and maintain the disease. Accordingly, the extraction of the afflicted tooth has entirely removed the cephalalgia. As in every other species of headach, a careful consideration of the peculiarities of each indivi- dual case can alone lead to a discriminating and successful treatment. Where no local irritation can be traced, and no congestive symptoms about the head appear, cinchona in substance, or the Vol. II. — 48 2&« sulphate of quinine, may be exhibited in the in- tervals, as soon as the bowels have been thoroughly cleansed by a dose of calomel conjoined with rhu- barb, jalap, or some other effective purgative. In some peculiarly obstinate cases, it may be right to have recourse to the arsenical solution, preserving, at the same time, a regular state of bowels by some mild aperient, in combination with the pilula hydrargyri or the compound pill of the submuriate of mercury. Where the paroxysms are extremely violent, much relief may be often gained by a full opiate conjoined with the compound spirit of sul- phuric ether, given just before the expected acces- sion. In the more limited forms of the periodical cephalalgia, the extracts of belladonna and opium, applied to the part affected, sometimes afford con- siderable mitigation. [In all the forms of nervous headach, immediate relief is often afforded by the application of strong counter-irritant lotions to the forehead and tem- ples. For various forms of application, and espe- cially for those of Granville and Raspail, the reader is referred to the article Counter-Irri- tation. In one of the most severe cases of hemicrania that ever feK under the writer's attention, and which, (unae. tie idea that encephalic hyperaemia existed,) had been treated by bloodletting on each attack, so that the patient, a female, was com- pelled to be bled once or twice a month, and when the writer first saw her, was highly anaemic and impressible, subcarbonate of iron, given in large doses, Qi.—Qii. three times a day,) entirely restored her to her family, to which she had been wholly unable to attend ibr months previously. Since that time — many years ago — she has had HEART, (DISEASES OF THE)—Diseases of the heart were, until 'recently, supposed seve- rally to present symptoms of very much the same general character, and therefore to constitute a class of maladies which possessed considerable unity in their intrinsic nature. They are now, however, found to consist of a variety of distinct affections producing very different and sometimes opposite symptoms. Thus, hypertrophy produces increased, and dilatation diminished force of the circulation. In order, therefore, to appreciate the value, and familiarize ourselves with the nature, of each class of symptoms, it is necessary to study the several affections in an isolated form. We are thus enabled, on meeting with a compound case—one consisting of a complication of several of the simple affections — to analyze or unravel the symptoms, ascertain the relative importance of each class, and in this manner establish rational and secure principles of treatment. In conformity with this view, the various articles on the diseases of the heart, instead of being assembled under the present head, are, for facility of reference, dif- fused alphabetically throughout the work. We have here only to put the whole together m a systematic form,, so as, by pointing out the affini- ties between detached articles, to enable the stu- dent to prosecute his studies in a consecutive form, and to find with facility any given article or topic to which he may wish incidentally to refer 378 HEART, (DISEASES OF THE) Physiology of the heart's action, and physical signs—healthy and morbid. In the article Aus- cultation will be found a sketch of the physi- ology of the heart's action according to the prin- ciples of the writer, adopted throughout this work, and a general exposition of the principles of auscultation in reference to the heart. A more particular and differential account of the signs afforded by auscultation and percussion will be round in the several articles to which the signs respectively refer: viz. — in the article-Heart, (Hypertrophy of the) are all the signs charac- terizing this affection, whether simple or combined with dilatation. In Dilatation are the signs of the simple and the attenuated forms of the disease; the other forms, with their signs, being comprised under Hypertrophy with Dilata- tion. In Dilatation the range of sound, and in Hypertrophy that of impulse, is more parti- cularly described. Under Heart, (Diseases of the Valves of the) are the signs of all the va- rieties of this affection, with the diagnosis from analogous signs produced by nervous derange- ments : Under Aorta, (Aneurism of the) are the signs of disease of the great vessels, with the diagnosis from nervous affections; and under Heart, (Malformations of the, and Heart, (Polypus of the) are the peculiar signs, ac- cording to the writer's observation, of those mal- adies. We would recommend the student to adopt the following arrangement of the articles in studying the various diseases of the heart consecutively. Inflammatory affections of the heart and great vessels, as they give birth to a large proportion of the organic diseases, should take precedence of the rest. Thus Pericarditis leads to Adhe- sion of the Pericardium, (which subject is discussed at the end of Pericarditis) ; and the latter leads to Hypertrophy with Dilata- tion. Carditis (which is treated of under Pericarditis) gives rise to Softening, Indu- ration, Dilatation. Arteritis, acute and chronic, contains an account of the morbid altera- tions of the valves and internal membrane of the heart and arteries, to which it gives origin. Under this head, also, the other probable causes of some of these alterations are fully discussed. Hyper- trophy should next be studied. It embraces the varieties in which it is conjoined with dilatation. After reading this article the student should pro- ceed to Dilatation, in order that, by contrasting the respective varieties, the mode of production, and the pathological effects of hypertrophy, and of dilatation, he may be enabled to form a just and comprehensive idea of the relative nature of the two affections. Dilatation presents an ac- count of those varieties only in which the force of the heart's action is not increased : viz. — Di- latation with Attenuation, and some cases of Simple Dilatation ; those in which the action is increased being described under Hyper- trophy with Dilatation. After reading Hy- pertrophy and Dilatation, the student should proceed to Diseases of the Valves, as he is now prepared to understand how these produce their effects, and become causes of hypertrophy »nd of dilatation. Heart, (Diseases of the "alves of the) comprehends every variety of these affections, with the signs physical and gene- ral ; and also an account of cardiac asthma. The following diseases of the muscular structure may next be studied : Partial Dilatation, or nEAi Aneurism of the Heart; Softening; Rup- ture ; Induration; Fatty and Greasy De- generations ; Productions, (Accidental) j Atrophy of the Heart. Aorta, (Aneurism of the) comprising an account of nervous pulsa- tion of the aorta, forms an elaborate article, much original matter being added with a view to estab- lish the diagnosis—one of great importance, and now, we trust, presenting little obscurity: the study of this subject should be deferred till the reader is acquainted with Hypertrophy, Dila- tation, and Diseases of the Valves, as he will thus be better qualified to understand how disease of the aorta gives birth to that of the heart, and constitutes one of the most formidable com- plications of cardiac affections. Malformations, Angina Pectoris, Polypus of the Heart, Displacements, Hydro-Pericardium, Pneu- mo-Pericardium, Palpitation, particularly nervous and dyspeptic, are severally brought under consideration in separate articles. Treatment. — In the article Pericarditis, the treatment of the inflammatory affections is fully considered. A few remarks are also ap- pended to Arteritis. In Hypertrophy and Dilatation respectively, the observations on treatment are confined to the immediate and pecu- liar effects of each disease ; while Heart, (Dis- eases of the Valves of the) is a general article on treatment, not only embracing all the secondary effects, but giving a detailed account of the man- ner of exhibiting, and the modus operandi of the various remedies employed. In Aorta, (Aneur- ism of the) the mode of spontaneous cure and the medical treatment are fully explained, and re- marks are added on the treatment of nervous aortic pulsation. We shall conclude this brief explanatory and indicatory notice with a few remarks on the di- agnosis and treatment of cardiac affections in general. Diseases of the heart were formerly involved in deep obscurity. This is no longer the case. By a conjunction (and the necessity for this conjunc- tion cannot be too strongly impressed) of the physical signs, or those afforded by auscultation and percussion, with the general signs, improved as they have been in consequence of being studied with the aid of auscultation, the diseases in ques- tion may be detected with a facility and precision which can scarcely be surpassed in any other class of affections. The direct practical advantage re- sulting from this is, that instead of being almost incurable, as they were formerly regarded in con- sequence of seldom being detected till they had attained an incurable degree, they now, from ad- mitting of detection even in the earliest stage, can in numerous instances be completely cured; and when not, can in general be so far counteracted as not materially, and often not at all, to curtail the life of the patient. The collateral practical advantages are no less important. Apoplexy and palsy, in a scarcely credible number of cases, are directly dependent on hypertrophic enlargement of the heart. Should the cause be detected, the HEART, (DILAT ATION OF THE) 379 effect may be obviated ; should it be overlooked, the patient would probably fall a martyr to the "active exercise" supposed necessary to reduce his apoplectic fulness of habit. No less frequently are the most dangerous cases of asthma, of dropsy, and of epilepsy, referable to disease of the heart; and this malady seldom occasions long-continued obstruction of the circulation without producing enlargement of the liver,—one of the least gener- ally known of the common facts in medical science. Nervousness and dyspepsia very often assume the aspect of disease of the heart; and this, on the other hand, being frequently productive of ner- vousness and dyspepsia, may be disguised by, and mistaken for them, though with the aid of auscul- tation the diagnosis presents no difficulty. In acute rheumatism the most formidable source of danger is inflammation of the pericardium. In- flammation of the lungs supervening on organic disease of the heart is singularly rapid, uncontrol- lable, an', lestructive. In fever and inflammation in genei >1, the state of the pulse as to fulness, hardness, weakness, or irregularity, may be com- pletely disguised by a co-existent disease of the heart. In all the above instances the appropriate treatment would differ widely and perhaps entirely from that which the practitioner would probably adopt were he to remain ignorant of the affection of the heart. This brief sketch is sufficient to display the ex- tensive relations and vast importance of the subject of cardiac affections, and to show, that unless the practitioner be conversant with it, not only may he compromise the safety of his patient, but his reputation must be responsible for many mortify- ing falsifications of his diagnosis, and for the blind impression that danger was remote when it was at the threshold. HEART, (DILATATION OF THE)—The disease commonly known by this name consists of an amplification of one or more of its cavities. The ventricular parietes may be thickened, natural, or attenuated. The disease accordingly resolves itself into three varieties, corresponding with these states. 1. Dilatation with thickening, in which the cavity is enlarged and the walls are thickened. 2. Simple dilatation, in which the cavity is enlarged and the walls are of their natural thick- ness. 3. Dilatation with attenuation, in which the cavity is enlarged and the walls are attenuated. The first variety is identical with that variety of hypertrophy called hypertrophy with dilatation, different names being employed for the two, in order to express, in dilatation with thickening, a predominance of dilatation, and, in hypertrophy with dilatation, of hypertrophy. The second va- riety is perfectly identical with hypertrophy by increased extent, with natural thickness of the walls; but the term simple dilatation is preferable when the dilatation is so great that its symptoms predominate over those of hypertrophy. Two, or all three of the forms of dilatation are sometimes found together in different parts of the same cavity. The anatomical characters of simple dilatation and that with thickening will be described in the article on Hypertrophy. To dilatation with attenuation we here direct our attention. It seldom affects one ventricle without the other. The emaciation may be such as to reduce the most substantial part of the left ventricle to two lines in thickness, and the apex to a mere membrane, of which we have seen more than one instance. Extreme attenuation is more common in the right than in the left ventricle. In either, the columnar carneae appear stretched and spread. The inter- ventricular septum is proportionably much less attenuated and softened than the other parts. Dilatation takes place more in the transverse than in the longitudinal direction of the ventricles, and it accordingly communicates to the heart an un- usually spherical form, so that the diameter of the organ near the apex is almost as wide as at the base, the apex itself being often scarcely distin- guishable. This alteration of shape is the best criterion for determining whether a heart be dilated or not when the enlargement is so inconsiderable as to render the question doubtful. When both the auricle and ventricle are much dilated, it is not unusual to find the intermediate aperture widened, and its valve sometimes not large enough to close it. The muscular substance, sometimes healthy in every form and degree of this affection, in general is not so. For, when the organ is con- siderably enfeebled, its parietes are usually more or less softened and flaccid, and in some cases of a deeper red, (a consequence of venous engorge- ment,) in others paler or more fawn-coloured thar. natural. Dilatation may give rise to rupture of the heart, especially as it is so often attended with softening. We witnessed a case of this kind a few years ago, and are acquainted with others. In order to judge accurately of dilatation of the auricles, it is necessary to have distinct ideas re- specting their natural form and dimensions. The four cavities of the heart are very nearly equal in capacity; but, as the parietes of the auricles are thin, and those of the ventricles are comparatively thick, the auricles, when merely full, and not dis- tended, form only about one-third of the total volume of the organ ; or, what is the same thing, the volume of the auricles equals about half that of the ventricles. (Laennec, de 1'AuscuIt tom. ii. p. 523.) The right auricle being of a more elongated, flattened form than the left, and being generally found in a state of distension, has the appearance of being considerably larger, though in reality it is only a little so. Distension, taking place during the last mo ments of life, and observable, though more rarely, in the left auricle as well as in the right, consti- tutes the great source of fallacy in determining, after death, whether these cavities are really dilated or not; for the engorgement, though only of a few hours' duration, may stretch them to a magni- tude almost equalling that of the ventricles. M. Laennec has given good criteria by which a dilated may be distinguished from a distended auricle. An auricle simply distended is tense, and through its thinnest parts distinctly shows the dark blood within. One dilated does not present the same appearance of tension, and its parietes are more opaque. When the blood is evacuated through the vessels without cutting into the cavities, the latter, if merely distended. 3S0 HEART, (DILATATION OF THE) return at once to nearly their natural size; where- as, if dilated, they maintain almost the same size as they had when full. Dilatation of the auricles is almost invariably accompanied with more or less thickening of their parietes. The method of distinguishing distension from dilatation is much the same in the ventricles as in the auricles: namely, when merely distended, they are found enlarged, firm, and tense; but these conditions almost entirely disappear when the blood is pressed out through the natural aper- tures. On the contrary, when truly dilated, they have no appearance of tension, are more or less flaccid, and the enlargement persists after the blood has been evacuated. Dilatation of the heart is a purely mechanical effect of over-distension. Blood, accumulated with- in its cavities, exerts a pressure from the centre towards the circumference, in every direction; and when once it surmounts the resistance offered by the contractile and elastic power of the parietes, these naturally yield and undergo dilatation. The rapidity with which this process takes place, and the extent to which it is carried, depend on the degree in which the distending exceeds the resist- ing force; and as the latter bears a direct ratio to the volume of the muscle, supposing it to be healthy, it follows that those cavities which have the thinnest parietes are, cxteris paribus, the most susceptible of dilatation. Accordingly, we find that the right ventricle is more frequently and promptly dilated than the left, and the auricles than either. In order to produce permanent dilatation, the operation of the exciting cause must either be prolonged for a certain time, or frequently repeated at brief intervals. Contraction of an orifice, for instance, acts in the former manner; and nervous palpitations, or occupations requiring constant reiteration of muscular efforts, produce their effect in the latter way. When the operation of the cause is only brief and transitory, the result is merely a temporary distension, from which the muscle recovers itself by its own elastic and con- tractile re-action so soon as the distending force is removed. This cannot be regarded as a patholo- gical state, and it must, therefore, be carefully dis- tinguished from genuine dilatation. The exciting causes of dilatation are, 1st, defi- cient power of the heart, whether congenital or acquired, in proportion to the system; 2d, in ge- neral terms, all obstructions to the circulation, whether situated in the orifices of the heart, or in the aortic or pulmonary system. The latter class of causes are, in fact, essentially the same as the exciting causes of hypertrophy ; for it depends on the proportion which the resistance of the muscle bears to the distending force, whether the one affection or the other is produced. When, there- fore, dilatation occurs in one of the cavities with naturally thick walls, in which we should more properly expect hypertrophy, it must be ascribed either to a congenital disproportion of the heart, in consequence of which the cavity in question is thinner, and therefore more disposed to dilata- tion, than natural; or it must be attributed to the obstruction, from its nature or situation, bearing more in proportion on that particular cavity than on any other. It is from having overlooked these considerations respecting the relations of the re- sisting and distending forces to each other, that some have excluded dilatation from the catalogue of mechanical diseases, and supposed that it takes its rise in any cavity of the heart either by chance or by some vital predilection — some vague, unin- telligible predisposition. Dilatation occasionally affects only a single ventricle, and it is generally the right; but much more commonly it attacks both. The auricles, being protected by their valves from the direct in- fluence of the numerous causes of pressure which operate on the ventricles, are far more exempt than they, both from dilatation and hypertrophy. But when the auricular valves are diseased, whe- ther their state be that of contraction, which im- pedes the transmission of the auricular blood, or of permanent patescence, which allows a regurgi- tation of the ventricular, the auricles, suffering unnatural distension, become dilated. It is seldom that dilatation of the auricles occurs under any other circumstances than those of dis- ease of their valves; so seldom, indeed, that Laen- nec does not recollect to have seen an instance, though he does not deny the possibility of the oc- currence. More instances than one, however, have fallen under our own observation, and we have generally found the dilatation connected with some circumstances incapacitating the ven- tricle from freely evacuating its contents. It is natural, indeed, to suppose that when such is the case, the stagnation of blood in the ventricles must, for the time, have an effect in distending the auricle equivalent to that produced by con- traction of the auriculo-ventricular valve; and considering the frequency of stagnation in the right ventricle, we might at first expect dilatation of the corresponding auricle from this cause to be frequent. But it must be remembered that, for the production of the disease, it is necessary that the operation of the cause be permanent, or at least very prolonged. Such, however, is seldom the case with the stagnation in question; for a ventricle, though so feeble in itself, or so encum- bered by an obstacle before it in the course of the circulation, as to become gorged during an accele- rated state of the heart's action, will, when tran- quillity is restored, transmit its contents with a facility that could scarcely be anticipated. During such intervals, therefore, the muscular fibres of the auricle recover their contractile power, and restore the cavity to its natural size. M. Bertin contends that dilatation is never a primitive malady, but merely a consecutive effect of a pre-existing lesion — of an obstacle to the course of the blood ; and that the symptoms pro- duced by such obstacles, viz. vascular engorge- ment, dropsy, passive hemorrhage, &c. have no other relation to dilatation than as being results of the same cause — the obstruction of the circu- lation. We cannot concur with M. Bertin in these opinions. It is true that, in order to produce dilatation, there must exist a weight or pressure of the circulation upon the heart greater than the organ is capable of sustaining; and it is true that such pressure may be occasioned by the mecha- nical obstacles to which M. Bertin ascribes it, namely, contraction of the orifices of the heart, HEART, (DILAT ATION OF THE) 381 diseases of the aorta, and all maladies which im- pede the course of the blood, whether in the lungs or in the system of the great circulation. (Bertin, p. 380.) But it is equally true that the same pressure on the heart may result, not from in- creased weight of the circulation, but from defi- cient power of the heart; and such is its cause in those who, by original conformation, have the organ thin in proportion to the size of the body. Another class in whom debility of the heart exists as a cause of dilatation, comprises those who have had the organ softened or otherwise enfeebled by disease ; an effect not unfrequently produced by typhoid fever, and by inflammation of the sub- stance and membranes of the heart. Dilatation, then, occurring under the circum- stances described, is as justly entitled to the rank of a primitive disease as hypertrophy; for as in both the disease depends, not on the pressure of the circulation, but on the manner in which the heart resists that pressure, in both the organ itself is the part where the disease originates; the only difference being, that in the one case the effect is produced by deficient, in the other by superabun- dant, power of the muscle. In the next place, M. Bertin has, in our opinion, attributed far too much to the lesion of which he considers dilatation to be the effect, when he says that this lesion is the sole cause of all the symp- toms which authors have been in the habit of ascribing to dilatation. It is true that when the lesion is so great as to constitute an extreme ob- stacle to the circulation, it may produce the symp- toms in question ; but it does not produce them, or produces them only in a very slight degree, when the obstacle is not extreme. We have re- peatedly witnessed cases in which a well-marked if not a considerable obstacle, as a contracted valve, or a dilatation or aneurism of the aorta, had subsisted for a long period, even for years, without producing any material symptoms of an obstructed circulation ; hut the moment that dilatation of the heart supervened, the symptoms made their ap- pearance in an aggravated form. We apprehend, therefore, that the heart is the part mainly con- cerned in their production ; nor do we think this opinion less tenable because the symptoms are more severe when enlargement of the heart co- exists with an obstacle than when the enlargement exists alone ; for it is natural to suppose that when two causes conspire to produce the same effect, that effect will be greater. But this is not all; for not only does each produce its own effect, but one increases the effect of the other; namely, the obstacle adds so much to the pressure of the circulation on the heart, that this organ labours under a double disadvantage, first, from its own diminished power, and, secondly, from a preter- natural pressure upon it. Thus the resulting effect of the obstacle and the dilatation of the heart com- bined, is greater than the sum of the two taken separately. In further invalidation of M. Bertin's opinion, we. may add that we have seen numerous instances in which all the phenomena of an obstructed cir- culation were occasioned by dilatation alone, as no other obstacle capable of accounting for them could be detected in the course of the circulation. According to the foregoing arguments then, it appears, first, that dilatation may be a primitive disease, and that, as such, it is capable of pro- ducing all the phenomena of an obstructed circu- lation ; secondly, that when it is consecutive to another lesion, it plays a prominent, and perhaps, even, in some cases, a more important part than that lesion in producing the phenomena of an obstructed circulation. In order to ascertain the real effects of dilata- tion, it is necessary to confine ourselves, in study- ing them, to the simple uncomplicated form of the disease. Taking into consideration this form alone, and admitting, on the foregoing grounds, that it is capable of producing all the phenomena of an ob- structed circulation, we have next to inquire how, or by what mechanism, it produces them. To answer this question, — it produces them by putting the muscular fibres of the heart preterna- turally on the stretch, whereby their contractile power is diminished ; they lose, as it were, in force what they gain in length; and it is this deficiency of power in the main-spring of the cir- culation which constitutes the obstacle, if it may be so called, to the circulation, in the same way that weakness of the spring of a time-piece retards its movements. Diagnosis of Dilatation. — General signs. —We have shown that the effect of dilatation is to enfeeble the heart, and thereby occasion the phenomena of an obstructed circulation. We have now to examine these phenomena as signs of dilatation. The heart, when dilated, is subject to palpita- tions of a feeble oppressed kind, and more or less distressing, frequent, and prolonged, according to the extent of the malady. The attacks are pro- voked by any over-exertion or mental excitement. The pulse is soft and feeble, and if the debility of the heart be very considerable, it is small. Irregu- larity and intermittence are rare, except during severe dyspnoea, or when the vital powers are much exhausted, as in the extreme stage of the disease. The languor of the arterial circulation causes the extremities and surface to be chilly, the dispo- sition to be melancholy, and the character to be deficient in energy. The blood, not being freely transmitted by the left ventricle, accumulates by retardation in the lungs; whence difficulty of respiration; cough, sooner or later attended with copious expectoration of thin, serous mucus; oedema of the cellular tissue of the lungs, greatly aggravating the dyspnoea; terrific dreams, with starting from sleep; and passive pulmonary he- morrhage of dark, grumous blood in small quan- tities, forming sanious sputa, and generally the precursor of death when it occurs in individuals affected with extreme difficulty of respiration. The lungs being obstructed, the engorgement i3 propagated backwards to the right side of the heart, to the great veins, and finally to all then ramifications. From this venous engorgement arises a series of striking phenomena, which we shall review successively. 1. Serous Infiltration.—This generally make* its appearance first in the lower extremities, be- cause it is in them that the circulation is most languid, the return of the blood being opposed by 382 HEART, (DILATATION OF THE) its gravity : while about the feet and ankles it is little promoted by the action of superincumbent muscles. Increased serous exhalation takes place in the serous membranes also; hence hydro- thorax, hydro-pericardium, and ascites, one or other of which is almost invariably present when there is much external dropsy. 2. Discoloration of the Face.— If the com- plexion was originally florid, it becomes purple or deep violet, principally on the cheeks, the end of the nose, and the lips, with intumescence of the latter. If originally pale, it becomes cadaverously exanguious, and has a dusky, leaden cast, espe- cially about the eyes. The lips are either livid or totally colourless. Lividity sometimes shows itself in the extremities as well as in the face. 3. Congestion of the Brain.—This produces sub-apoplectic symptoms, as dull headach, felt principally along the course of the great sinuses; hebetude of the mental faculties; stupor, convul- sions, and eventually complete coma. It is not unusual for these symptoms to supervene a few days before the fatal termination. Sometimes they depend not on congestion alone, but partly also on serous effusion into the ventricles. This, however, is not always the case, as we have ascer- tained by several dissections. 4. Injection of the Mucous Membranes.—It is common to find them after death so vascular as to present the appearance of inflammation. This is especially the case in the stomach and intestines, and it is necessary to be aware of the circum- stance, in order to guard against the error of attributing the redness to inflammation. 5. Passive Hemorrhage. — This takes place from the lungs, as already stated, from the nose, the stomach, the intestines, and more rarely from the bladder. It results from engorgement of the mucous membranes. The effusion consists of dark blood exuding in small quantities. When from the stomach, it has occasionally the appear- ance of coffee-grounds. 6. Congestion and Enlargement of the Liver. —This is so common a consequence of retarda- tion of the circulation on the right side of the heart, that few persons so affected in any consid- erable degree are exempt from it. By the obstruc- tion which it occasions in the system of the vena porta, it leads to ascites. The sign which, with Laennec, we think the most constant and characteristic of the equivocal signs of dilatation of the right ventricle in par- ticular, is permanent turgescence of the external jugular veins without sensible pulsation. This turgescence does not disappear when the vein is compressed at the upper part of the neck. Dilatation of the auricles presents no general signs distinguishable from those of disease in the corresponding ventricle or valve, to which it owes its origin ; but its existence may be inferred when the valve in question is either much obstructed or permanently open, or when, from any cause, there is great retardation of blood in the ventricle. Physical Signs. — The signs of the two first varieties of dilatation, namely, that with a thicken- ed, and that with a natural thickness of the walls, are given in the article on hypertrophy. It only remains for us to describe the signs of the third variety, or dilatation with attenuation. The Impulse.—In this variety the impulse is diminished, and in extreme cases entirely absent, even during palpitation. When felt, it is only a brief percussion of the thoracic parietes, not ele- vating the ear. When the dilatation is great, the impulse is a little lower down than natural. It sometimes happens that, of several beats of the heart that are heard, one only is felt,- and if this be vigorous, it warrants a conclusion that the parietes are little attenuated. Though Laennec does not make this observation, we have assured ourselves of its accuracy by numerous post-mortem examinations. The Sounds.—When the walls of the»ventricles are merely thin without being dilated, the first sound (the sound produced by the systole of the ventricles) is louder, shorter, and clearer than natural; it approximates in its character to the second sound, (that produced by the diastole of the ventricles,) which is analogous to the flapping of a pair of bellows. When there is dilatation, even in a moderate degree, the first sound becomes almost the same, and nearly as strong as the second ; and finally, when the dilatation is con- siderable, the two sounds cannot be distinguished either by their nature or intensity, but solely by their respective relations of synchronism or ana- chronism with the arterial pulse. The pulse in remote arteries, as the radial, often being, in dila- tation and various other diseases of the heart, later than the ventricular systole, the pulse of the caro- tid or subclavian should be felt. In proportion as the sounds of the heart are louder, they are audible at a greater distance over the chest; accordingly, M. Laennec has proposed a scale by which the extent is made an index of the degree of dilatation and attenuation. Before describing this scale, it is necessary to acquaint the reader with the range of the sounds in the natural state. In a healthy man, of medium stoutness, and whose heart is in the best proportions, the sounds, according to Laennec, are audible in the precor- dial region alone; that is, in the space comprised between the cartilages of the fourth and seventh left ribs, and underneath the inferior half of the sternum; also, if the sternum be short, in the epigastrium. We have generally thought that they may be heard a little beyond this range. The sounds are similar and equal on the two sides of the heart, those of the right being most audible under the sternum, and those of the left under the cartilages of the ribs. When^audible beyond the limits mentioned, they are heard successively in the following places, constituting the scale alluded to :—viz. 1st, along the sternum and on the left superior anterior part of the chest as high as the clavicle; 2d, over the same extent on the right side; 3d, on the left side of the chest, from the axilla to the region of the stomach; 4th, on the right side over the same extent; 5th, on the pos- terior left side of the chest; 6th, on the posterior right side. The intensity of the sound is pro- gressively less in the succession indicated, pro- vided the parts around the heart are in the same states. But there are so many diversities in these states, which may interfere with the order de- scribed, that we have found the scale of M. Laennac of little practical utility in estimating the HEART, (DILATATION OF THE) 353 degree of dilatation. Thus, in very fat subjects, in whom the impulse of the heart is not perceptible to the hand, the space over which its healthy sounds can be heard by the cylinder is much more limited than natural : Laennec has even found them confined, in some instances, to a square inch, though we cannot say that this has occurred to ourselves. On the other hand, in meagre persons, in those who are narrow-chested, and in children, the sounds are audible much further than ordinary : namely, over the two inferior thirds, or even three-fourths of the ster- num, sometimes even over the whole of that bone, and at the left anterior superior part of the chest as high as the clavicle; often, also, though less distinctly, below the right clavicle. In very mea- gre subjects, we have heard them over the whole chest, both posteriorly and anteriorly. Now, as it is almost impossible to make an exact estimate of the degree in which stoutness limits, and lean- ness, &c. extend the range of the sounds, this range is not a sure criterion of the degree of dila- tation. Again, a lung in any way consolidated, whether by hepatization, tubercles, or compression by fluid in the cavity of the pleura, transmits the sounds of the heart more readily than a lung that is sound and permeable to air — a phenomenon explicable on the principle that dense bodies are the best conductors of sound. The effect is the same, though there be cavities in a tuberculous lung; for the sound is transmitted, not through the cavities, but through their walls, which are denser than healthy pulmonary tissue. Under these various circumstances then, the sounds are irregularly propagated, and the progres- sive scale of Laennec is interfered with. For in- stance, if the right lung be consolidated, the sounds will be more audible on that side than on the left. Our own mode of estimating the degree of dila- tation is, by observing how far the first sound re- sembles the second, and comparing the intensity of the first, heard immediately over the ventricle affected, with what we believe, from experience, would be its intensity in the same subject if the heart were healthy. We then corroborate the estimate, if necessary, by the scale of Laennec, making allowances, as far as is practicable, for stoutness, leanness, youth, pulmonary condensa- tion, &c. The manner in which we judge of at- tenuation by the first sound, is less by its loud- ness than by its remarkable shortness and clear- ness ; for we think it is often louder in dilatation with hypertrophy, or even with a natural thickness of the parietes, than with attenuation. This opinion is opposed to that of Laennec, who " thinks he may regard it as constant, that the extent over which the beats of the heart are audible, is in the direct ratio of the feebleness and thinness of its walls." So far is this from being perfectly true, that we have met with cases in which the heart was dilated and attenuated to the extreme, yet the first sound was feeble : nor should we ex- pect it to be otherwise in such cases; for when the heart, from extreme dilatation, is too feeble to contract smartly, its sounds must necessarily be weak. Hence they are so in ramollissement, and in the moments preceding dissolution. Resonance on Percussion.—The resonance of the praecordial region on percussion is diminished by dilatation. The dulness is situated rather lower down than natural, and as it is always in propor- tion to the increase of volume of the heart, it is greater in hypertrophy with dilatation than in mere dilatation. Dulness of the praecordial region on percussion may exist independent of the enlarge- ment of the heart; namely, when the anterior borders of the lungs are hepatized, and extend in front of the heart. On-the contrary, dilatation sometimes does not occasion deficient resonance when the lungs are emphysematous, and their an- terior margins are forced between the organ and the sternum. Physical Signs of Dilatation of the Auricles. —Auscultation has not hitherto supplied any direct, signs of dilatation of the auricles; but as this affec- tion is in general the consequence of disease of the valves, and of enlargement of the ventricles im- peding the circulation through the heart, its exis- tence may be inferred from the presence of signs of these affections. Prognosis. —In many persons the heart, with- out being dilated, has naturally thin walls : those of the left ventricle, for instance, are not, at the utmost, more than twice the thickness of those of the right. This state presents the same signs as dilatation, but in a less degree ; namely, the im- pulse is diminished, the first sound is loud, short, and clear, and both sounds are more extensively audible than natural. Individuals so affected mr»y live for a great number of years,—even to an ex- treme old age, in a state of tolerably good health: it is only to be remarked that this conformation is in general accompanied with a delicate constitution, a slim stature, and small muscles. In fevers and diseases of the respiratory organs, the individuals in question experience, caeteris paribus, greater dyspnoea than others. If such a conformation augment, even slightly, a dilatation of the heart is the result. A slight degree of dilatation is nol a very for- midable affection. The dyspnoea is sometimes not so great as to deserve the name of morbid ; but the patient has merely a shorter respiration than most men, he more readily loses breath, and ex- periences palpitations from much slighter causes. With these slight symptoms, however, he gene- rally exhibits some traces of the cachexy proper to organic disease of the heart. The state de- scribed, which is that of a great number of asth- matics, may subsist very long without occasioning any disorder of a serious nature ; it may remain without making progress for a great number of years, and it does not always prevent the patient from attaining an extreme old age. When dilatation has advanced so far as to occa- sion morbid dyspnoea, it has a constant tendency to increase unless the circulation be kept tranquil by a very quiet life, and by judicious medical treat- ment when necessary. With these precautions the disease may be kept stationary, sometimes for an indefinite period, if not exasperated by fevers or inflammatory affections, which, by hurrying the circulation, are eminently prejudicial. When dropsy comes on, and, after having been removed by remedies, constantly shows a dispo sition to return, we may know that the dilatation tends to its fatal termination: and although the 384 HEART, (DILATATION OF THE) patient may sometimes rally from five, six, or even more attacks, he generally sinks in the course of one or two years or less. The progress of dilata- tion with hypertrophy is much more rapid, as ex- plained in the article on Hypertrophy The general prognosis is founded on the above considerations, and is favourable so fai as life is immediately concerned. The particular prognosis depends upon the degree of severity of the symp- toms and on the constitution of the patient. Treatment.—The treatment of dilatation with increased power of the heart, that is, with hyper- trophy, is described in the article on hypertrophy. In this place we have only to speak of the treat- ment of dilatation with diminished power, that is, with attenuation, and sometimes even with a natural degree of thickness of the parietes. The first indication is, to remove, if possible, the exciting cause of the dilatation; and if this be done before the disease has proceeded to such an extent as entirely to deprive the muscular fibre of its resilience and elasticity, these faculties come into operation and restore the organ to its natural size. Accordingly, if the cause be an obstruction in the pulmonary circulation, as that produced by peripneumony, hydro-thorax, or pneumo-thorax, emphysema, the use of wind instruments, ven- triloquism, tubercles, &c, the attention must be primarily directed to the removal of these affections and the prohibition of these habits. If the cause be, too violent exercises or passions, inebriety, oc- cupations which, by placing the patient in a con- strained posture, prevent the free circulation of the blood, as in shoe-makers, tailors, &c, the perni- cious exercises, habits or occupations must be abandoned and the passions calmed. All the causes enumerated being of a temporary nature, the dila- tation resulting from them, if not inveterate, can often be removed. But when the cause is perma- nent, as the contraction of an orifice of the heart, or a natural or acquired feebleness of the organ in proportion to its function, a cure of the dilatation is scarcely to be expected; but it may often be prevented from increasing, and the life of the patient may sometimes be prolonged even to its extreme limits. In such cases, therefore, the practitioner should steadily and perseveringly pursue a pallia- tive and prophylactic treatment, having first dis- carded from his mind the impression, no less erro- neous in itself than detrimental to the progress of medical science, that organic diseases of the heart are necessarily fatal, and that, therefore, all treat- ment is unavailing. The circulation should be kept as tranquil as possible by a quiet life and a moderate unstimulat- ing diet. The food, however, should be rather nutritious, comprising a little animal food or soup twice a day, in order to keep the muscular system in general, and that of the heart in particular, in good tone. The same object may be promoted by a clear, dry, bracing air, (as that of Brighton,) ar.d by the shower-bath ; from both of which we have seen the best effects result. Neither of them, however, have we found to suit those patients who have great pulmonary congestion with copious expectoration; as such require a warm humid at- mosphere to favour expectoration and the cuta- neous function, and they cannot bear the shower- hath on account of its determining too much from the surface to the heart and grea< vessels: neithei can they well bear opiates, as these remedies partly occasion diminished mucous secretion, and partly accumulation of that already secreted; both of which circumstances increase the dyspnoea. The general health and strength may likewise be im- proved by the occasional exhibition of bitters, mineral acids, and chalybeates, with aromatics. The stomach, in particular, should be kept in good order, as its derangements—even a little flatulence or acidity—have a surprising effect in disturbing the action of the heart. The same may be said of the biliary secretion. When there is an un- equal distribution of nervous power, indicated by hysterical symptoms, &c, antispasmodics, particu- larly the piluli galbani composita and valerian, are very useful adjuncts to other remedies. Febrile and inflammatory affections of every kind, but particularly inflammation of the lungs and bronchi, should be sedulously guarded against, and, when occurring, should be promptly treated. Even a slight pulmonary catarrh should be viewed as a serious affection. To prevent colds and re- lieve the heart by keeping up the circulation on the surface, flannel next to the skin is almost in- dispensable ; and, if the patient be chilly, as is frequently the case in dilatation, a jacket of wash- leather should be worn over the flannel during winter. Attacks of dyspnoea are best relieved by im- mersing all the extremities in warm water, a blanket being thrown round the patient to promote perspiration, and fresh cool air being admitted to satisfy the craving for breath. While this is being done, he should take an antispasmodic draught composed of ether, laudanum, camphor, ammonia, and assafoetida, combined according to circum- stances. (See treatment of Heart, Diseases or the Valves of the.) It may be repeated two or three times, at intervals of from half an hour to an hour according to circumstances. Bloodletting should not be resorted to in dilatation with deficient power of the heart, during the pa- roxysm, and merely for the purpose of relieving it. The abstraction of a small quantity has not the effect, and that of a large quantity is inadmis- sible, as it does more injury by increasing the de- bility of the heart and the system, than it does good by lightening the circulation; and conse- quently, an ultimate aggravation of dyspnoea en- sues. More than once have we seen a large and indiscreet bloodletting fatal, as the patient could not rally from the exhaustion produced by the attack of dyspnoea to which that from the deple- tion had been superadded. If there be an absolute necessity for bloodletting—that is, if the dyspnoea be constant, and cannot be relieved by any other means—the quantity drawn should not exceed six ounces at one time ; and it should be drawn very slowly, in the recumbent position, and during the intervals or remissions of the fits. In this way the bleeding may be repeated, if necessary, every one, two, or three months, provided it does not diminish, but rather increases, the strength of the patient. For the treatment of dropsy, cough, &c, we refer the reader to the article on Heart, (Diseasfs of the Valves of the.) [See on this subject Dr. Hope's Treatise on HEART, (DISPLAC Diseases of the Heart, Amer. edit, by Dr. Pen- nock, p. 288,—PhiladJ, 1842.1 J J. Hope. HEART, DISPLACEMENT OF THE.— Ectopia cordis, from tKToirifa or Urdrzior, displaced. The human heart, when occupying its natural position, is situated in the left side of the thorax, behind the sternum and cartilages of the true ribs, and between the right and left lungs. In this situation it is placed obliquely, so that if a line were passed through its axis at the moment of its pulsation, its direction would be downwards, for- wards, and to the left side. Its base is placed almost directly opposite the eighth dorsal vertebra, from which it is separated by the oesophagus and aorta, while its apex is turned forwards and ob- liquely over to the left side ; so that it corresponds, when in a state of repose, to the cartilage of the sixth true rib, and strikes during its pulsation between the cartilages of the fifth and sixth left ribs, at a point about two inches below the nipple, and one inch on its sternal side. The inferior or posterior surface of the heart is flat, and rests upon the tendon of the diaphragm, which supports it; its superior or anterior surface is convex, and is overlapped by the anterior edges of the lungs. From this, which may be considered the natural position of the heart, numerous forms of deviation have been observed, from a slight alteration in the direction of its apex, to the total displacement of the organ from the interior of the chest. Displacement of the heart may occur as a con- genital malformation, or as the result of accident or of disease. I. Some of the congenital displacements are very similar to those into which the heart is some- times forced by diseases of the pleura or lungs, or even by certain organic affections of the heart itself; others, again, are liable to be mistaken for aneurismal tumours or other organic diseases of the heart or large vessels, and might, therefore, mislead the physician into the most serious errors of diagnosis, and consequently of practice, if the possibility of their occurring as a congenital mal- formation were not borne in mind. For this rea- son we shall give a succinct account of the princi- pal congenital displacements of the heart, referring the reader who wishes for more ample details on this interesting subject to the excellent, " Memoire sur I'ectopie du Coeur," published by M. Breschet in the second volume of the « Repertoire General d'Anatomie," and to Dr. Paget's " Inaugural Dis- sertation on the congenital Malformations of the Heart" (Edinburgh, 1831.) The congenital displacement of the heart may be divided into two classes: the first comprising those cases where the heart is contained within the chest, but does not occupy its natural situa- tion there; the second containing those cases of malformation where the heart is situated out of the cavity of the thorax. Cases of this description, though of not very unfrequent occurrence, from the slight inconve- nience they occasion, have received comparatively little attention; yet from the resemblance they bear to the displacements produced by disease, they we, perhaps, the most interesting and important to the practical physician. The following are the principal deviations from its natural position de- Vol.II. —49 2h IEMENT OF THE) 385 pendent on congenital malformation which the heart presents while still situated within the thorax. Instead of being placed diagonally to the axis of the body, with its apex pointing to the left side, it may be situated, a. horizontally; b. vertically, with its apex pointing downwards: c. vertically with its apex pointing upwards; d. diagonally, with its apex pointing to the right instead of the left side; or e. transposed altogether to the right side of the chest. a. The heart has, we are informed, been found in the horizontal position; (Memoires de l'Acade- mie des Sciences, quoted by Breschet;) but this deviation is of very rare occurrence as a congenital malformation, and it may perhaps be doubted whether the effects of disease have not been mis- taken for such. We shall presently see that this alteration in the position of the heart is, as was remarked by Bertin, constantly produced by the enlargement of that organ from hypertrophy. b. The heart has occasionally, though very rarely we believe, been found in the centre of the thorax, occupying a vertical position, as in quadru- peds. A case of this kind is described by Bre- schet. (Memoire cit. page 17.) The infant was born at the full time, lived six weeks, and exhi- bited no external malformation: the heart, which was composed of a single auricle and ventricle, was situated exactly in the median line of the thorax, its apex having a slight inclination to- wards the left side. Another case, described by Klinn, (Acta Academiae, Caes. reg. Joseph, tom. 1, page 228,) is usually quoted as an example of this species of malposition; but there can be little doubt, even from his own description, that the displacement of the heart was caused by the pres- sure of an effusion which had taken place into the left sac of the pleura. c. A much greater alteration in the position of the heart, where the organ was so completely sub- verted that its basis was inferior and its apex superior, is related by Ignatius de Torres. " In a new-born female infant, the heart, destitute of a pericardium, was turned upside down, so that its basis with all the great vessels had fallen down as low as the navel, and its apex, still in the left side, lay hid between the two lungs." (Phil. Trans. abridged, vol. viii. p. 509.) d. The direction of the apex of the heart to the right side, and the situation of the entire organ more or les^ to the right of the mesial line, is among the most common of the situations which the heart occupies when out of its usual place. c. Breschet dissected four cases in the Found- ling Hospital at Paris, where the heart was situ- ated at the right side, without any of the othe*- viscera being transposed. (Op. cit.) Otto, (Hano buch der patholischen, &c. Breslau, 1814,) Moellenbrock, (Miscell. natur. curios, dec. 1, ap. obs. 76,) Mohrenheim, (Wiener Beitr&ge, etc. tom. 2, page 305,) and Elvert, (De phthisi pul monali, etc. Tubing. 1780,) have likewise de scribed this species of congenital displacement. In the greater number of cases where the heart is placed from birth at the right side, there is als« a similar transposition of the other thoracic and of the abdominal viscera. A case highly illustra tive of this general transposition of the viscera i* HEART, (DISPLACEMENT OF THE) 386 recorded by Dr. Bryan in the Trans jctions of the j College of Physicians of Dublin, and the speci- men is preserved in the superb museum of the College of Surgeons of that city. The apex of the heart, instead of pointing towards the left, corresponded to the interval between the fifth and sixth ribs of the right side ; its auricles and ventricles occupied a position exactly the contrary of their ordinary relative situations ; and the aorta, which gave off those vessels to the right that it usually furnishes to the left, descended along the right side of the verte- . bral column. The left lung was divided into three lobes, while the light had only two. The pyloric orifice of the stomach was turned towards the left hypochondrium, which was occupied by the liver, the spleen being at the right side. The whole intestinal tube was transposed in like manner, the caecum resting on the left iliac fossa, &c. &c. In short, all the parts usually situated at the right side were placed at the left, and vice versa. The subject of this case, we are informed, was a woman advanced in life, who had borne several children, and enjoyed good health until a short time before her death. The appearances found on dissection in the kidneys, uterus, and bladder, sufficiently accounted for the symptoms under which she suffered -, but no suspicion was enter- tained that there existed any thing peculiar in her conformation, nor did the displacements lead to any particular symptom—not even to a preference of using her left hand. We have been informed by Dr. Kennedy, that a respectable middle-aged female presented herself last summer at the Dublin General Dispensary, com- plaining of dyspnoea and distressing palpitations. On examinatior with the stethoscope, it was disco- vered that the neart was pulsating at the right side, and no disease could be detected in any of the thoracic viscera to account for the displace- ment ; in addition to which the woman positively avowed that she had felt her heart beating in the same place as long as she could remember. The physician to whom we are indebted for these par- ticulars seemed to entertain little doubt that the displacement in this case was congenital. The second class of congenital displacements of the heart, comprising those cases of malforma- tion in which that organ is situated out of the cavity of the chest, may be divided into those where the heart is situated on the surface of the body, and those where it is situated in the interior, but not in the thorax. " The first kind, in which the heart is on the ■ uitside of the body, includes some of the most fa- tal as well as most frequent cases of exposition of this organ. It is generally connected either with deficiency in the diaphragm and abdominal mus- cles, or with absence of some part of the walls of the thorax. In the former case, we generally find the heart, liver, and stomach, and often the lungs, and all the abdominal viscera, contained in a sac, sometimes covered only by peritoneum, (Archives Generates, tom. 23. p. 511,) sometimes by an ex- tension of the common integuments, (Meckel, Dis- wrt inaugur. page 6, Acta Helvetica, vol. vii. p. 56, de fuetu monstr. «Stc.,) and sometimes occupy- 'iir/ tno sheath of the umbilical cord, (Rep. Gen. d'Anat. tom. ii. p. 25,) forming a variety of umbl- lical hernia." (Paget, op. cit. p. 33.) Protrusion of the heart may likewise take place through a fissure, or deficiency in the sternum or ribs. Some cases of this description are quoted by Breschet in the Memoire already so often allu- ded to; they seem to have arisen principally from a deficiency in the lower part of the sternum from the imperfect development of that bone, and were not accompanied with any other malformation. Such cases are, however, exceedingly rare in com- parison with those where the fissure of the sternum and the protrusion of the heart through it are ac- companied with other malformations arising from a defective development of the parietes of the dif- ferent cavities from the circumference towards the centre, such as large apertures in the parietes of the chest and abdomen with hernia of their con- tents, spina bifida, cleft palate, hare-lip, open peri- neum &c. When the heart is situated in the interior of the body, but not within the chest, it may be found either in the abdomen or in the neck. Heart Situated in the Abdomen. — Ra- mel relates the case of a girl ten years of age, whose heart was placed from birth below the dia- phragm, in the situation usually occupied by the stomach. During infancy she did not appear to suffer any inconvenience from the malposition, and as she grew up it was only on crying violently, or using any particular exertion, that she was seized with palpitations, dyspnoea, and occasion- ally with epistaxis. Ramel attended her for two years, during which time her health and strength continued to improve, until it seemed at length as if nature had become completely reconciled to this unusual arrangement of the circulating system. (Journal de Medecine, tom. xlix. p. 423.) Ano- ther case of this species of malposition of the heart was found by Dr. Wilson in an infant seven days old. (Phil. Trans. 1798, p. 346.) The central and tendinous portion of the diaphragm was deficient, as was also the inferior portion of the pericardium. The heart, consisting of a single auricle and ventricle, was lodged in a deep groove on the convex surface of the liver. In this case there were several other malformations of the prin- cipal blood-vessels, as well as of the abdominal vis- cera, which were sufficient to account for the death of the individual, independently of the dis- placement of the heart. But the most extraordi- nary case of this kind on record is that related by M. Deschamps, (Journal General de Medecine, etc. tom. xxvi. p. 275,) where the heart was found occupying the place of the left kidney. The in- dividual in whom this malformation was found was an old soldier who had served several cam- paigns, and enjoyed excellent health, with the ex- ception of nephritic pains, to which he had then been for some years subject, and on account of which he eventually obtained his discharge from the service. Notwithstanding the frequent recur- rence of these pains, he married, and became the father of three children ; at length, however, the symptoms of renal disease became more violent, and recurred more frequently; hectic fever set in, and he died after an agony of forty hours; his ab- domen covered with large gangrenous spots. On dissection, the right kidney was found very large HEART, (DISPLACEMENT OF THE) 387 and in a state of suppuration ; the place of the left kidney was occupied by the heart, enveloped in its pericardium. In the thorax, there was no trace of the heart to be found, nor was there any appearance to indicate its ever having been placed there. It is remarkable that this extraordinary displacement of the heart was never discovered or even suspected by the individual or his medical at- tendants, all the functions of the heart being as ef- fectually and as regularly performed as though it had occupied its natural position within the tho- rax. It does not appear that there was any mal- formation of the diaphragm, or indeed of any other part in this instance. Heart Situated in the Keck. — In M. Bre- schet's excellent Memoire on this subject, three cases of this extraordinary malformation, which he proposes to designate ectopia cordis cephalica, are related. In one of these cases the heart, lungs, and thymous gland, were all situated in the front of the throat, where they formed a large tumour immediately underneath the lower jaw. The apex of the heart was attached to the base of the tongue, and lay between the rami of the in- ferior maxilla. The chest was filled with the ab- dominal viscera, which had passed up through an aperture in the diaphragm. As such complicated malformations are manifestly incompatible with the extra-uterine life of the individual, their de- scription can afford little practical interest to the physician; we shall, therefore, content ourselves with thus briefly noticing the existence of this va- riety of congenital displacement, and refer the sci- entific anatomist to the original essay on the sub- ject by M. Breschet. Without entering at length into the causes of the different varieties of congenital malposition of the heart, which would be the more unnecessary as the subject will be fully considered in a sepa- rate article on Malformations of that organ, we may remark in general terms, that the greater number of these congenital misplacements depend on an arrest of development at a period before the evolution of the fcetus is completed. In this way may be explained the imperfect union of the parietes of the different cavities, and the conse- quent displacement of the organs usually contained within the thorax and abdomen, their protrusion out of these cavities, &c.; to this cause may also be attributed, with considerable probability at least, the situation of the heart in the neck; as all wri- ters on the development of the embryo are agreed that the heart is situated immediately underneath the head during the first period of the evolution of the fcetus, and that the aorta, instead of forming an arch, descends directly into the chest. It is obvious that if the development of the heart be arrested at this early period, the organ will remain out of the thorax, in the anterior part of the throat, as in the ectopia cephalica of Breschet. We must not, however, suppose that all con- genital misplacements of the heart may be thus accounted for, as there are some which evidently result from a perversion of the natural order of de- »elopment: to this class belong the inclination of the heart's apex to the right, and the total trans- position of the organ to that side, accompanied, as it usually is, with a similar transposition of the other viscera. In this way, also, wc must explain the situation of the heart in the place of the kid- ney in the remarkable case recorded by Deschamps, inasmuch as the organ never occupies that posi- tion at any period of the evolution of the foetus, and, d fortiori, could not continue to occupy that position in consequence of an arrest of its devel- opment ; neither was there any malformation or disease of any of the neighbouring viscera to ac- count for the displacement. II. Displacement of the heart may likewise be occasioned at any period of life by accident or by disease. Displacement from the former cause sel- dom falls under the observation of the physician, as any accident which is of sufficient violence to force the heart out of its natural situation seldom fails to prove instantaneously fatal. Indeed, the only recorded exception that we are aware of is furnished in the remarkable " case of probable dis- cation of the heart from external violence," pub- lished by Dr. Stokes in the Edinburgh Medical and Surgical Journal, No. 108, from which we copy the following account : " Mr. B., aet 21, had enjoyed uninterrupted health until the 7th of May, 1822, when he was severely crushed between a water-wheel and the embank- ment on which the axle was supported. He re- mained for three hours after the accident in a state of complete insensibility. As soon as an examination could be made, the following injuries were> discovered. Two ribs in the lower portion of the left side, the right clavicle and humerus, and the fifth, sixth, and seventh ribs on the right side, were broken. The right side of the face and chest was emphysematous, and there was com- plete paralysis of motion in the right arm, with considerable loss of sensation. The patient felt great pain in the right side of the chest, with a sensation, as if a foreign body preventing respi- ration had been introduced into the right lung .- the pain was accompanied with violent throbbing and heaving, and it was soon discovered that his heart was pulsating ut the right side of the ster- num. He had a short dry cough, but experienced no haemoptysis; and there was no pain or other symptom of pleuritic inflammation at the left side,—a point of considerable importance in the diagnosis of the lesion.* From that period to the present his heart has continued to pulsate on the right side of the sternum, the pulsation being generally strong, and aggravated by mental emo- tion, exercise, or the occurrence of pain in the side. He has never had orlhopnoea, but has al- ways experienced great difficulty of breathing on exercise, or when he has attempted to lie on the left side. Since the accident he has every winter experienced several inflammatory attacks, in which he suffers from violent pain of the right side, with great increase of palpitation and dyspnoea. These attacks are only relieved by bleeding, and he thinks he has been bled upwards of fifty times. It is a remarkable circumstance that syncope has never been produced even after the loss of so much as thirty ounces of blood at a time, and that he * We had lately an opportunity, through Dr. Stop's kindness, of examining this patient, and of ascertaining the accuracy of the above statement. The patient, when interrogated, stated without the Iiiast hesitation, thai before the accident his heart had always beat at I he left side, and that he was himself the first to notice tta change of position after that event. 383 HEART, (DISPLACEMENT OF THE) has taken the powder of digitalis in the dose of eight grains every night for the space of three months, without his pulse ever descending below eighty. When he does not take digitalis, his pulse is generally between one hundred and one hundred and twenty, regular in strength and never intermitting; but when he uses that remedy in his ordinary state, the number of respirations is about thirty in the minute. His habit of body is spare but muscular, and the countenance is not expressive of pain. From August to the latter end of April last he shared constantly in the sports of the field : hunting and shooting were his con- stant employments. " On stripping the patient and examining his chest carefully, the right shoulder appears de- pressed, but the right side inferiorly measures an inch in circumference more than the left. " The left side of the thorax sounds perfectly clear, even to its most inferior portion, and in the situation usually occupied by the heart. Respira- tion of the puerile character, and mixed with some bronchial rales, is to be heard over the en- tire lung, and is as distinct in the mammary re- gion as in the other portions. Neither the sound nor impulse of the heart is perceptible in the car- diac region. At the right side the upper portion of the lung sounds clear, but from the fifth rib downwards there is complete dulness, and here the integuments are exquisitely sensible. In the upper portion, both anteriorly and posteriorly, the respiratory murmur is of the same character as in the opposite lung, but from the fifth rib downward it is wanting ; there is no bronchial respiration or resonance of the voice. The pulsations of the heart can be seen and felt in the right mammary region, between the sixth and seventh ribs, and within an inch of the sternum. When.not over- excited, the sounds of the heart are almost natu- ral. There is no sign of valvular disease." That the heart was actually displaced in this case, there can be no doubt whatever; and that the displacement was caused by the external in- jury is rendered highly probable, from the fact of its being observed for the first time almost imme- diately after the accident, and from the absence (as ascertained by auscultation and percussion) of all those diseases of the adjacent parts which usu- ally cause the displacement of the heart from the left to the right side. Besides the causes of displacement already enu- merated, viz. congenital malposition, and accident or external injury, the heart is likewise liable to be forced out of its natural situation by various morbid alterations of the adjacent parts. On studying the anatomical relations of the heart, we perceive that it is retained in situ by the large blood-vessels which form its superior attach- ment,—by the adhesion of the pericardium to the diaphragm, which attaches it inferiorly,—and by the walls of the mediastinum and the equal pres- sure of the lungs, which oppose its displacement to either side. But as none of those forces which retain the heart in its natural position is of a fixed or unyielding nature, it follows that, whenever a degree of pressure sufficient to overcome their re- sistance is exerted on the heart by the enlarge- ment or other morbid alteration of any of the sur- rounding parts, that organ is pressed out of its natural situation, and forced upwards or down wards, to the right or left side, according to the direction in which the pressure is exerted. The following are the diseases which have been observed most frequently to cause displacement of the heart: 1. Effusion into the Sac of the Pleura.— In nine cases out of ten where the heart is re- moved out of its natural situation, the displace- ment will be found to have arisen from empyema or pneumothorax ; accordingly this displacement is now generally regarded as the most constant and least fallible symptom of these diseases. Of twenty-seven cases of empyema and pneumotho- rax that have come under the author's observation, in the extensive hospitals attached to the Dublin House of Industry, the heart was perceptibly dis- placed in every instance. Pathologists have long remarked that effusion into the left pleura, by the pressure which it exerts on the parietes of the cavity, as well as on the organs contained within it, is capable of thrusting the heart over to the right side of the sternum ; but they do not seem to have been aware that effusion into the right side, by protruding the mediastinum and pressing on the heart, may cause a very considerable dis- placement of that organ to the left of its natural position. In a case of pleuro-pneumothorax, with fistulous communication through the lung of the right side, which was lately operated upon by Mr. MacDowel, in the Richmond Hospital, the heart was distinctly seen and felt pulsating between the fourth and fifth ribs, near the left axilla, from which situation it gradually returned to its natural position, as the pressure which caused its dis- placement was removed by drawing off the air and fluid from the opposite side. In all cases of extensive effusion, whether of air or fluid, into the pleura of the right side, we have uniformly observed a similar displacement of the heart pro- portioned to the extent of the effusion. This dis- placement of the heart to the left can in some cases only be detected by minute examination, and even in extreme cases is less likely to attract observation than the displacement to the right of the sternum, which seldom fails to arrest the at- tention of the patient even though it should be overlooked by his medical attendant. We have already entered at length into the consideration of the value of this symptom as indicative of effu- sion into the pleura, and shall therefore refer the reader to the article Empyema, where he will find this subject fully considered. 2. Aneurism of the Aorta.—When tumours of this kind come in contact with the heart they seldom fail, as they increase in size, to force it to a greater or less distance from its natural position. Dr. Hope records a case of aneurism of the as- cending aorta displacing it to the left The writer has seen an instance of aneurism of the arch thrusting the heart downwards, so that its apex pulsated in the epigastrium. It is evident from their relative anatomy that aneurism of the tho- racic aorta may cause displacement of the heart according to the direction which the sac takes; and Drs. Graves and Stokes have shown that con- siderable displacement of the central organ of the circulation may be produced by aneurism of the abdominal aorta pressing on the diaphragm and HEART, (DISPLACEMENT OF THE) 389 pericardium. In the interesting case which they have recorded, " the heart was at first found to beat in the epigastrium, the impulse having left the usual situation. In the course of a few days it became feebler in the epigastrium, but could be felt pulsating on the right side, at the sternal end of the fifth rib, and ultimately became fixed in the intercostal space of the third and fourth ribs." (Dublin Hosp. Reports, vol. v. p. 10.) We may remark that in two cases of aneurism of the ascending aorta which we had lately under our care, the sac presented a double sound at each pulsation: in neither case was there any perceptible displacement of the heart, as the tu- mour took a direction upwards and to the right side; but in one of the cases which we subse- quently had an opportunity of inspecting, we as- certained that the aneurism was in actual contact with the pericardium and heart, from which no doubt it received and transmitted the double pul- sation. In two cases related by Drs. Graves and Stokes, (op. cit.) the aneurismal tumour gave a double pulsation; and we believe that a similar phenomenon will be observed whenever the aneur- ism is so situated, as to have the double stroke of the heart mechanically communicated to it. 3. Tumours.—Tumours of every description developed in the vicinity of the heart, when they take such a direction and attain so great a size as to press upon that organ, may mechanically dis- place it. In a young woman who died in the Hardwicke Fever Hospital with symptoms of acute thoracic inflammation, we found on dissec- tion, at which we were assisted by the late Pro- fessor Bennet, a large encephaloid tumour, which appeared to have originated in the bronchial glands situated at the root of the left lung, and thence to have descended between the pleura and pericardium, thrusting the heart over into the right side, and eventually eating its way by ulce- ration through the pericardium, where its eruption excited violent inflammation. A similar displace- ment of the heart, and apparently from a similar cause, was found by Boerhaave on the dissection of the Marquis de St. Auban. (Zimmermann, Traite de 1'Experience, tom. iii.) 4. Pulmonary Emphysema. — Laennec states, « that when a single lung is affected, it sometimes becomes so much more voluminous than the other as to press aside the heart and mediastinum." (Forbes's Translation, p. 152.) Judging, however, from our own experience, we feel inclined to rank this among the least frequent cduses of displacement of the heart, as in most instances where one lung is sufficiently emphy- sematous to produce such an effect, the other par- ticipates in the morbid alteration, and by its in- creased volume maintains the pressure which the heart sustains in equilibrio : such at least we have found to be the case in the numerous dissections that we have made. 5. Diaphragmatic Hernia. — It is evident that when the abdominal viscera are forced into the tl orax through an opening in the diaphragm, they may exert such a degree of pressure on the heart as to force it from its natural position. This species of hernia is often congenital, and arises from imperfect development of the dia- phragm, in consequence of which an aperture is 2h* left, through which several of the abdominal vis- cera are protruded into the chest by the contrac- tion of the abdominal muscles. We have already recorded examples of congenital ectopia from this cause. It seldom happens that such subjects sur- vive longer than a few hours after birth, in conse- quence of the obstruction which the respiration encounters. Instances, however, are not wanting of life being prolonged for a considerable period under these apparently hopeless circumstances. In Dr. Wilson's case already quoted, the infant lived some days ; but decidedly the most interest- ing case of this description on record is related by Drs. Graves and Stokes. " A man about forty years of age died of tuber- cular phthisis. The oesophagus, after passing through the usual opening in the diaphragm, was found to re-enter the thorax by another very large opening in the tendinous portion towards the left side. The stomach occupied the inferior portion of the left thoracic cavity, its cardiac and pyloric orifices both lying in the opening. A considera- ble portion of the transverse arch of the colon was also included in the left side of the chest: these viscera, loosely but permanently fixed by means of the serous membranes, all rested on the convex surface of the diaphragm, and pushed the heart and mediastinum towards the right side." (Op. cit. p. 84, 5.) There seems little doubt that the hernia in this case was the result of congenital malformation. Hernia of the abdominal viscera into the thorax, and consequent displacement of the thoracic viscera, has likewise been caused by wounds of the diaphragm, (Essai sur l'Anatomie Pathologique, par J. Cruveilhier,) by rupture of that septum occasioned by a fall; by great exer- tion, (Richter, on Hernia) ; and, as has been al- leged, by enormous distension of the stomach. (Huller, Disput. Chirurg. tom. iii.) 6. Enlargement of the Iiiver.—This is also enumerated by authors among the occasional causes of displacement of the heart; we are not, however, acquainted with a well-authenticated instance of the kind. It is probable that a consi- derable hypertrophy of the left lobe may elevate the diaphragm and displace the heart; the same effect may likewise be produced by excessive en largement of the spleen, or by the development ol any morbid growth in the epigastrium or left hypo chondrium. 7. Hypertrophy with Dilatation of the Heart.—When the heart is enlarged, its apex is carried to the left, and its basis to the right side, in such a manner that it lies almost transversely across the chest This observation, originally, we believe, made by M. Bertin, (Traite des Maladies du Cceur, pi. 2me.) has been repeatedly verified by the writer. It has also been remarked by Bertin that in those cases where the size and weight of the heart are very considerably aug- mented, the organ presses with all its weight on the diaphragm, so that that portion of the septum on which it reposes is thrust before it like a pouch in the abdomen. Sometimes this depression has been known to take place without any visible cause, in which case the affection has received the name of prolapsus of the heart. (Laennec, op. cit. p. 615.) Some authors have thought that this prolapsus migh. be caused by relaxation of 390 HEART, (DISPLACEMENT OF THE) the vessels, by which the heart is as it were sus- pended in situ. (Bertin, op. cit. p. 442.) We think it more probable, however, that the displace- ment in such cases must have been more apparent than real, as we know from experience that the heart's pulsation may be felt in the epigastrium in a great many persons, particularly when the sternum is short, although the heart retains its natural position. Diagnosis and Treatment.—Displacements of the heart are now easily detected by the aid of auscultation and percussion: the disappearance of the usual phenomena of the heart's action from the cardiac region, and their appearance in another and different situation, afford unerring evidence of a corresponding change in the position of the organ. As, however, the changes of position which the heart undergoes are, in every instance almost, the effect of more serious organic lesions, their di- agnosis becomes a matter of very secondary im- portance, as compared with that of the disease by which they were caused, and of which they should properly be regarded as a symptom. Indeed, the principal advantage, in a practical point of view, of detecting a displacement of the heart, is derived from the light which it throws on the nature, ex- tent, and situation of the primary disease by which it was produced, and on which the danger of the displacement, as well as its appropriate treatment, in a great measure depends. It is, therefore, to the accurate diagnbsis of the cause of the displace- ment that the scientific physician will chiefly di- rect his attention ; these causes we have already enumerated, and we beg to refer the reader to the respective articles which treat of the particular diseases, for such diagnostic characters as may enable him to decide in any doubtful case the true cause of the displacement. From the circumstance of displacement of the heart being so constantly combined with other and more serious lesions, it is extremely difficult to ascertain the effects on the system resulting from the simple displacement In congenital malpositions the alteration in the heart's place is usually coupled with other malformations of a more serious character, which either cut short the life of the individual, or else complicate the symptoms of the displacement in such a way that it is im- possible to analyze them correctly. In those rare cases where the displacement of the heart was the principal or only deviation from the natural ar- rangements of parts, little or no inconvenience seems to have resulted from it. In Ramel's case already quoted, where the heart was situated be- low the diaphragm, the individual experienced no inconvenience during infancy; as she grew up she occasionally suffered from palpitations and dyspnoea, and at the age of twelve she is repre- sented to have enjoyed as good health as other people. M. Deschamp's case affords a still more remarkable example of the absence of any distress- ing symptoms from the displacement, though the heart was situated in the place of the left kidney. In this, case the great vessels were disposed in the most favourable manner for transmitting the blood from the heart; but when the displacement is cruised by accident or disease, the large vessels are necessarily contorted more or less, in order to ac- ♦ommodate themselves to the new position of the heart; and if to this we add the pressure and consequent obstruction to the due discharge of their functions which the parts that the heart is forced amongst necessarily sustain, we shall see sufficient reason for concluding that the conse- quences must be most serious and detrimental when the displacement is at all considerable; but even to those untoward circumstances the powers of nature are capable of adapting themselves. In Dr. Stokes's case the patient, though occasionally subject to palpitations in the right side, has so much improved in health as to spend his time be- tween shooting and fox-hunting. In all cases of displacement that we have seen, the pulse was rapid and feeble, and the patient suffered from oc- casional attacks of dyspnoea and palpitation; but in each of these cases the displacement was com- plicated with empyema or pneumothorax, either of which was of itself sufficient to produce these symptoms. In general, however, we observed that they were immediately relieved by drawing off'the fluid, and allowing the heart to resume its natural position. We are, therefore, disposed to conclude that slight displacements occasion little incon- venience, but when considerable they may produce serious functional derangements, especially until such time as the system has become habituated to the change. The treatment of displacement of the heart must obviously depend on its cause; where that is of such a nature as to admit of removal, no sooner is its pressure taken off than the heart resumes its natural position, unless retained by morbid adhe- sions. When, on the other hand, the cause of the displacement does not admit of removal, the replacement of the heart is impracticable ; and all that the resources of our art can effect is to palliate symptoms as they arise. In all our attempts, there- fore, either to restore the heart to its natural po- sition, or to mitigate the symptoms which its dis- placement produces, we should ever bear in mind that we are only treating a symptom — a mere mechanical effect of pressure ; and that, by reliev- ing the primary disease which caused the pressure, we take the most effectual method of remedying the displacement it produces. On referring to the list of diseases we have enu- merated among the causes of displacement, it will appear that many of them, such as aneurisms of the aorta, tumours developed within the thorax, &c. are of such a nature as not to admit of re- moval or diminution. Congenital malposition is equally irremediable : even in those cases where the heart was placed in front of the chest, imme- diately under the integuments, it was found that the attempt to force it into the thorax through the fissure in the sternum immediately brought on the most alarming symptoms. (Breschet, Mem. cit.) In all such cases our best resource lies in the palliative treatment. The patient should be kept as quiet as possible, and every other precau- tion adopted to prevent the circulation being ex- cited. When palpitations are troublesome, digi- talis may be administered with advantage ; its ex- hibition, however, requires considerable attention, as it has been observed not to produce its effects in such cases unless administered in full doses, and we have witnessed the most alarming conse- quences from its over-action. Counter-irritation HEART, (FATTY AND GRE ASY DEGENERATIONS OF) 391 may likewise be employed with advantage; we have repeatedly found blisters applied over the heart most efficacious in controlling this symptom: when a more permanent effect is desirable, a seton may be introduced in the side near the heart. Dr. Stokes's patient, when we last saw him, declared that he experienced the most decided relief after the introduction of a seton into his right side, and that on one occasion when he withdrew it for a fortnight he was attacked with his former symp- toms of pain and palpitation, which again disap- peared after the seton had been introduced. We have already stated our opinion that effu- sions into the pleura are decidedly the most fre- quent cause of displacement of the heart. By the operation of paracentesis thoracis, these may no doubt be removed; but in deciding on the expe- diency of this operation there are many circum- stances of greater importance than the displace- ment, which the physician must take into con- sideration. (See Empyema.) In the case of diaphragmatic hernia, Laennec suggests the idea of making an incision into the abdomen and drawing back the intestines. We conceive that if such an operation could ever be justifiable, it would only be when the pressure of the abdominal viscera on the lungs threatened im- mediate suffocation, in which case a doubtful re- medy might perhaps be preferred to none: but how are the intestines to be prevented from again returning into the chest through the aperture in the diaphragm! R. Townsend. HEART, (FATTY AND GREASY DEGE- NERATIONS OF) —In individuals of great obe- sity, and occasionally in others of only moderate embonpoint, the heart is sometimes overloaden with fat. It is deposited beneath the pericardium, and not only invests the organ externally, but fre- quently penetrates a considerable depth between the muscular fibres, which, as if losing (probably by the pressure) what the adipose tissue gains, become attenuated and flabby. Sometimes, how- ever, the intermixture of adipose matter gives the appearance of attenuation, though there is none in reality. The old authors imagined that this affection was the cause of more or less severe symptoms, and even of sudden death. Corvisart thinks that an enormous accumulation might sometimes be capable of producing such an effect; but, in the persons in whom he had met with very fat hearts, he had seen nothing which could prove to him "that the state was morbid, that is to say, carried to such a point as constantly to derange the func- tion of the organ, and thus constitute a malady." The experience of Laennec has led him to the same conclusions; nor have we seen any thing that militates against them. It would be natural to suppose that the substi- tution of adipose for muscular tissue, and the ex- treme attenuation which the walls, especially the apex and the posterior part of the right ventricle, sometimes undergo from this cause, would be emi- nently favourable to rupture of the organ ; yet this accident is very rarely the result. Morgagni has seen an instance of it, but Bertin has only met with one of rupture of the auricle; while Corvisart and Laennec have not witnessed an in- stance at all. Fatty degeneration is different from that deno- minated greasy degeneration of the heart. This, according to Laennec, is « an infiltration of the muscular substance with a matter which presents all the physical and chemical properties of grease; it is an alteration exactly similar to the greasy degeneration which Halter and Vicq-d'Azyr have observed in the muscles. Laennec has never found it but in a very small portion of the heart, and only near the point. It was of a pale yellow- ish colour, like dead leaves, and therefore very similar to certain varieties of softening; but he thinks that it may be distinguished from softening by its strongly greasing paper between which it is pressed. We have seen a remarkable case in which a degeneration of this kind occupied the greater part of both ventricles. , -TT J. Hope. HEART, (HYPERTROPHY OF THE) — In this article we propose to develope, with as much brevity as the importance of the subject will allow, many of the leading principles common to organic diseases of the heart in general. Hypertrophy of the heart is an augmentation of its muscular substance, resulting from increased nutrition. The terms active and passive aneurism of the heart we discard as vague and inaccurate, and adopt the following classification and nomen- clature. 1. Simple hypertrophy, in which the walls are thickened, the cavity retaining its natural dimen- sions. 2. Hypertrophy with dilatation. This, the eccentric or aneurismal hypertrophy of Bertin, pre- sents two varieties : viz.— a. With the walls thickened and the cavity di- lated. b. With the walls of natural thickness and the cavity dilated : i. e. hypertrophy by increased ex- tent of the walls. 3. Hypertrophy with contraction. In this, the concentric hypertrophy of Bertin, the walls are thickened and the cavity is diminished. This classification is no less convenient than conform- able to nature. The form of the second variety was not known to Laennec, though it was to Ber- tin. That it really consists of an augmentation of muscular substance, and therefore constitutes hypertrophy, is too manifest to require comment: but a further proof than mere structure affords is that it sometimes produces the symptoms of hy pertrophy,—a fact which the writer ascertained and made known several years ago, before he had any knowledge that M. Bertin had done the same. (Vide an Essay by the writer in 1824, read to the Royal Med. Soc. Ed.) The terms " eccentric or aneurismal" and " con- centric" are not so simple and expressive as hy- pertrophy with dilatation, introduced by Laennec, and its natural converse, hypertrophy with con traction. There is a further objection to the n« menclature of Bertin. His first variety of dilata tion, identical in its nature with his second variety of hypertrophy, is designated by a totally different name, viz. active aneurism (Bertin, p. 376), which could scarcely fail to lead the inexperienced stu dent into the erroneous idea that there was a dif- HEART,(HYPERTROPHY OF THE) 302 ference in the nature of the two affections. Now the only difference consists in degree—in a pre- dominance of the one state over the other. The terms, therefore, should be such as distinctly to imply identity in nature, and difference in degree only : and this is done in the simplest manner by giving precedence to the word hypertrophy, or dilatation, according as the one affection or the other predominates. Thus hypertrophy with di- latation denotes a predominance of hypertrophy, while the converse, dilatation with thickening (see Dilatation), denotes a predominance of di- latation. Hypertrophy by increased extent (with- out altered thickness) of the walls,—the form b. of the second variety,—is thus designated when it is accompanied with the symptoms of hypertro- phy ; but it is called simple dilatation when the symptoms are those of dilatation. We have thought it necessary to speak thus particularly on the subject of nomenclature, as up to the present moment it has created much con- fusion, and must continue to do so until the terms active and passive aneurism are forgotten. Anatomical Characters of Hypertrophy of the Heart.—Before describing the anatomical characters of hypertrophy of the heart, it is neces- sary to give the reader an idea of the natural di- mensions of the organ. Unfortunately, it is im- possible to determine these exactly ; for as they vary according to age, sex, and other circum- stances, there is no immutable standard of com- parison which might serve as a criterion. It is only by the eye, therefore, (and an experienced eye is necessary for the purpose,) that it can be determined whether the proportion of the heart to the system, and of its several parts to each other, is natural. The proportions assigned by Laennec approach perhaps as near the truth as it is possi- ble to arrive: they are as follows. " The heart, comprising the auricles, ought to have a size equal to, a little less, or a very little larger than the fist of the subject. The walls of the left ventricle ought to have a thickness a little more than dou- ble that of the walls of the right: they ought not to collapse when an incision is made into the cavity. The right ventricle, a little larger than the left, and having larger columnae carneae, not- withstanding the inferior thickness of its walls, ought to collapse after an incision has been made into it. Reason indicates and observation proves that in a sound and well-built subject the four cavities of the heart are, within very little, equal to each other. But as the walls of the auricles are very thin, and those of the ventricles have con- siderable thickness, it results that the auricles form scarcely a third of the total volume of the organ, or the half of that of the ventricles." In the foetus and very young children, the thickness of the left ventricle does not exceed that of the right to the extent described. The right cavities are rather larger than the left, and this is not owing to sanguineous distension attendant on dissolution ; for the disparity is found, though in a less degree, in animals destroyed by hemorrhage. [In another work (Human Physiohgy, 5th edit. it. 73, Philad. 1844) the writer has given the dimensions of the heart after various observers. (See, also, Dr. Pennock's edit, of Hope on Dis- •nwes of the Heart, p. 233.) Of late M. Ranking (Lon. Med. Gazette, No. xxiv., 1842) has pub- lished the results of measurements, evidently made with accuracy, of upwards of ICO hearts, care being taken to exclude all those that exhibited any trace of organic change. The following were the mean admeasurement of 15 male hearts; the mean circumference was 9^. inches; of 17 fe- male hearts, Q\% inches. The mean length of the male heart was 41-£ inches; of the female, 4-;r>. The mean thickness of the left ventricle in the' male was |^ths of an inch ; in the female, ?-'-ths ; of the right ventricle in the mate 38Eths ; in the female, 3°?ths. The septum ventriculorum has, in the male, a mean thickness of f |ths of an inch; in the female, {^ths. The entire orifice in the male had a mean circumference of 2|4ths inches ; the right auriculo-ventricular orifice 4"ths inches ; the left auriculo-ventricular ori- fice 3i| inches. The corresponding parts, in the female, were relatively less. The inferences, drawn by Dr. Ranking from all his observations, are, that the length of the healthy heart to its cir- cumference is rather less than 1 to 2;—that the thickness of the parietes of the right ventricle is to that of the left as 1 to 3 nearly;—that the pul- monary artery is slightly wider than the aorta; and lastly, that the right auriculo-ventricular opening is considerably larger than the left.] The muscular substance in hypertrophy is usually firmer and redder than natural. These characters, however, are not essential to the dis- ease ; and when they exist in a great degree, they constitute induration, a distinct affection, depen- dent, not on increased, but rather on altered nu- trition of the part. Hypertrophy may be confined to a single cavity, or it may affect several, and even the whole simul- taneously ; and sometimes one ravity is thickened white another is attenuated. The reasons of this will be explained when we come to treat of the exciting causes. When all the cavities are hy- pertrophous, and at the same time dilated, the heart attains a volume, two, three, and occasionally even four times greater than natural ; its form, instead of being oblong, is spherical; its apex is scarcely distinguishable ; and as the diaphragm does not retire sufficiently to yield space downwards for the enlarged organ, it assumes an unnaturally horizontal position, encroaching so far upon the left cavity of the chest, as sometimes to force the lungs upwards as high as the level of the fourth rib, or even higher. When great enlargement is accompanied by adhesion of the pericardium, the organ is secured by the attachments of the mem- brane in a higher situation than its gravity would otherwise dispose it to assume ; and being thus impacted between the spine and the anterior pari- etes of the chest, it is apt to occasion a preternat- ural prominence of the praecordial region. We are not aware that this remark has been made by any other writer, but we have seen the phenome- non in so many instances, that we are disposed to assume it as a general fact. (See Peiiicab- DITIS.) The left ventricle, being more prone to thick- ening, and not less to dilatation than the right, sometimes attains a volume seldom or never ac- quired by the right ; and when its enlargement is enormous, it occupies not onlv the left praecordial ROPHY OF THE) 393 base, the septum, the apex, the columnae carnese, or the external walls; the remainder of the cavity being either natural or. attenuated. Again, a thickened ventricle may be contracted in one part, while it is dilated- in another. In examining the dead subject in mixed cases, it is necessary to counterpoise the opposite conditions, to balance the hypertrophy against the attenuation, and the dilatation against the contraction, in order to de- termine which is the predominant affection. The hypertrophy of the auricles is almost in- variably of the second species, or that with dilata- tion. Laennec even states that he has never met with any other. (De 1'AuscuIt. tom. ii. p. 524.) The simple and the contracted forms, however, are not without example. The thickening is dif- fused in a very uniform manner throughout the cavities, the musculi pectinati being the only parts in which it is more considerable than elsewhere; and as they are larger and more numerous in the right than in the left auricle, it is in the former that hypertrophy proceeds to the greatest extent It occasionally renders the auricle nearly as thick as the right ventricle. This we have never known to take place in the left auricle. Sometimes the musculi pectinati are the only parts in which hy- pertrophy shows itself. The thickening of the auricular walls seldom exceeds double the natural state, and being even then inconsiderable, it may easily be overlooked by an inexperienced eye. When it amounts to a quarter of an inch, which is rarely the case, it is very perceptible. Mode of Formation and Predisposing Causes of Hypertrophy. —Hypertrophy takes place in the heart by the same process as in any other muscle. Increased action causes an aug- mented afflux of blood, and there results a corre- sponding increase of nutrition. Diminished action, on the contrary, has the reverse effect. Thus, the arms of the smith and the legs of the dancer are usually robust; while limbs paralysed or not exer- cised are pate and emaciated. If, however, the circulation can be re-invigorated in the palsied part, nutrition is increased. In the same way, when from mechanical obstruc- tion or any other cause blood is inordinately accu- mulated in the heart,—short, however, of that de- gree which would paralyse its remittent power— the organ is provoked to extraordinary efforts; it struggles against the obstacle ; it frets and labours to overcome it; the coronary arteries are excited to increased activity; augmented nutrition ensues; the parietes are thickened, the muscular power is increased; the effects, superadded to the cause, in- duce a still greater violence of action ; and thus the disease is not only established, but has a con- stant tendency to increase. The left ventricle is much more prone to hyper- trophy than the right ;* and the right, again, than the auricles. This admits of explanation on very simple principles. It is found that hollow muscles resist over-distension by their cor tents with a force exactly proportionate to their strength. Thus, if. we suppose two cavities, one twice the strength of the other, and add to the natural pressure on those cavities such a surplus as will exactly overpowci HEART, (HYPERT region, but extends far under the sternum, where its impulse and sound may be mistaken for those of the right ventricle. (Laennec, tom. ii. p. 507. Treatise on Disease of Heart, by Dr. Hope: case of Lambert.) The walls of the left ventricle, the natural thickness of which averages about half an inch in the adult, may be increased to the extent of one, one and a half, or, according to some, of two inches. The cases are rare in which it exceeds an inch and a quarter. The situation of the greatest thickening is usually a little above the middle of the ventricle, where the columnae carrteae take their origin. Thence, the thickness decreases rather suddenly towards the aortic orifice, and gradually towards the apex, where it is reduced to less than half. When hypertrophy maintains these pro- portions in the different parts of the ventricle, the state is only an exaggeration of the natural form. The case is different when the hypertrophy takes place inwards and diminishes the cavity ; for then the whole ventricle is nearly equally thickened, and it is usually globular and firm. The columnae carneae generally participate in hypertrophy, but sometimes, when there is much coexistent dilatation, they appear to be stretched, flattened, and attenuated. The inter-ventricular septum, though belonging almost entirely to the left ventricle, is commonly less thickened than the external walls of this cavity. When the left ven- tricle is greatly enlarged, the right, if unchanged, is applied in a flattened form to its superior and lateral part, and by contrast looks singularly small. But if, as generally happens, the right is elongated, it is, as it were, folded around the left. When the right ventricle alone is hypertro- phous, it may descend lower than the left, and constitute the apex of the heart. Its columnae carneae, naturally more numerous and interwoven than those of the left, are more susceptible of thickening than the walls themselves. Hence the increased size of the columnae is commonly the first object that arrests the attention, and to them alone is the hypertrophy in many instances con- fined. They are sometimes so curiously inter- laced and attached as to traverse the ventricle in every direction, subdivide it into various compart- ments, and in some cases almost totally to fill up its cavity: (as in case 89 by Bertin, and that of Collins, p. 469 of Treatise of Dr. Hope.) These changes never take place to the same extent in the left ventricle. The total thickness of the walls of the right ventricle, naturally averaging three lines, rarely exceeds four or five; yet it has been known to attain from eleven to sixteen, as appears from the 88th case of Bertin, and one, by Soins, in the Archives de Medecine. In a girl of nine years old we have met with it measuring six or seven lines, which is equal in proportion to nearly double that extent in the adult. Hyper- trophy without dilatation is much more rare in the right than in the left ventricle. The greatest thickening of the right ventricle is near its base : towards the apex, though the columnae carneae be enlarged, their interstices are usually thin, and not unfrequently translucent. Hypertrophy may not only be confined to a single ventricle, whether the right or the left, but it may be limited to particular parts only, as the Vol. II. —50 *[This is the general opinion, but M. Louis affirms, that of 49 cases of hypertrophy of the ventricles, 29 vver« of the right ventricle.] 394 HEART, (HYPER1 the weaker, this surplus will bring into action only one half of the supplementary strength of the more vigorous. Now, as the act of resistance, by stimulating the arteries to increased action, is the cause of increased nutrition, it follows that stronger muscles must be the more susceptible of hyper- trophy. Accordingly, on referring to the heart, we find that the relative structure of its several compartments is such as to predispose the organ to those changes which it actually undergoes from over-distension. The left ventricle, being charged with the immense burden of the greater circula- tion, is proportionably substantial and robust; the right, having the comparatively light task of pro- pelling the blood through the minor or pulmonary system, is little more than one-third as thick and powerful as the left: the auricles, again, having a still less laborious function to perform, have a still more limited muscular provision. Hence, it is easily understood how a given increase of distend- ing force, sufficient to overcome the contractile and elastic power of the right ventricle, might operate merely as a stimulus to the superior mus- cularity of the left. While the former, therefore, incapable of re-acting on its contents, would dilate, the latter, excited to extraordinary efforts, would become hypertrophous. It is not however to be supposed, that while the left ventricle is becoming hypertrophous, it may not at the same time undergo dilatation ; nor, on the other hand, that the right ventricle, while yielding to dilatation, may not become hypertro- phous; for observation teaches us that the combi- nation of hypertrophy with dilatation, either in the left ventricle alone, or in the two conjointly, is the most ordinary form of organic disease of the heart. For an explanation of the cause why dilatation accompanies hypertrophy, the reader may refer to the article on Dilatation. Why hypertrophy sometimes accompanies dilatation of the right ventricle may be here explained, and it admits of an explanation iii one or other of two ways. 1. It has been remarked by' Laennec (Traite, tom. ii. p. 496,) that a large proportion of mankind are born with ill-proportioned hearts, the parietes being a little too thin or a little too thick on one or both sides. Now when this abnormal thickness exists in the right ventricle, it is clear, from what has been said above, that it must impart to that ven- tricle an increased disposition to hypertrophy. This explanation, however, is not satisfactory, as the existence of the malformation described by Laennec cannot be positively proved: still, as all the other organs and parts of the body are liable to defects of natural conformation, it is consistent with analogy to suppose that the heart may be liable to them also. 2. As augmented nutrition is excited in the left ventricle by stimulating it in proportion to and not beyond its power, so a stimulus bearing the same proportion to the power of the right ventricle, . must have the same effect on it also. Accordingly, in the majority of cases of hypertrophy of the right ventricle, an obstacle is found to exist of such a nature as to stimulate it in the manner de- scribed. The obstacles which we have most fre- quently found to produce the effect, are, contrac- ion of the mitral valve operating in a retrograde 'ROPHY OF THE) direction through the lungs, and that of the semi. lunar valves of the pulmonary artery. These affections being usually slight at their commence- ment and slow in their progress, oppose an obstacle to the circulation not only moderate in degree, but constant in its operation,—the two circum- stances best calculated to induce hypertrophy of the right ventricle. M. Bertin conceives that the greater tendency of the left ventricle than of the right to hyper- trophy, depends upon the more stimulant quality of the arterial blood circulating through the former. This opinion he founds on the circumstance that hypertrophy of the right ventricle in most cases accompanies patescence of the foramen ovale, which lesion he thinks causes an influx of arterial blood into the right ventricle. But, admitting that arterial blood in the right ventricle does occasion hypertrophy, it does not follow that it should have the same effect on the left; for of the former ven- tricle it is a morbid stimulus, but of the latter it is the natural one. Accordingly, direct proof is to be found in the auricles, that arterial blood is not the cause of hypertrophy; for the left auricle, which on M. Bertin's principle ought to be more subject to hypertrophy than the right, is less so. It will be shown, moreover, in the article on malfor- mations of the heart, that, in the cases on which M. Bertin founds his opinion, the blood does not enter the right ventricle. Exciting Causes.—According to the foregoing opinions on the mode of formation of hypertrophy, it will be apparent that every circumstance capable of increasing the action of the heart for a sufficient length of time,—a period which must be very considerable,—may be a cause of hypertrophy, These circumstances may be either, 1. of a nerv- ous, or 2. of a mechanical nature. 1. The former class comprises all moral affections and all derange- ments of the nervous function that excite long continued palpitation. To these we would add protracted rheumatic fevers; for we have known these give rise to hypertrophy, though there was apparently no inflammation of the heart or its membranes. 2. The latter class embraces all physical causes which can either accelerate or ob- struct the circulation, and thus occasion a preter- natural pressure of the blood upon the heart. The physical causes which accelerate the circulation, are, violent and protracted corporeal efforts of every description. In growing youths, excessive rowing is one of the most efficient. We have met with several in which it has produced the effect. The physical causes which obstruct the circulation are very numerous. They comprise smallness of the aorta, whether congenital or acquired : dilatation of the aorta; inequalities of its internal surface; all diseases of the valves of the heart which either contract their apertures or impede their movements; adhesion of the pericardium; all affections of the chest that obstruct the circulation through the lungs, as peripneumony, acute or chronic; em- pyema ;' hydrothorax ; chronic catarrh ; emphy- sema ; phthisis ;* narrowness of the chest, either * We hnve not found that phthisis is so decided a cause of disease of the heart as we should be led to suppose from the ejtr.-me pulmonary obstruction to which it sometimes gjves rise. The reason of this appears to be, that, in the early stages, when the disorganization isnot extensive, the circulation is little embarrassed; and in HEART,(HYPERTROPHY OF THE) 395 congenital, or occasioned by curvature* of the spine, &c.; encroachment of the diaphragm on the cavity of the chest from the pressure of tight stays, of the gravid uterus, of abdominal dropsy, aneurism, &c. In reference both to the nervous and the physi- cal causes of palpitation, it may be said that young persons of a plethoric habit and sanguine temper- ament are the most susceptible of their influence. Hence it is that very stout and high-coloured fe- males, from the age of seventeen to twenty-five, are peculiarly subject to hypertrophy. We have noticed this fact more especially in servants coming to London from the country. Order of succession in which the several com- partments of the heart are rendered hypertro- phous by an obstacle before them in the course of the circulation.—As an obstacle to the circula- tion operates on the heart in a retrograde direction, the cavity situated immediately behind it is the first to suffer from its influence. Accordingly all the impediments seated in the aorta, its mouth, or the arterial system, act primarily on the left ventricle, which, being likewise exposed to the heaviest burden when the circulation is accelerated, has to conflict against a greater variety of exciting . causes of hypertrophy than any other cavity of the heart. On this account, therefore, as well as from the thickness of its parietes, it is subject to hypertrophy in a greater degree than any other. So long as the left ventricle is capable of pro- pelling its contents, the corresponding auricle, being protected by its valve, remains secure. Hence, in a large majority of cases, the auricle is perfectly exempt from disease, while the ventricle is even enormously thickened and dilated. But when the distending pressure of the blood preponderates over the power of the ventricle, its contents, not being duly expelled, constitute an obstacle to the transmission of the auricular blood. Hence the auricle becomes over-distended, and the obstruction may be propagated backwards through the lungs to the right side of the heart, and there occasion the same series of phenomena. When the ob- struction thus becomes universal, as,is frequently the case, it may happen either that all'the cavities are thickened, or those only which from their con- formation have the greatest predisposition to it. When the mitral orifice is contracted, especially if the aperture be very small, the left ventricle, being insufficiently supplied with blood, is not sti- mulated to its ordinary contractile action, and con- sequently becomes emaciated and occasionally flaccid or softened. Meanwhile, the left auricle, having to struggle against the contracted valve in front, and also to sustain the distended pressure of the blood flowing in from the lungs, invariably becomes thickened and dilated. The engorgement, extending backwards through the lungs to the right ventricle, occasions its hypertrophy and dilatation ; under which circumstances, namely, hypertrophy the advanced stages, the mass of circulating fluids is so much diminished in consequence of deficient nutrition and augmented cutaneous transpiration, that the heart sustains little additional burden from the obstruction in the lungs. In most cases, however, the right ventricle is found somewhat dilated,—a remark which has been made more especially by Al. Louis and Dr. Williams. *The majority ot humpbacked persons are ultimately attacked by disease of the heart. of the right ventricle and contraction of the mitral valve, the lungs suffer in a pre-eminent degree; for being exposed to the augmented impulsive power of the right ventricle behind, and incapable of unloading themselves on account of the straitened orifice in front, their delicate and ill-supported vessels are strained beyond the power of resistance. If, therefore, they cannot disgorge themselves suf- ficiently by a copious secretion of watery mucus, they effuse blood by transudation into the air-vesicles and tubes, and form the disease denominated pul- monary apoplexy. We have found this affection to occur more frequently under the circumstances described than under any other. When the mitral orifice is permanently pates- cent, so that, at each ventricular contraction, blood regurgitates into the auricle, this cavity suffers in a remarkable degree; for it is not only gorged with the blood which it cannot transmit, but, in addition, sustains the pressure of the ventricular contraction. Permanent patescence of the mitral orifice, therefore, constitutes an obstruction on the left side of the heart, and the effect of this, as of contraction of the orifice, may be propagated back- wards to the right side. W hen the impediment to the circulation is primitively seated in the lungs, the right ventricle, situated immediately behind them, is the first to experience its influence ; and when the cavity is so far overpowered by the distending pressure of the blood as to be incapable of adequately expel- ling its contents, the obstruction extends to the auricle ; the process being exactly the same as that already described in reference to the left ven- tricle and auricle. Obstruction in the right auricle, whether from this or any other cause, presents an obstacle to the return of the venous blood, and therefore ulti- mately causes retardation throughout the whole venous system. Nor is this all; for the retarda- tion is propagated through the capillaries to the arterial system, and thus at length returns in a circle to the heart. In this way is explained what at first sight appears an anomaly ; namely, that the left cavities are sometimes rendered hypertro- phous by an obstruction situated behind them in the course of the circulation. The left ventricle, for instance, may be rendered hypertrophous by a contraction of the mitral orifice. The reader must here be again reminded that the exciting causes of hypertrophy are equally those of dilatation, and that, supposing no un- known agencies to interfere, as may sometimes possibly happen, it depends on the proportion which the exciting cause bears to the re-acting energy of the cavity exposed to its influence, whether that cavity become affected with hyper- trophy, with dilatation, or with a combination of the two. It may be said, generally, that when congestion is constant in a cavity, dilatation is more com- monly the result; and that when there is only resistance to the expulsion of the blood, without constant engorgement of the cavity, it is more common for hypertrophy to be produced. Con traction, for instance, of the aortic orifice causes hypertrophy of the left ventricle in a greater de- gree than dilatation; whereas patescence of that orifice, attended with regurgigation and constant 396 HEART, (HYPERTROPHY OF THE) engorgement of the cavity, causes dilatation in a greater degree than hypertrophy. Hypertrophy with contraction most commonly proceeds from straitening of an orifice. Thus the greatest hypertrophy with contraction of the right ventricle upon record was accompanied with straitening of the pulmonary orifice to two lines in diameter. (Case 87 by M. Bertin.) We have met with a very similar case; and several con- nected with malformation of the heart are on record. It may be useful to subjoin a list of the various forms and combinations of hypertrophy and dila- tation, and to show the comparative frequency of their occurrence. On the latter point we shall offer the result of our own observation, and we believe that they correspond very closely with those of others. The diseases are of more frequent occurrence in proportion as they are higher in the following scale. 1. Hypertrophy, with dilatation of the left ven- tricle, and a less degree of the same in the right. 2. Hypertrophy, with dilatation of one ventri- cle, especially the left, with simple dilatation of the other. 3. Simple dilatation of both ventricles. 4. Simple hypertrophy of the left, and hyper- trophy with dilatation of the right. 5. Dilatation with attenuation of the left. 6. Hypertrophy with contraction of the left. 7. Hypertrophy with contraction of the right. Of the Auricles.— 1. Distension, particularly of the right, from congestion during the act of dissolution. 2. Dilatation with hypertrophy. 3. Simple hypertrophy. 4. Hypertrophy with contraction. Pathological effects of Hypertrophy, and mode of their Production.—M. Laennec sup- poses the general symptoms of all organic dis- eases of the heart to be nearly the same. (De PAuscult. tom. ii. p. 487.) It may be said with- out prejudice to one who has done so much, that, on this subject, both he and all the authors who preceded him have entertained inaccurate ideas. They had studied these diseases in the aspect under which they most commonly present them- selves, namely, complicated one with another; and it is unquestionable that when so viewed, they display a great similarity in their symptoms. But it had never occurred to those authors to analyze each disease in an isolated form. When so ex- amined, although certain symptoms are common to all, they severally manifest differences of a strik- ing kind, obviously dependent on their respective organic peculiarities, and which may, therefore, be fairly regarded as the essential and diagnostic characters of each. M. Bertin has the merit of having been the first to display in a clear light the essential pathology of hypertrophy. His distinguished talent for generalization, however, has, we believe it will be allowed, carried him too far. He contends that authors are wrong in having assigned to hyper- trophy or active aneurism as its symptoms, dysp- noea, suffocation, violet injection of the face, en- gorgement of the lips and of the venous capilla- ries in general, passive hemorrhages, and serous infiltration. He contends that these are the signs, not of hypertrophy, but of some coexistent lesion, as a contracted orifice or any other affection capa- ble of obstructing the circulation ; and that pure uncomplicated hypertrophy is characterized by signs of increased activity and energy of the cir- culation, instead of by dropsy and the other signs of retardation of the blood. That this is true in reference to the pure ura- complicaled form of the disease, before embarrass- ment of the capillary circulation has taken place, will not be denied by any one who has had op- portunities of verifying the symptoms by dissec- tion. But M. Bertin is not, in our opinion, sup- ported by sound observation when he says that serous infiltration and the whole class of symp- toms bespeaking an obstructed circulation, are totally foreign and repugnant to hypertrophy, The truth we believe to be, that the very same energy of the circulation which gives rise to active hemorrhages, apoplexy, &c, causes, as its next effect, engorgement of the arterial capillary sys- tem ; the necessary consequence of which is serous infiltration, and more or less of all the other symptoms indicative of retardation of the blood. M. Bertin is of opinion that the impediment to the respiration which attends enormous enlarge- ment of the heart, results from the encroachment of the organ on the lungs. This, however, is disproved by the fact that tumours of a much larger size, as for instance, aneurisms of the aorta, malignant tumours, &c. have existed in the chest, even for years, without producing similar incon- venience. The primary effect of universal obstruction of the lungs by engorgement resulting from hyper- trophy of the heart, is, to produce cedema of their cellular tissue and dyspnoea. The secondary effect is, to gorge the right side of the heart, and thus impede the return of the venous blood from the system at large; which impediment co-operates with the increased energy of the arterial circula- tion in producing anasarca. Hypertrophy, however, does not produce serous infiltration so readily and promptly as a direct, primary obstacle to the return of the venous blood, —a fact which admits of a rational and obvious explanation. When there is an obstacle to the return of the venous blood, suppose, for instance, contraction of the tricuspid orifice, two causes conspire to produce the capillary congestion; namely, the direct pressure of the arterial vis-a- tergo, and the retrograde pressure of the retarded venous blood. But when the latter pressure does not exist, when the veins freely receive and trans- mit their natural proportion of blood, the force of the arterial circulation must be very greatly in- creased, before it can so far overcome the elasticity of the capillaries as to give rise to engorgement and infiltration. This satisfactorily accounts for the difference in the history and character of infiltration as result- ing, on the one hand, from pure hypertrophy, and on the other from contraction of a valve or other primary obstacle to the circulation. In the for- mer case, it appears late, is generally moderate in extent, and requires for its production an aggra- vated form of hypertrophy ; in the latter case, it appears comparatively early, is more copious, and yields with less facility to remedies. HEART, (HYPERTROPHY OF THE) 397 The same reasons that account for the tardy occurrence of dropsy in pure hypertrophy, account, likewise, for another characteristic of this malady when moderate in degree; namely, the slight and transitory nature of the attacks of dyspnoea. For if the quantity of blood impelled into the lungs by the right ventricle, and the force with which it is impelled, are not very excessive, the pulmo- nary veins are capable of relieving the engorge- ment almost as quickly as it takes place : conse- quently the hurry of the respiration subsides promptly after the removal of its exciting cause; in other words, as soon as the action of the heart becomes a little calm. The sum, then, of all that has been said, is, that pure hypertrophy gives rise to increased force and activity of the circulation, and that, when this force surmounts the natural tonic power of the capillaries, congestion, infiltra- tion, and the other phenomena of an obstructed circulation, ensue. To these principles an exception presents itself in hypertrophy with contraction, whenever the cavity of the ventricle is too small to be capable of transmitting the natural quantity of blood. In this case, supposing the left ventricle to be the one affected, the arterial circulation sustains a diminu- tion of force and activity; and whether the one ventricle or the other be affected, the disease cre- ates an obstruction tantamount to that produced by valvular contraction: on the same principles, therefore, it generates dropsy and the other pheno- mena of a retarded circulation. The effects of hypertrophy of the left ventricle on the brain are so pre-eminently important that it is necessary to advert particularly to this sub- ject, for the purpose of bringing it prominently into view. Since the researches of the present day have demonstrated that even a slight thick- ening of the walls of the heart constitutes a mor- bid state, and have unfolded to view the connec- tion subsisting between that state and a train of symptoms formerly either wholly overlooked or attributed to other causes, instances of apoplexy supervening upon hypertrophy have been so fre- quently noticed, that the relation of the two as cause and effect is one of the best established doc- trines of modern pathology. Eight or nine cases of suddenly fatal apoplexy, and numerous cases of palsy, from hypertrophy, have, within a few years, fallen under our own observation. In the majority of them the patient exhibited what is commonly called the " apoplectic constitution;" that is, a robust conformation, a plethoric habit, and a florid complexion : in others, the secharac- ters were absent; but the total number of the cases of apoplexy from hypertrophy is much greater than we have witnessed, during the same period, of apoplexy from causes independent of hypertrophy -, whence we are led to believe, with MM. Richerand and Bertin, that hypertrophy forms a stronger predisposition to apoplexy than the apoplectic constitution itself; and that, in most instances, those persons who present the apoplectic constitution in conjunction with symptoms of in- creased determination to the head, are, at the same ume, affected with hypertrophy. Nor is it to apoplexy alone, but to cerebral inflammations and irritations of every description, and even to inflammatory action in general, that 2i hypertrophy of the left ventricle gives a tendency. The history of individuals affected with it fre- quently presents a striking narrative of violent headachs, brain fevers, various inflammatory com- plaints, and states of great nervous irritability and excitation. As the ophthalmic artery is derived from the carotid within the cranium, the eye par- ticipates with the brain in the effects of hypertro- phy, and is vascular, brilliant, and very prone to ophthalmia. The wasting away of the eye which Professor Testa has remarked as one of the effects of disease of the heart, is, with good reason, sup- posed by M. Bertin to be connected with ossifica- tion of the ophthalmic arteries, a frequent concom- itant of*hypertrophy of the left ventricle. The shock of an hypertrophous left ventricle may to a certain extent be intercepted, and its effects on the brain counteracted, by contraction of the aortic orifice. A patient was under the care of Mr. Babington, at St. George's Hospital, Sept. 16, 1829, for a surgical complaint, in whom the walls of the left ventricle were an inch thick, without any change of the cavity ; and the aortic and mitral orifices were respectively encircled by a ring of bone as thick as a writing-quill. The two valves, though overspread with calcareous scales, were capable of discharging their functions. Notwithstanding this extraordinary state of dis- ease, the patient had attained the age of eighty without manifesting symptoms of diseased heart sufficient to arrest his own attention or that of his medical attendants. His advanced age, indeed, proves that they could not have existed in any considerable degree. In this case, therefore, the valvular contraction appears to have been exactly sufficient to countervail the hypertrophy, and maintain the circulation in a state of equilibrium. The generality of authors, however, have greatly over-rated the power of contraction of the aortic orifice to counteract the effects of hypertrophy on the brain. They have supposed that a moderate and even a slight degree of contraction is sufficient for the purpose. There can be no greater error; and it is one into which they could not have fallen, had they been aware that an inconsiderable degree of contraction has very little effect in diminishing the strength, tension, and regularity of the pulse, as is shown in the article on valvular disease. To have demonstrated the influence of hyper- trophy of the left ventricle on the brain, is equiva- lent to having shown that of the right ventricle on the lungs. For, in the same way that the brain receives directly the shock of the blood, which the left ventricle shoots into the aorta, so the lungs receive immediately the impulse com- municated to the column of blood, which the right ventricle propels into the pulmonary artery. Con- sequently, when the walls of this ventricle are augmented in thickness and energy, they impart a corresponding activity to the pulmonary circula- tion, and sometimes overcome the tonic power of the vessels. Hence ensues hemorrhage, or what was called by Laennec pulmonary apoplexy, from its taking place by the same mechanism as apo- plexy properly so called, in cases of hypertrophy of the left ventricle. The haemoptysis resulting from this cause consists of fluid, red blood, and is generally copious, sudden, and productive of febrile excitement of the circulation. It is, iv 398 HEART, (HYPERTROPHY OF THE) short, an active, arterial hemorrhage, and essen- tially different from that passive species, hereafter to be described, which results from retardation of the blood in the venous capillaries of the lungs. (SeePcr-MoxAUT Apoplexy and H.t.mopttsis.) Diagnosis of Hypertrophy.—The signs of hypertrophy are of two classes: 1. general; 2. physical. According to our experience, neither of these classes, taken separately, is sufficient to indicate any disease of the heart with perfect certainty ; taken conjointly, they render the diag- nosis so easy that a material error can scarcely be committed. 1. General Signs.—In describing these we shall follow the course of the circulation ; com- mencing, after having noticed the action of the heart, with the circulation through the lungs, proceeding to that through the aortic system, and concluding with that through the veins. The description of symptoms which we are about to offer, refers, it must be distinctly under- stood, to simple hypertrophy, unless when it is otherwise stated : the symptoms of hypertrophy with dilatation, which will be noticed in passing, are only an aggravated degree of the same—as the reader will sufficiently understand, if duly acquainted with the foregoing principles relative to the formation and effects of these diseases. When the dilatation predominates over the hyper- trophy, the symptoms of course approximate more nearly to those of dilatation. (Vid. Heart, dila- tation of the). The symptoms of hypertrophy with contraction will also be noticed incidentally with those of simple hypertrophy. Palpitation___By this is to be understood a morbidly increased action of the heart, both as to strength and frequency. As the hypertrophous heart acts with an energy which, even in its tran- quil state, verges on palpitation, and which, under the slightest excitement actually amounts to it, the patient experiences this symptom more unin- Urmittingly than in any other disease of the organ. It is induced by stimulants of any descrip- tion : as muscular efforts, particularly that of ascending; mental emotion ; flatulence; acidity or bile; spirituous or highly seasoned ingesta, and sometimes by a full meal of any kind. The violence of the attack generally subsides promptly after the operation of the exciting cause has been suspended, and little remains but a slight sense of pulsation in the precordial region. In the ad- vanced stage, however, of hypertrophy, and still more of this conjoined with dilatation, when the circulation has become embarrassed, the paroxysms are sometimes very severe and prolonged, though the}7 nevei attain that fearful extreme of violence and obstinacy which is witnessed in cases com- plicated with valvular or aortic obstruction, or adhesion of the pericardium. Dyspncca. — While the enlargement of the heart is moderate, the patient, during a tranquil state of the circulation, feels little or no difficulty of respiration; but he is incapable of making the same corporeal efforts as other persons without losing breath: to use a common phrase, he is " short-winded." After a respite of a few minutes, however, he recovers, and is, therefore, seldom deterred by this symptom from prosecuting his accustomed avocations. We have frequently ob- served that individuals who pant on first setting out on a walk, are capable of sustaining great exertions without inconvenience when they get warm and the blood is freely determined to the surface. When the disease has proceeded so far as to occasion dropsy, more or less dyspnoea becomes habitual, and it sometimes occurs, con- joined with palpitation, in paroxysms of excessive severity. From this period, indeed, the symptoms are a compound of those of hypertrophy and those of an obstructed circulation, the latter of which are more particularly considered in the article Dilatation. Hypertrophy with contraction, as already stated, is sometimes accompanied with symptoms of an obstructed circulation. Cough.—There is generally little or no cough in the early stages, but it always supervenes when dropsy appears, in connection with which more or less sanguineous and serous congestion almost invariably takes place in the lungs, and gives rise to the symptom in question. When the hyper- trophy is confined to the left ventricle, the cough is milder and later in its appearance than when the right ventricle is affected. We have seen a dry, hacking and wheezing cough amongst the earliest symptoms in young and plethoric females, whom it attacks in paroxysms after any over- exertion, as ascending a stair. It is often also very troublesome on first rising in the morning. Hxmoptysis. — This may occur at any period of the disease, and the hemorrhage, being active —the result of a too impetuous discharge of blood into the capillary system — is generally sudden and copious, consists of fluid arterial blood, and is attended with febrile excitement. Pulse.—The pulse in hypertrophy of the left ventricle undergoes, from valvular and other le- sions, a variety of modifications which disguise its real nature. It must, therefore, be studied in cases totally exempt from complication. In such it is almost invariably regular, and bears strict relations in strength and size to the thickness and capacity of the left ventricle. Thus, in simple hypertrophy it is stronger, fuller, and more tense than natural: it swells gradually and powerfully, expands largely, dwells long under the finger, and is sometimes accompanied with a thrill or vibra- tion. These characters are still more marked in hypertrophy with dilatation, so long as the hyper- trophy is predominant; but when the dilatation has proceeded so far as to diminish the contractile power of the muscular fibres, the pulse, though still full and sustained, is soft and compressible. In hypertrophy with contraction of the cavity, it is strong, hard, and tense, but small and cord-like, expanding little under the finger. The action of the carotids corresponds with that of the radials, and they may generally be seen to pulsate from the sternum to the angle of the jaw. In the temporals also a sense of throbbing is usually experienced. Affections of the Head. — The patient com- plains of a « rushing of blood to the head" on making any corporeal effort or stooping; of intense throbbing and lancinating headachs, aggravated by the recumbent position, and especially by the act either of suddenly lying down or rising up; he complains also of vertigo, tinnitis aurium, scintillations and other visual illusions ; and some- HEART, (HYPER1 times of a lethargic somnolency, which so com- pletely subdues the faculties both of the mind and the body, as utterly to incapacitate him for every species of exertion. These symptoms, if not re- lieved, terminate in palsy or apoplexy. From this catastrophe, the patient is often preserved by the opportune occurrence of epistaxis, to which, happily, he is peculiarly liable. From the circu- lation in hypertrophy being active in the eye, this organ is bright and sparkling, and sometimes vascular or blood-shot. Complexion.—The effect of hypertrophy is to heighten the colour so long as the capillary circu- lation continues unembarrassed, but afterwards to diminish and change it. Every individual, how- ever, does not acquire a florid colour. Whether he acquire it or not, depends, in truth, upon the original complexion, the series of changes being different in those who are naturally florid, and those who are pale—a fact not generally known. In the former, the colour becomes remarkably vivid, and being generally accompanied with ple- thoric turgescence, it gives the aspect of health and good condition. But when the capillary cir- culation begins to labour, the red changes into a purplish patch on the cheeks, the nose and lips become more or less purple, violet, or livid, and the intermediate skin becomes sallow and ca- chectic. In great hypertrophy with dilatation the purple and violet colours are sometimes of the deepest dye. In those who are naturally devoid of colour, hypertrophy either does not excite it at all, or merely increases in a slight degree the general vascularity of the face. This vanishes entirely when the capillaries become obstructed, and is superseded by universal cadaverous pale- ness, extending sometimes even to the lips. They, however, are generally somewhat livid. Serous Infiltration. — This, for reasons already assigned, seldom appears before the hypertrophy is very considerable or becomes conjoined with dilatation. It frequently shows itself first in the face; a circumstance attributable to the great number and size of the cerebral arteries, and to the force with which the blood is injected into them in consequence of their proximity to the heart. With the dropsy supervene, to a greater or less degree, all the other symptoms of an ob- structed circulation. Signs of Hypertrophy of the right Ventricle.— Hypertrophy of the right ventricle produces, ac- cording to Corvisart, a greater difficulty of respira- tion and a deeper colour of the face than is pro- duced by the same affection in the left ventricle. Another sign is, the more frequent expectoration of pure arterial blood. Turgescence of the external jugular veins ac- companied by pulsation synchronous with that of the arteries, was pointed out by Lancisi as a sign of " aneurism," i. e. hypertrophy with dila- tation, of the right ventricle ; and we have rarely known it absent in this affection. Of such cases, therefore, we regard it as one of the best general signs. Venous pulsation is not, in our opinion, attributable to regurgitation through the tricuspid valve, as Bertin supposes; in substantiation of which opinion we may say that regurgitation would be al tended with a bellows or other such «ound : this sound, however, is not found to be a 'ROPHYOFTHE) 399 concomitant of jugular pulsation. Is the rationale of the phenomenon as follows? namely, as the ventricle, when hypertrophous, contracts with aug- mented power, the recoil of the tricuspid valve is preternaturally impetuous: hence, the column of blood in the act of descending into the ventricle is repelled with such an increase of force, that its impulse is propagated as far back as the jugular veins. This effect would be more considerable when the orifice and valve are enlarged, as is usu- ally the case in hypertrophy with dilatation, be- cause the quantity of fluid repelled would be greater. The effect would also be favoured by congestion of the great veins, (a state which gene- rally accompanies hypertrophy with dilatation of the right ventricle,) because, when congested, they are more tense unyielding tubes, and transmit an impulse more readily. The jugular pulsation is double : a weaker pul- sation precedes that occasioned by the ventricular systole. The weaker is occasioned by the auri- cular systole, and the mechanism of its formation we conceive to be this: at the time that the auri- cle contracts, the ventricle is in a state of mode- rate or natural fulness; it therefore offers a certain degree of resistance to the ingress of more blood from the auricle ; consequently, so much of the blood compressed by the auricular systole as can- not get forward into the ventricle, is forced back into the veins and causes their pulsation. A difficulty has sometimes been experienced in distinguishing jugular pulsation from that of the carotid arteries; an error which may easily be avoided by observing that the jugular pulsation is confined to the lower part of the neck, and is fai on the humeral side of the carotid. The pulsations of the artery, on the contrary, extend as high as the angle of the jaw, and in the direction of the anterior margin of the sterno-cleido mastoideus muscle. The jugular turgescence, again, disappears in some degree during inspiration, and reappears on expiration ; which movements, therefore, must not be confounded with the pulsations answering to the systole of the ventricle. General Signs of Hypertrophy of the Auricles. — There are none that are distinguishable from those of disease or obstruction in the correspond- ing ventricle or orifice, to which the hypertrophy of the auricles owes its origin. The detection of hypertrophy of the auricle is of little importance, the cause that produced it being the source of danger. II. Physical Signs___Impulse. — In simple hypertrophy, the impulse communicated by the stethoscope while the patient is in a calm state, is usually so strong as distinctly to raise the head of the observer, and sometimes even sufficient to pro- duce a shock disagreeable to the ear. The greater the hypertrophy, the longer this heaving takes for its performance. When the malady exists in a great degree, we evidently perceive that the heav- ing takes place with a gradual progression ; ii seems as though the heart swelled and applied itself to the parietes of the chest, at first by a sin- gle point, then by its whole surface, and finallv sank back in a sudden manner. This sinking back, which we have been in the habit of desig- nating by the term back-stroke, ["diastciic »»>i 400 HEART, (HYPER'J pulse,"] is occasioned by the diastole of the ven- tricles, during which action the heart sinks back from the walls of the chest with a force greater in proportion to its thickness and capacity. Accord- ingly, the back-stroke is strongest in hypertrophy with dilatation, but it may also be very considera- ble in simple hypertrophy. In the healthy heart it is not perceptible, neither is it in dilatation with- out hypertrophy. A strong, slowly heaving impulse, then, is the principal sign of simple hypertrophy; and the af- fection may be known to be greater when the im- pulse is followed by a back-stroke. Both these siyns exist in hypertrophy with contraction, but in a less degree, and the hack-stroke may be ab- sent if the disease is not great. In simple hypertrophy and that with contrac- tion, the impulse is seldom perceptible much be- yond the praecordial region, except during attacks of palpitation. In hypertrophy with dilatation the signs are a compound of those of hypertrophy and those of dilatation. The contraction of the ventricles can easily be felt by the hand applied to the praecor- dial region, and we find, especially during palpi- tation, smart, violent shocks, which strongly repel the hand. If we attentively examine the patient, even when most calm, we see that his head, his limbs, and even the bed-clothes, are strongly shaken at each contraction of the heart. The pulsations of the carotids, the radials, and the other superfi- cial arteries are often visible. The impulse of the heart can sometimes be distinctly felt under the clavicles and on the left side of the thorax; some- times even in the back, especially in meagre sub- jects and children. In hypertrophy with a predominance of dilata- tion, the pulse is ordinarily not considerable ; but it becomes very marked during palpitation, espe- cially if accompanied with fever, and it has a very different character from that occasioned by simple hypertrophy. The beats are strong, hard, and produce a shock analogous to the blow of a ham- mer ; but the blow seems to strike a small space ; it expends itself as it were on the thoracic parie- tes, and does not communicate to the head of the ausiultator a heaving proportioned to its force: it differs, in short, from the impulse occasioned by great hypertrophy, in the circumstance that, in the latter, the ventricles in a distended state seem to heave with their whole length against the thoracic parietes, which yield to the effort; while, in the former case, the point only of the heart seems to strike the parietes with a sharp, smart, accurately circumscribed blow, only capable of producing a sort of concussion rather than a real heaving. The same species of impulse takes place in purely nervous palpitations, in reference to which we have called it jerking. When the impulse is increased on one side only of the praecordial region, that is under the inferior part of the sternum for the right side, and between the cartilages of the fifth and seventh left ribs for the left, we infer that the corresponding ventricle only is affected ; and when it is increased on both sides, we conclude that both are affected, which is more commonly the case. In hypertrophy, and hypertrophy with dilata- tion, independent of valvular disease, the beats of rRO PHY OF THE) the heart even during palpitation are rarely irregu- lar, unless when they become enfeebled by exces- sive dyspnoea or by failure of the vital powers on the approach of dissolution. The impulse of the heart is diminished by loss of blood, diarrhcea, any exhausting disease, rigid and long-continued abstinence, and, in general, by all the causes capable of producing debility. Consequently, a moderate hypertrophy might, without due care, be overlooked in a patient under any of these circumstances. The impulse of the heart, moreover, may, even in cases of marked hypertrophy, cease entirely when there supervenes intense dyspnoea, connected with some affection of the lungs, especially pcri- pneumony, pleurisy, oedema of the lungs, asthma, and the pulmonary congestions which form during the last moments of life. The sounds likewise diminish, or even entirely cease: no inferences, therefore, should be drawn from an exploration made under such circumstances. Sounds. — Hypertrophy has the effect of dead- ening the sounds of the heart. In simple hyper- trophy, the first sound, i. e. that produced by the ventricular contraction, is duller and more pro- longed than natural in proportion as the hyper- trophy is more considerable, and it generally ter- minates in the second sound without any interval. When the hypertrophy exists in an extreme de- gree, the first sound becomes nearly and some- times wholly extinct. The second sound, i. e. that produced by the ventricular diastole, is very brief and dull, and in extreme cases scarcely perceptible. The interval of repose is shorter than natural, in consequence of the first sound being longer. Both sounds are proportionably weaker when the ven- tricle is contracted as well as hypertrophous. In most cases of this description the sounds can scarcely be heard under the left clavicle and at the upper part of the sternum. Sometimes they can- not be heard farther than the impulse can be felt; that is to say, scarcely beyond the limits of the praecordial region. Each sound of the heart, though essentially one, consists of the sounds of the two sides united. This is proved by a bellows murmur in the left praecordial region being audible in the right, and vice vers&. It does not follow, therefore, thai be- cause one ventricle is hypertrophous, the sound of the heart in general should be very limited in its range ; for that of the other will be heard over an extent proportioned to its intensity, though not quite so far as when strengthened by its fellow. On the other hand, a morbidly increased sound of one ventricle, as by dilatation or a bellows-murmur, will be heard alone at points beyond the range of the natural sound of the other or healthy ventri- cle. Accordingly, it is only in hypertrophy of both ventricles that we must expect to find the sounds confined within very narrow limits. We have not been able to verify the remark of Laennec, that " in hypertrophy, often when a strong heaving, without any first sound, is felt in the praecordial region, and the second sound can scarcely be distinguished, the latter is heard alone under the clavicles, and even on the back ; and in less severe cases of this kind it is always heard , more distinctly in these places than in the prae- | cordial region, especially in meagre and narrow- HEART, (HYPERTROPHY OF THE) 401 chested persons." We cannot understand on what principle it could be so, even supposing the auricular contraction were, as he imagines, the cause of the second sound ; for as both the right auricle and ventricle are in immediate proximity and partly in contact with the sternum, it is in- conceivable how the sound of either should be less distinct not an inch from its source than at 'a re- mote point. We have, however, found Laennec's remark true when the sound was drowned in the praecordial region by a bellows-murmur or pulmo- nary rale ; the explanation of which is, that the second sound, being of a more acute nature than the murmurs, is more readily transmitted to a distance. On the same principle also, is to be explained another doctrine of Laennec, the accuracy of which we have frequently verified : namely, that »in healthy subjects, but in whom the heart has rather thin walls, the sound is sometimes stronger under the clavicles than the first, although the same difference is not observable in the praecordial region." The reason of this is, that the second sound, being more acute, is more easily propa- gated. In hypertrophy with dilatation the sounds are increased. The first is, as it were, a compound of the sound of dilatation and that of hypertro- phy : namely, from dilatation it derives a loud, abrupt, or flapping commencement, and from hy- pertrophy a prolonged termination, like a respira- tory murmur. The second sound, though not in general changed in its tharacter, is louder than natural. These sounds may frequently be heard over the whole chest, both posteriorly and ante- riorly, especially in children and meagre subjects. In hypertrophy with dilatation the sound of the ventricular contraction is sometimes accompanied with a bellows-murmur. This we have found to be almost always the case when the heart is ex- tremely large and contracting with vehemence. The sounds of the heart, in every form of hyper- trophy, may be diminished by the same causes that diminish the impulse. Resonance (See much valuable information on this subject in the " Procede Operatoire" of M. Piorry, Paris, 1830, p. 112, et seq.) of the prae- cordial region on percussion is defective in sim- ple hypertrophy, provided the heart be considera- bly enlarged; but, as hypertrophy and dilatation is the disease in which the organ attains the great- est volume, it is that in which resonance is most frequently and most extensively defective. In all cases of considerable enlargement the dulness as well as the impulse are lower down than natural, except in adhesion of the pericardium, by which affection the heart is more or less braced up. Progress and Termination of Hypertro- phy.—Hypertrophy, while moderate, and not com- plicated with any mechanical impediment to the circulation, is productive of very little inconve- nience. This is especially true with respect to children.- In them the heart is naturally larger in proportion than in adults; and in many this amounts to a very considerable degree of hyper- trophy with dilatation, accompanied with greatly increased impulse and sound; yet the general symptoms manifested by such are often scarcely appreciable, and the increased action itself sub- Vol.IL —51 2i* sides towards the period of puberty by the estab- lishment of a more correct proportion and equi- librium between the heart and the system. At the adult age also, and during the whole period of manhood, an individual of an otherwise sound and vigorous constitution may be affected with hypertrophy to a moderate extent, without experiencing any sensible deterioration of the gen- eral health (with the exception of being more lia- ble than others to cerebral and phlogistic affec- tions), or any diminution of muscular force and activity ; and if his habits with respect, to diet and exercise be moderate, he may pass a long series of years, and even attain the extreme period of senility, without being conscious that he is the subject of organic disease. The only general signs denoting the existence of the malady will be, perhaps, a little shortness of breath on exer- tion, and occasional feelings of slight palpitation. Amongst the labouring classes these symptoms, even in a considerable degree, are so. little regard- ed that their presence is often disavowed by the patient, though palpably manifest to the physician. If, however, an individual affected with hypertro- phy abandon himself to intemperate living, or engage in occupations requiring great corporeal exertion, he rarely fails to bring on either apo- plexy, palsy, hemoptysis, or an irremediably aggra- vated state of/the disease, which embitters and curtails his existence. The celerity with which these accidents are induced depends on circumstances. In general, the progress of hypertrophy is very slow and gradual, but in some cases it is rapid : in several instances we have known it terminate fatally with- in a year from its commencement. The circum- stances occasioning these variations are connected with—1, the form of the disease ; 2, its compli- cations ; 3, the nature and intensity of the exter- nal exciting causes ; and, 4, the constitution of the patient. It is of the utmost importance that the practitioner be able to form some estimate of the influence of these circumstances ; for it is by this means only that he can foresee the course of the disease, and direct his treatment with judg- ment and decision. It may be useful, therefore, to enlarge a little on this subject. 1. The progress and termination of hypertro- phy are influenced by the form of the disease. Simple hypertrophy is more apt than any other form to induce apoplexy while the patient is ap- parently in perfect health. This is to be account- ed for by its tendency to create plethora, while at the same time it does not incapacitate the patient for active corporeal exercise and the pleasures ol the table. When premature death does not occur from apoplexy or hemoptysis, simple uncompli- cated hypertrophy runs a more chronic course than any other form of the disease. Hypertrophy with dilatation, especially if great, is a far more harassing, dangerous, and, if we may be allowed the term, acute affection than the pre- ceding. All its symptoms are more violent, and its course is more rapid. It is somewhat less apt to occasion unexpected attacks of apoplexy ; pre bably because the greater dyspnoea which it occa- sions deters the patient from violent exercise and high living. When once the palpitation and dys- pnoea have attained such an extent as imperatively 402 HEART, (HYPERTROPHY OF THE) to demand periodical bleedings at brief intervals, the malady hurries with an uninterrupted course to its fatal termination. 2. The progress and termination of hypertro- phy are influenced by its complications. When hypertrophy is connected with contraction of an orifice or any other obstacle to the course of the blood, the symptoms are greatly aggravated. For, first, in consequence of that obstacle, the hyper- trophy proceeds to a greater extent; and, second- ly, the violent struggles of the heart to surmount the obstacle subvert the general balance of the circulation. To speak more explicitly, suppose the obstacle to be situated in the aortic orifice. While the left ventricle is palpitating to disgorge itself through the contracted aperture, the right, acting in concert with it, deluges the lungs with an inordinate quantity of blood; whence ensues a paroxysm of dyspnoea : next, in consequence of the pressure of blood through the lungs, the supply to the left ventricle is increased. This ven- tricle, therefore, instead of relieving its engorge- ment by palpitation, only aggravates it, and the fit does not subside until either the heart becomes gradually exhausted by its own efforts, or (what is more common) until the internal congestion is relieved by determination to the surface or a co- pious discharge of watery mucus from the lungs. The most violent, though perhaps not the most distressing, paroxysms of palpitation and dys- pnoea that we have witnessed have occurred in the particular complication described.' In others there may exist a greater feeling of suffocation (the source of the greatest distress), as will here- after be explained in the articles Heart, Dis- eases of the Valves of the, and Polypi. Adhesion of the pericardium, which rarely fails to produce hypertrophy with dilatation, is an ex- tremely formidable complication of this malady. It greatly aggravates all the symptoms, and accel- erates the fatal event, which not unfrequently takes place within the period of a year ; and we have known it occur in nine months. Febrile or inflammatory complaints supervening on an advanced degree of hypertrophy exasperate the malady in a surprising manner, so as not un- frequently to carry off the patient in the course of a few days. The effect seems to be produced by the febrile excitement keeping up, as it were, a perpetual fit of palpitation and embarrassment of the circulation, which the constitution cannot support beyond a brief period. Peripneumony has pre-eminently this effect; apparently because it not only excites the heart, but obstructs the cir- culation through the lungs. 3. The progress and termination of hypertro- phy are influenced by the nature and intensity of the external exciting causes. The principal of these are, over-exertion, ex- cesses at table, and mental perturbation, the latter of which, though not strictly external, may be ranged under this head. The effect of these re- quires no explanation, but it may be said that the dangerous influence of over-eating is greatest in simple hypertrophy, because it generates plethora and '.ncreaso'! the tendency to apoplexy; while ove exercise and intemperance are more prejudi- cial in hypertrophy with dilatation, because they increase the dilatation, which is the more danger- ous part of the disease. 4. The progress and termination of hypertro- phy are influenced in a remarkable degree by the constitution of the patient. The robust resist its encroachments much longer than those who are delicate and effeminate : and if the former, either from bad air or want of exercise, from disease, or from age, become unhealthy, emaciated, and fee- ble, they are rendered much more susceptible of the effects of the disease. This (if we may indulge in a mere speculation) is possibly in consequence of emaciation taking place to a greater extent in the muscular and adipose tissues than in the in- ternal viscera, whence, the latter becoming pre- dominant in size, the equilibrium between the heart and the system is subverted. This is ex- actly the converse of what occurs at the period of puberty in those who had laboured under en- largement of the heart when children, for in them the equilibrium is restored by the system enlarg- ing with the growth in proportion to the size of the heart. Prognosis.—The general prognosis is favour- able in the early and unfavourable in the advanced stages of the disease. The particular prognosis must be founded on an estimate of the various circumstances of the case formed according to the above rules. Treatment of Hypertrophy.—As it is easi- er to diminish the nutrition of the heart than to increase it, or to remove a valvular or other me- chanical obstruction, it is very conceivable that hypertrophy.is more susceptible of cure than any other organic affection of the heart. In the treatment the first care should be to re- move any known exciting cause of the malady. It is equally obvious that as this malady consists in an increased power and action of the heart, bloodletting and other reducing and tranquillizing means are the appropriate remedies. Laennec strongly recommends that they be employed with courage and perseverance on the plan of Albertini and Valsalva. We cannot say that our own ob- servation leads us to coincide entirely in this opin- ion. We shall first, therefore, give a sketch of the treatment alluded to, the sanction accorded to which by names of the highest authority renders it at least deserving of the most attentive conside- ration; and shall afterwards point out in what respects it appears to us to be objectionable. This treatment, according to M. Laennec, ought to be prosecuted in an energetic manner, especially in the commencements; and in aiming to enfee- ble the patient, we ought much more to fear rest- ing short of the mark than exceeding it We should commence by abstracting blood as copiously as the patient can support without falling into a state of sinking; and we should repeat the ope- ration every two, four, or eight days, until the pal- pitations have ceased, and the heart no longer gives, under the stethoscope, more than a mode- rate impulse. We should, at the same time, re- duce to at least one-half the quantity of aliments which the patient ordinarily takes, and diminish even this quantity if he preserve more musculai strength than suffices to take, step by step, a walk of a few minutes in the garden. In a stout adult Laennec usually reduces the quantity of aliment? HEART, (HYPERTROPHY OF THE) 403 to fourteen ounces a day, amongst which he thinks there should be only two ounces of white animal food. If the patient wishes to take broth or milk, he counts four ounces of these liquids for one of animal food. Wine ought to be interdicted. When the patient has been about two months without experiencing palpitation, and without strong im- pulse of the heart, we may dispense with the bleedings, and somewhat diminish the severity of the regimen, if habit has not yet been able in any degree to reconcile him to it. But. it is necessary to revert to the same means, and with equal rigour, if in the sequel the impulse of the heart increase again. We ought not to have confidence in the cure until the expiration of a year of complete absence of all the symptoms, and especially of all the physical signs of hypertrophy. We must be afraid of allowing ourselves to be deceived by the perfect calm which bloodletting and abstinence sometimes very promptly produce, especially if we have commenced the treatment at a period when the hvpertrophy was already accompanied with extreme dyspnoea, with anasarca, and with other symptoms which gave reason to fear an approaching death. If we begin the treatment of hypertrophy of the heart at a period when it has already produced severe effects, particularly anasarca, ascites, osdema of the lungs, and a very marked state of cachexy, we ought not on that account to shrink from bleeding and abstinence. To obtain success, it is necessary, according to the same author, that the physician and the patient arm themselves with almost equal patience arid firmness; for it is not more difficult for the latter to resign himself to perpetual fast and frequent bloodlettings, than for the former to struggle daily against the opposition of relations and friends, and the discouragement which cannot fail to seize upon the patient in a treatment which ought to continue at least several months, and sometimes to be prolonged during several consecutive years. Such is the manner in which M. Laennec em- ploys the treatment of Albertini and Valsalva; and he states that he could cite a dozen instances of cures of hypertrophy, either simple or with dila- tation, which have not been falsified for several years. One important case which he details, seems to prove that the treatment causes atrophy of the heart; for the organ was remarkably less than the fist of the subject, and was shrivelled or wrinkled in a longitudinal direction. Our objections to the treatment described are founded on the circumstance that, though we have invariably found the greatest benefit to be derived from sparing abstractions of blood at intervals of two or three weeks or more, we have constantly noticed that when, from the severity of the dys- pnoea and palpitation in the advanced stages of the complaint, the practitioner was induced, or thought himself compelled, to resort to frequent bleedings at short intervals, the patient, though perhaps momentarily relieved, progressively de- clined from that moment, the paroxysms recurring more frequently and with greater violence, until they eventually terminated in his destruction. Noiv, on comparing a patient under these circum- stances with one under the influence of mere re- action from loss of blood, the analogy appears to us to be very intimate. In both, the violence of the heart's action, so far from being repressed by a reiteration of the bloodletting, is only increased; in both the blood is, and necessarily must be, at- tenuated and deteriorated in consequence of the fibrinous portion and red globules being replaced to a greater extent than natural by serum, which is more expeditiously regenerated. These, then, are apparently the causes of the patient's decline. The prejudicial effects of the re-action are sufficiently obvious; and the state of the blood not only contributes in all probability to the re-action, (Vid. Treatise on Diseases of the Heart, by the writer, p. 75,) but, by its deterio- rated quality, is unsuitable for the due nutrition and conservation of the system.* It would appear, therefore, that the indications in the treatment of hypertrophy are, to diminish the quantity-without materially deteriorating the quality of the blood, and to do this in such a manner as, without producing re-action, perma- nently to enfeeble the action of the heart and the energy of the circulation. The safest and most effectual means of fulfilling these indications have appeared to us to be the following: Four, six, or eight ounces of blood should be taken every two, three, four, or six weeks, accord- ing to the strength of the patient, and sufficient to keep down palpitation, dyspnoea, and strong impulse of the heart. If the head be much af- fected, the blood should be drawn by cupping from the nape of the neck. The diet should con- sist of white animal food and liquids in small quantity, unless, from the advanced state of the disease, the blood be so impoverished as to be in- sufficient for the maintenance of the system, when a more nutritious though still spare diet may be allowed. Every thing stimulating, as spirituous and fermented liquors, and highly seasoned dishes, should be avoided. Any exercise taken should be so gentle as never to hurry, and, if possible, never even in the slightest degree to accelerate the cir- culation. When the action of the heart appears to increase, and yet general bleeding is not expe- dient, three or four copious and watery alvine evacuations should be procured daily by saline aperients, of which none answers better than one or two drachms of sulphate of magnesia in infu- sion of roses twice or thrice a-day. This may be continued for a week or ten days according to the effect; and either the same or some analogous aperients should be employed habitually in suffi- cient doses to keep the body gently open, and to procure, if possible, liquid evacuations. When salines are used habitually, their debilitating ef- fects on the intestinal canal may be in a great measure counteracted by adding to the infusion of roses,an equal quantity of compound infusion of orange-peel, and six or eight minims of diluted sulphuric acid. In addition to purgatives we have seen the most decided advantage result from diuretics; and not only when there was dropsy, but equally when * It does not follow that though the treatment of Al bertini and Valsalva he unsuitable for hypertrophy, it is equally so for aneurism of the aorta; as in the lattei the object is to produce a sudden and extreme, though temporary reduction of the force of the circulation, iii order to promote the formation of fibrinous coagula in the sac: an expedient which is sometimes perfectly suc- cessful in effecting a cure of aneurism, but which wiV not have the same effect on hypertrophy. 404 xlEART, (HYPERTROPHY OF THE) there was none. Their mode of operation ap- pears to be ultimately the same as that of purga- tives ; namely, they drain off the serous portion of the blood. We have found many patients, conscious of the benefit which they derived from this class of remedies, to be in the constant habit of taking cream of tartar, broom-tea, and other similar popular medicines. One patient affected with contraction of the mitral valve to the size of an ordinary pea, by these means warded off drop- sy, beyond the slightest oedema of the feet, for ten years. When decided dropsy appears, it must be combated by the most efficient diuretics — the super-tartrate, tartrate, acetate, and nitrate of potass, squill, digitalis, spirit of nitric ether, de- coction of broom, &c, with mercury if not contra- indicated. As no class of remedies is more varia- ble and uncertain than this, when one fails another should be resorted to; and it not unfrequently happens that a weaker is more successful than a stronger. Should diuretics wholly fail, hydra- gogue purgatives, as elaterium, tincture of jalap, infusion of senna with tartrate of potass, &c. are often invaluable substitutes. The state of the stomach and of the biliary secretion should never be overlooked in hypertro- phy, as their derangements are amongst the most efficient exciting causes of palpitation. The re- medies suitable for dyspepsia and bile are there- fore to be resorted to. We deem it unnecessary here to enlarge on them, and on the treatment of dropsy, cough, dyspnoea, &c, as these subjects will be found fully discussed in the article Heart, (Diseases of the Valves of the). It frequently happens that, notwithstanding the most judicious use of the remedies mentioned, the irritability of the nervous system frustrates their tendency to reduce and tranquillize the action of the heart. In this case sedatives are eminently useful, and the best effects often result from tinc- ture of digitalis, to the extent of m.xx. or xxx. twice or thrice a-day; from two or three drops of hydrocyanic acid, administered as often; from three or four or more of extr. of hyoscyamus or conium once or twice a-day ; and from half a grain of acetate of morphia twice a-day. The above, and indeed every other mode of treatment is unavailing if not steadily pursued, and it must be pursued for one, two, three, or more years. Thus employed, we have found it effect cures in a considerable number of instances, some of which were advanced even to the second degree. In the first degree, especially before the period of puberty, this fortunate event is often obtained although bleeding be resorted to only at long intervals, as of from six weeks to three months. [See Pennock's edit, of Hope, on Dis- eases of the Heart, p. 230.1 , „ J J. Hope. [HEART, (INFLAMMATION OF THE)— See Carditis and Pericarditis.] HEART, (MALFORMATIONS OF THE) —Under this head we comprehend all those devia- tions from the natural mechanism or form of the heart which are developed in its original confor- mation, or in the progress of its early growth. They arise, for the most part, from an arrest or interruption in those successive changes which the heart undergoes from its first formation until it is adapted to support the double circulation of post- natal life ; but as in the case of other monstrosities, they sometimes consist of an irregular, and some- times of a superfluous, development of parts. 1. Defective Malformations.—As there is a period in foetal life in which the heart does not exist, so there have been instances in which the constructive process has been at this period inter- rupted with respect to this organ; so that, while other parts of the body were more or less perfectly developed, the heart was entirely deficient; its place being sometimes occupied by a mere sac or net-work of vessels, as in the zoophytes, and in other cases the communication between the arte- rial and venous system being direct. In nearly all the cases of acardia on record, the brain and spinal marrow were also wanting; but Andral (Pathological Anatomy, translated by Drs. Towns- end and West, vol. ii.) quotes an instance from the second volume of the Repertoire d'Anatomie, in which the nervous centres were nearly entire, but there was neither heart, nor lungs, nor large vessels. As these are cases more of physiological than of practical interest, we need not dwell longer upon them. It has not been distinctly ascertained by obser- vation that the heart of the embryo is ever quite of the simple structure of the heart of fishes : in the early stages of its existence, however, it differs only in having the rudiments of a septum at the apex of the ventricle, and probably at a more re- mote period it is quite simple, consisting of a single auricle and ventricle ; and this condition remain- ing stationary until birth, constitutes a variety of malformations of the lowest order. Of this de- scription we find the record of eight instances.* In these cases the aorta gives off one or more pul- monary arteries, and the pulmonary veins termi- nate either in the auricle or in the vena cava. Some of these infants lived for several days with- out any apparent irregularity or defect in the performance of their functions, except some dys- pnoea and blue discoloration of the skin, which varied considerably in different instances and a different times. In Dr. Farre's case the skin was very pale, and with but slight lividity, while the action of the heart and diaphragm was excessive and these symptoms are explained by the fact that the orifice of the aorta was much contracted, so that, white the system was ill-supplied with blood, the heart and lungs were kept constantly engaged. Of the two cases related in the Philosophical Transactions, one lived ten days with no other un- common sign than a purple skin; in the other this only occurred shortly after birth and again just before death, which happened on the eighth day. The next gradation of malformation is that in which there are two auricles with one ventricle. Of this we have found only two examples recorded, the subject of one of which, quoted by Laennec from Kreysig, (vol. iii. p. 100,) attained the age of twenty-two years. This fact proves that, great as the anomaly in this case was, the body can *1. Phil. Trans. 1798, p. 2; 2. ibid. 1805, p. 2: 3. Dr. Farre, Patholog. Researches; 4. Ephem. Nat. Cur., Dec. l.Obs. 40; 5. ibid. Dec.2, Obs. 44; 5. Fleischmann, Leichen- offnungen, 1815; J. F. Meckel, de Monstrosa Duplicitate, 1815; 8. Burns, ou Diseases of the Heart p 27 HEART, (MALFORMATIONS OF THE) 405 better adapt itself to this sort of reptile-like circu- lation than to those malformations which greatly obstruct the course of the blood. Nearly allied in effect to the preceding, although their more perfect structure would entitle them to a step higher in the class, are the cases of imper- fections or perforations of the septa between the ventricle and between the auricles.* Many of this kind have been described, in a considerable variety of combination. There is commonly a contraction of the orifice of the pulmonary artery, and in the fcetus born with this malformation the ductus arteriosus is either totally wanting, or im- perforate. Some subjects of this malformation have survived for several years, (one reached twenty-seven,) but always in a state of great dis- order, being affected with blueness of skin, faint- ings, &c. The foramen in the septum of the ventricle is always nearest to the base of the heart, ind it is often so near the origin of the aorta or pf the pulmonary artery, that the vessel communi- cates freely with both ventricles. These all ap- pear to be instances of arrest of development, cor- responding with the state of the foetal heart in the early stages of its existence; and the disorder which they occasion in post-natal life is generally in proportion to the extent of the imperfection, but it is always greatly augmented wherever there is a contraction of the arterial orifices. The last order of malformations from simple interrupted development or adaptation are those in which the heart retains, after birth, one or both of the peculiarities naturally destined only for the foetal state, the open state of the foramen ovale and of the ductus arteriosus. As the occlusion of these channels of auxilary circulation is essen- tial to the well-being of the perfect breathing ani- mal, nature admirably contrives that the first re- spiratory act shall in normal cases effect this change, and the means by which it fulfils this end are worthy of attention. According to Meckel, there is little difference in thickness between the two ventricles of the heart at the time of birth, the left scarcely presenting any of that superiority which is so evident in after-life. In fact, it appears that before birth the right ventricle, through the ductus arteriosus, assists the left in the systemic circulation ; and when the post-natal change takes place, there must be not only an additional outlet given to the blood from the right ventricle, but also an increase of power to the left ventricle, to main- tain the aortic circulation ; which now depends solely on it. A full and perfect respiratory act fulfils both these objects ; by expanding the lungs it gives a free outlet to the blood from the right ventricle, and, by arterializing the blood which re- turns to the left ventricle, it stimulates it to such an increased energy of contraction as enables it, unaided, to supply blood through the system. This increased energy is soon followed by an in- creased thickness of the muscular walls of the ventricle, which gives a permanency to the greater * Farre, op. cit. p. 30, 27, 28 ; Meckel, Tab. Anat. Path. Fasc. 1, Fig. 1 ami 2: Senac, Traite sur la Structure du Creur, t. ii. |) 404; Dr. Hunter, Medical Obs. and Inq., vol. vi. p. ii;il-Sl9; Corvisart, sur les Mai. du Coeur, pp. 270, 29!) 298; Barthoiuivs, Acta Hofniens. t. i. p. HIO; Jiberncthy. Surg, and Pliys. Essays ; Dr. Crampton, Trans. Coll Pins., Dublin, vol. i.; Dr. Hope, on Diseases of the Ueart, p. 403. power required in its important function. The ductus arteriosus, thus freed from the current of blood through it, contracts, as in the case of all obstructed or empty arteries, into an impervious cord. The progress of this contraction has been minutely described by Bernt as a test applicable to the investigation of cases of supposed infanticide (Handbuch der Gerichtlitch. Arzneikunde.) The obliteration of the foramen ovale is probably a much slower process, and one of less consequence, for its ordinary state at the time of birth is such that, unless there be considerable inequality of pressure between the auricles, it is sufficiently closed by its valves to prevent the passage of blood through it. From these circumstances we are inclined to consider patescence afterbirth of the foramen ovale in most cases, and of the ductus arteriosus in every case of its occurrence, to be the result of loss of balance between the effective forces of the two sides of the heart at the time of birth. The ductus arteriosus stands in the same relation to both ventricles, that is, it communicates with the great artery proceeding from each : as long as these two arteries are filled with equal force, there will be no current in the duct; and such is the state under which, in natural cases, it contracts into an im- pervious tube. But if there be greater pressure on one end, whether from the pulmonary artery or from the aorta, a current must then pass from the stronger to the weaker side. Now the causes of such an inequality of pressure are various; and it will be worth while to point out a few of them, as we shall thereby gain a clearer understanding of the complicated pathology of several kinds of mal- formation. In several cases on record the open state of the ductus arteriosus has been found in conjunction with a manifestly contracted state of the orifice of the pulmonary artery, and in some with its total obliteration. Dr. William Hunter relates the case of a child born in the eighth month of gestation, which, after exhibiting a livid skin, dyspnoea, and violent palpitations, died of convul- sions on the twenty-third day from its birth. On dissection, the pulmonary artery was found reduced to an impervious cord, whilst the foramen ovale and ductus arteriosus were both open. Dr. Farre gives the history of two similar cases, one of which died in a week, the other lived six months. In all these the muscular power of the right ventricle had become useless; in Dr. Hunter's case its cavity was nearly obliterated, and in both of Dr. Farre's a perforation of the inter-ventricular septum made the right a mere appendix to the left ventricle. The part which the ductus arteriosus bore here was important, for, open to pressure only at its aortic end, it must have supplied the place, of the pulmonary artery, by conveying the blood in a re- trograde course from the aorta to the lungs. The same thing occurs in a minor degree when the pulmonary artery is merely contracted at its orifice, If, on the other hand, the aortic orifice is contracted, so that the artery does not receive the due influence of the systole of the left ventricle, the pressure on the right end of the ductus arteriosus will be greatest, and a current will flow from the pulmo nary artery to the aorta. Any obstruction to the circulation through the lungs would have a similai effect, and for the reasons which we have already observed to obtain in fcetal life. 106 Openings in the septum of the ventricle, when combined with decided contractions of either of the arterial tubes, we cannot but view as in most instances the effects of the latter; for it is a sim- pler idea, and one more consistent with the laws of development, to suppose that an obstruction, which, pathologically speaking, is of frequent oc- currence, retains the current of blood in the course which it held in the early period of its formation, than to ascribe a perforated septum to some specific and inexplicable arrest in its natural development. The most common combination of an open duc- tus arteriosus is, however, with considerable pa- tescence of the foramen ovale ; and we would still view this latter in the light of a cause. Any con- siderable direct communication between the auricles must, to some extent, frustrate the longer inter- course through the lungs; and from the blood passing thus directly in a venous state to the left side of the heart, two things affecting the balance of the circulation must result: 1. the left ventricle, not receiving its proper stimulus of pure arterial blood, does not contract with increased energy, as an the moment of birth it ought to do; 2. this de- fective force in the left ventricle occasions some stasis of blood in the pulmonary vessels; whence the pressure of the aortic extremity of the ductus arteriosus continuing to be less than at the right end, the blood persists to flow through it as before birth, and its canal is kept permanently open. 2. Irregular Malformations. — The next description of malformations are those which con- sist of a misplaced or erroneous position or attach- ment of parts in the heart, constituting the quali- tative malformations of Meckel. Examples of transposition of the aorta and pulmonary artery are described by Farre, (Op. cit. p. 29) ; Langstaff (Lond. Med. Rev. p. 83) ; and Baillie; (Morbid Anatomy, p. 36.) The subject of one lived five months and died of small-pox ; the surface was cold and extremely susceptible, and the skin blue, with incessant cough in any posture but on the right side. During the eruptive fever there was increased heat only in the head, the limbs and body remaining cold. The valve of the foramen ovale was found perforated with five holes; the aorta sprung from the right, and the pulmonary artery from the left ventricle. In Mr. Langstaff's case the child lived ten weeks with similar symp- toms, and here both the foramen ovale and ductus arteriosus were open. In two cases related by Sir Astley Cooper, the pulmonary artery commu- nicated with both ventricles, and gave off the descending aorta; the ascending aorta rose from the left and divided into the innominata, and the left carotid and subclavian; the foramen ovale was also open. A remarkable instance of malformation is de- scribed by Dr. Holmes in the first volume of the Transactions of the Medico-Chirurgical Society of Edinburgh. The subject was a young man aged 21, who had from childhood been affected with palpitation, dyspnoea, blueness of skin, pain about the heart, and frequent faintings, with cold limbs. The foramen ovale was found open, and the right auricle, instead of opening into the right ventricle, communicated with the left by a large aperture, which was furnished with a tricuspid valve. The auricle was enlarged to the capacity IA TIONS OF THE) of a pint. The right ventricle gave off the pul- monary artery as usual, and must have received blood only through an opening in the left ventri- cle, immediately beneath the aortic valves. The valves of the heart have been found in an unnatural state, which many pathologists have considered to be congenital. Laennec describes a union of the laminae of the tricuspid and of the mitral valves at points near their extremities, but leaving apertures through which a finger might be passed. In the same case the semilunar valves of the aorta and of the pulmonary artery were also adherent to one another. Small, smooth, round, or oval openings are occasionally met with in the different valves, which may be regarded as congenital; and Laennec met with a case in which holes of this kind had converted the tricus- pid valve into a mere net-work. There have been noticed other irregularities in the valves, such as an inequality in their size, and a superfluity in their number. 3. Superfluous Malformations. — The last or- der of malformations to be noticed are those con- sisting of excessive development. Well-described examples of these are not numerous, nor do they bear any remarkable feature. The heart has been found with supernumerary auricles and ventricles, and even double the natural number. Meckel describes instances of these double hearts, all having occurred in double monsters. (De Monstrosa Dupl.) Winslow met with one in a fcetus which was defective in the oesophagus and trachea. Andral has seen a heart with three auri- cles, and another with four ventricles. An appen- dicular auricle or ventricle is not uncommon: we have met with an instance of the latter. Super- numerary septa, partially or entirely separating portions of the different cavities, have likewise been described. The foramen ovale has been found closed in the foetus (Vieussens sur la Structure du Coeur) ; and in one case of this kind there existed an unusual communication between the vena cava and pulmonary veins. Bertin quotes a case of a double arch of the aorta. The pathological effects of malformations of the heart depend on two physical causes, an ob- struction to the circulation, and an intermixture of venous with arterial blood. The first of these is probably the most important; for the latter, although decidedly injurious, does not appear to encroach so seriously on the functions of a body accustomed to its effects, as to prove fatal, unless when conjoined with material obstruction to the circulation. These two, moreover, produce and re-act on each other in a manner sufficientlj interesting to merit a little consideration. Some cases of single heart already noticed, prove that the free admixture of venous blood in the arteries is not incompatible with life, as the subjects lived for several days. There was in these cases, besides, some obstruction to the circu- lation, in the aorta, or in the pulmonary artery; the one being characterized by pallor, and the other by a blue discoloration of the skin : and it is a question whether, but for these impediments, life would not have been considered prolonged; for the simplicity of the moving power would prevent any of that loss of balance which is so frequent a cause of obstructed circulation in the HEART, (MALFORJ HEART, (MALFORMATIONS OF THE) 407 double heart. This loss of balance, or undue action of one compartment of the heart, is an almost inevitable consequence of any malforma- tion which causes a mixture of venous with arte- rial blood; and if it be great, it will generally aggravate the evil effects of the malformation ; whence, in such cases, the obvious tendency to progressive disorder. In the greater number of instances the right side of the heart suffers more especially. Naturally its task may be said to be lighter in post-natal life than that of the left side, but the various congenital irregularities of me- chanism fall heavy upon it; whence, according to the observations of Louis, it is almost always affected with dilatation or hypertrophy. Thus in perforation of the septum of the ventricles, as well as in the open state of the ductus arteriosus with a free pulmonary artery, the right ventricle has to contribute to the aortic circulation as well as to maintain the pulmonary, whence it gradually assumes a more muscular structure than the left ventricle. The right auricle may suffer in a similar way from an open foramen ovale; but as the con- tractile power of the auricles is but trivial in force, this malformation will scarcely produce great dis- order without the addition of another cause. Such a cause is any obstruction to the circulation though the lungs; for example, a contraction of the pulmonary artery. Where this exists, the blood will not proceed so fast as it arrives ; there is consequently an accumulation in the auricle, with an unequal pressure and a flow through the foramen ovale. But in the history of cases de- scribed, we find the worst complication of this malformation is with an imperfection in the tri- cuspid valve. This is illustrated in Corvisart's case of the postilion. (Op. cit. p. 279.) The man, aged 57, said to have been previously healthy, was attacked with blueness of skin, palpitation, dyspnoea, &c. after injuries from a carriage passing over him, and a violent blow on the epigastrium. From this time he suffered in various degrees, and in four years sank under the usual symptoms of valvular disease of the heart, accompanied by discoloration of skin. The right auricle and ven- tricle were found greatly dilated and thickened ; the left auricle was also dilated, but the left ven- tricle was both thinner and smaller than natural. The foramen ovale was more than an inch in diameter, and the right auriculo-ventricular open- ing so much dilated as to admit four fingers, whilst that on the left side only admitted one ; the mouth of the aorta was likewise contracted. Laennec ascribed the open state of the foramen ovale to this accident; but we think it more probable that this was congenital, and, as is often known to be the case, harmless in its effects until the period of the accident. The violence may have occasioned a rupture or dilatation of some portion of the tricuspid valve, so that it ceased to close the auriculo-ventricular orifice, whence re- gurgitation into the right auricle, and such pres- sure as to drive the blood through, and in time gieatly to dilate the foramen ovale. We have said that an imperfect state of the tricuspid valve is the worst disorder of the mechanism that can complicate itself with an open foramen ovale; and the reason is, in addition to what we have just remarked, that the impulse of the right ven- tricle is propagated through the foramen ovale to the left auricle, and there opposes the course of the blood, which, during the systole of the ventri- cle, ought to flow into it from the lungs. It may be thus seen why in the above and in all similar cases on record, there has been an excessive oppression of the respiratory function. The con- traction of the left ventricle and aorta was obvious- ly the effect both of the small quantity of blood which the lisordered mechanism of the right ven- tricle could propel into it, and also of the unstimu- lating quality of that blood. We may remark, in conclusion, that every kind of malformation which leads to a mixture of' venous with arterial blood, must, as we have before explained, occasion an obstructed circulation through the lungs, and consequently add to the labour of the right ventricle. Bertin ascribes the frequent occurrence of hypertrophy in the right cavities of the heart, in cases of malformation, to the more stimulating influence which arterial blood obtaining entrance through the unnatural opening, exercises upon them. (Traite des Mai. du Cosui, p. 436.) Laennec thinks, however, that the pathological change results from the necessity imposed on the right cavities (naturally the weakest) cf a more energetic action, in order to resist the impulse of blood flowing from the left side. (Dr. Forbes's Translation, p. 630.) This opinion is more clearly supported by Dr. Hope, in his valuable work on Diseases of the Heart (Op. cit. p. 463), who remarks on the opinion of Bertin, that the obstructions in the pul- monary artery which so frequently prevail, would throw the current too much in the opposite direc- tion, from right to left, to permit the entrance of arterial blood into the right cavities ; and he con- siders that the greater labour thrown on the right ventricle in supporting the weight of the aortic circulation, is a sufficient cause for the changes in question. The dilatation in the same cavities is the generally acknowledged effect of over-disten- sion ; and Dr. Hope considers that this always depends on some obstruction to its course on the left. M. Louis gives the following numerical com- parison of the pathological changes in nineteen cases of congenital malformations. (Archives de Med. tome iii. Nov. and Dec.) Contraction of the orifice of the pulmonary artery in ten ; of the aorta in only one. Dilata- tion of the right auricle in eighteen, five of which were with hypertrophy, and two with attenuated parietes. Right ventricle simply dilated in five ; simply hypertrophied in six; dilated and hyper- trophied in four. Left auricle dilated in eight; hypertrophied in three. Left ventricle dilated in four; hypertrophied in two. Tricuspid valve more frequently diseased than the mitral, but neither often. Symptoms. — Malformations of the heart sometimes give rise to very prominent and well- marked symptoms, whilst in other instances they have only been discovered by the scrutiny of the anatomist after death. When the disease is ex- tensive, and particularly when combined with hypertrophy of one of the cavities or obstruction in some of the orifices, some or omer of the following signs are always present;—discoloration 408 HEART, (MALFORMATIONS OF THE) of the skin, varying from a slight reddish purple tinge to a deep purple or livid colour, especially affecting those parts which are naturally red, as the lips, tongue, fauces, and nails, which are sometimes almost black;—considerable diminu- tion of the superficial heat, with great sensibility to cold ;—palpitation of the heart coming on in paroxysms, especially after exertion or mental emotion ;—the pulse very variable, but generally irregular; occasionally syncope; — in children convulsions;— respiration habitually short and difficult, with fits of severe dyspnoea, which some- times occur periodically, and after tormenting the patient for a variable period, are terminated with sighs and yawning; — torpidity of bodily habit, with irritability of temper ;—severe pain of the head, vertigo, and defective vision ;—atrophy, and a disposition to hemorrhage. It was, until lately, a general opinion that the blue discoloration of the skin, or cyanosis, as in its greater degrees it is termed, is a characteristic sign of malformations of the heart which occasion the mixture of venous with arterial blood. This has been called in question in consequence of some cases described by Fouquier, Meckel, and Breschet, in which there existed malformations of this description without cyanosis ; and on the other hand an example of cyanosis reported to the Academy of Medicine by Dr. Mare, where no organic disease of the heart, congenital or other- wise, was discovered on dissection. Another op- posing argument has been urged by Fouquier, founded on the alleged fact that the blood in the arteries of the fcetus is dark without there being any blueness of the skin. Bertin (Mai. du Coeur, p. 437) and Ferrus (Diet de Med. art. Cyanose) have accordingly taken up the idea that the mix- ture of venous with arterial blood has no necessary connection with cyanosis, but that a stagnation ■if blood in the capillaries, generally dependent on in obstruction to the circulation in the heart, is !he universal cause of the blue discoloration in question : and that the presence of this sign in malformations arises only from the impeded state of the circulation which generally attends them. This view appears to us at least quite as incon- clusive as the former one; for we know that the circulation is impeded in almost every considerable disease of the heart or lungs, often without any cyanosis, and never (except, according to Laennec, in emphysema of the lungs) with that degree which is seen in congenital malformations. More- over, the cases before quoted (from Farre, Lang- staff, and Baillie) prove that in some most, re- markable examples of constant discoloration of the skin, there were no apparent obstructions to the course of the blood. We confess that we are still inclined to prefer the old opinion, modified in some degree accord- ing to the objections which the foregoing facts bear against it. With respect to Fouquier's argu- ment, it may be stated that the fact of the blood in the foetal arteries being dark is denied by later writers ;* and it is familiar to accoucheurs that a newly-born infant is often livid or purple, till it * Bostock's Physiology, vol. ii. p. 109. Holland on the ihysiology of the Fcetus, &c. p. 154. See also, an excel- lent inaugural dissertation on Malformations of the Ueurt, by Dr. Paget. Edinburgh, 1831. cries; crying is a proof of complete respiration, and then this colour gives place to a general red- ness. The absence of cyanosis in the cases of malformations before named was conjoined with a general pallidity of the surface ; and it would seem, therefore, that defect of blood in the capillaries was the reason of the absence of a dark colour. It must be remembered that in many cases we often see the countenance and surface so pale that the colour of the blood obviously does not affect them; and it is not to be expected that blueness of the skin should be apparent in a greater proportional number of cases of malformation with free commu- nication between the cavities, than is the redness of the same parts visible in other subjects. Dr. Paget well observes that, " as the colour of any organ is partly derived from the blood it contains, a change of the colour of the blood must affect the colour of the organ ;" and we can conceive no cause of this change more efficient than one which throws black blood into vessels which naturally contain it of a visible red. To assert that mal- formations are the only source of cyanosis would be to take an occasional for a proximate cause: in the collapsed stage of cholera, in asphyxia, and in emphysema of the lungs, we find a similar disco- loration of the skin ; and in these the same proxi- mate cause must be recognised, the presence of black blood in vessels which ordinarily convey red. In these cases, as in the former, and as also in the healthy state, an additional obstruction, the effect of posture, exposure, or exertion, will be fol- lowed by a still further injection of the capillaries, and where an ordinary subject would become florid and flushed, these assume a deeper and more livid hue. In most of the cases accurately described, a diminished temperature with chilliness of the sur- face has been remarked in those malformations that are attended with blueness of the skin. Dr. Farre submitted some of these to the test of the thermometer, and found the internal heat to be as usual, but that of the surface depressed in various degrees according to the exposure of the part. In some instances, when a limb has been exposed, it has been observed to become quite cold and livid. The patients commonly like to approach the fire at all seasons, and require an unusual quantity of clothing; when exposed to cold, especially if accompanied with wind, they sometimes become quite torpid and incapable of exertion. This is well instanced in a case described in Dr. Hope's work. (Op. cit. p. 470.) [See, especially, Dr. Pennock's Amer. edit. p. 449, Philad. 1842.] The palpitation, syncope, and dyspnoea may generally be said to be more frequent than in any ordinary disease of the heart; but the paroxysms are not often so severe as in the advanced and aggravated forms of valvular disease ; neverthe- less, when verging towards a fatal termination, they scarcely differ in symptoms from valvular disease, with which in fact they are frequently complicated. The greater blueness of skin, when present, is the most decisive distinction. It would appear that the intermittent form of the dyspnoea depends here, as in other diseases of the heart, in some measure on a sympathethic spasm, excited in the bronchial tubes by the engorgement of the right cavities of the heart. The relief of these HEART, (MALFORMATION OF THE) 409 exacerbations by deep sighing and yawning, which favour the oxygenation of the blood and its trans- mission through the lungs, is more remarkable than in other asthmatic diseases. The torpidity of habit, as well as the vertigo, acute headach, and defective vision frequently present, must be ascribed to the influence of the venous blood cir- culating through the brain; and the same cir- cumstance renders the nutritive process inactive, whence the subjects are commonly thin and slen- der. We have no reason to think that malformations of the heart are characterized by any distinctive physical signs; but the accompanying organic changes may be recognised by their usual signs, which are ably stated elsewhere. (See Heart, ACSCCLTATIOX, HTPF.RTROPIir, DlLATATIOtf, and Diseases of the Valves of the.) Con- tractions of the arterial orifices would be attended with a hissing, grating, or bellows-murmur during the first sound ; and a similar sound, more pro- found or remote, would probably accompany re- gurgitation into either auricle. In a case related by Dr. Hope, in which there was a perforation through the septum of the ventricles with a contraction of the pulmonary artery and open foramen ovale, there was a loud, superficial, hissing, bellows-murmur accompanying the first sound. Dr. Hope considered the superficial cha- racter of this sound to indicate an obstacle in the passage of blood from the right ventricle. It is probable that a free communication between the ventricles might occasion a murmur with the first sound; but an open foramen ovale can scarcely be expected to have any such effect, as the flow of blood through it, if there be any, would scarcely be forcible enough to become sonorous. Corvi- sart (Op. cit. p. 276) perceived, in one instance, a peculiar bruissement in the region of the heart, sensible to the hand. One of the aortic valves was absent. Treatment.—Although it is obvious that the cure of malformations is beyond the reach of art, yet, as we have seen that their fatal tendency depends greatly on their complication with other pathological conditions, the treatment which is adapted to retard the progress of these will gene- rally delay the fatal subversion of the functions to which both, when united, inevitably proceed. Any thing which causes an additional embarrass- ment to the breathing, or in any way injures the balance of the circulation, will not only produce a temporary disorder in fits of palpitation or asthma, but will permanently aggravate the organic mis- chief by increasing the attendant dilatation or hypertrophy, and by favouring the habitual pas- sage of blood through all devious and unnatural channels. Hence it becomes of the utmost con- sequence to watch those patients who are supposed to labour under congenital disease of the heart, and to keep their functions as near as possible on a balance; forbidding every sudden or violent exertion or mental excitement; enjoying a mode- lately nutritive but light diet of the most easily digestible kind; carefully excluding from cold a frame so susceptible to its effects; and, if neces- sary, aiding the excretory functions by the occa- sional cautious administration of appropriate medi- cines. The defect of the proper arterial quality Vol. II___52 ?K of the blood is probably more oi less felt by all the organic functions ; in none, perhaps, more than in the secretion of urine, which is generally turbid and scanty. Hence the artificial aid of diuretics, especially colchicum, with nitre and other salts, may prove serviceable. Dr. Farre supposes that the skin may be made in some measure to compen- sate for the defective action of the lungs in the pro- cess of arterialization; and although the experi- ments of Magendie and others scarcely permit us to believe that the process of oxygenation goes on at this surface, it is probable that, by keeping it in a more perspirable state, more relief may be afforded to the pulmonary and cardiac congestion than by any other measure. The warm bath, partial or gene- ral, has been found of great effect in relieving the paroxysms of palpitation and dyspnoea occurring in these complaints; and the application of warmth by gentle frictions with hot flannels is a measure of some utility, and one which may very often be resorted to. In individual cases relief may often be procured during the paroxysms by particular postures ; it is important to try to discover these in each case, but no general rule can be laid down. From what we have before remarked, it may be deduced that malformations may occasionally take their origin at the time of birth from a defective state of the respiration; and we do not deem it quite useless to suggest the expediency of watch- ing this function in the new-born infant, and of exciting it, if any lividity of the skin should show it to be imperfect, through the various channels of sympathy that are familiar to physiologists, such as by sprinkling the face and neck with cold water, or tickling the nostrils with a feather ; or, if these fail, by artificial inflation of the lungs. C. J. B. Williams. [HEART, (NEURALGIA OF THE). See Angina Pectoris.] [HEART, (POLYPUS OF THE). Poly- pous, polypiform or fibrinous concretions in the heart. In ordinary cases of death, the fibrinous portion of the blood is found coagulated in the heart, and either confined to the cavity in which it is chiefly met with, or extending to the arteries proceeding from it. At one time, these concre- tions were considered to be morbid, and were termed polypi, in consequence of their shape. They may take place before death, and, at times, interfere with the circulation of the blood through the heart, so as to give rise to physical signs, which may cause their presence to be suspected. They are, doubtless, owing to impeded flow of blood through the pulmonary artery or the aorta, the consequence of which is, retardation in its flows through the cavities of the heart, and con- sequent coagulation. Wagner (Elements of Phy- siology, translated by R. Willis, part 2, p. 267: Lond. 1842,) affirms, that the absence of blood corpuscles in their interior is an evidence of their formation some time prior to dissolution; the columnae carneae and chordae tendineae acting upon the blood in the same manner as thfc swilcli acts upon freshly drawn blood, when we beat it to separate the fibrin from it. Many cases have been published in which such 'mpediment to the cardiac circulation has been suspected. At a late clinical lecture at the Philadelphia Hospital, the writer 410 HEART, (RUPTURE OF THE) exhibited to the class a semi-organized fibrinous concretion in the right ventricle, the existence of which he had foretold before dissolution, owing to the sound of impeded transmission of blood through the heart, in a person dying of pleuro-pneumonia ; and a similar case, occurring in his service in the Baltimore Infirmary, was published by Dr.M'Neal, (American Med. Intelligencer, July 1, 1837, p. 125.) It appears to be generally admitted at the pre- sent day, that blood, under special circumstances, mav become organized after coagulation in the vascular system. No one denies the plastic or formative powers possessed by the liquor sanguinis of the blood ; and it is not difficult to comprehend that blood itself may be endowed with similar properties. Diagnosis.—The diagnosis of polypiform con- cretions in the heart cannot be easy. It has been conceived, however, that if, along with an increased, irregular, and confused action of the heart, there be a sudden and excessive aggra- vation of dyspnoea, without any obvious cause, the patient being in agony from an intolera- ble sense of suffocation, remaining restless and distressed till death, with cool surface and extre- mities, and a livid countenance, occasionally ac- companied with nausea and vomiting, the presence of a fibrinous concretion may be suspected. Many of these phenomena, however, are the usual pre- cursors of dissolution; and, as elsewhere remark- ed, (Practice of Medicine, 2d edit. i. 481,) it is not clear what can be the connection between this state of the heart and the affection of the stomach. The nausea and vomiting can only be regarded as an accidental circumstance. Occasionally these concretions are the cause of death by blocking up one of the apertures of the heart. Treatment.—The diagnosis being so difficult, it is not more easy to suggest an appropriate treat- ment When positively diagnosticated, indeed, the affection can only be treated according to the phenomena that present themselves. There can be no mode of reaching the mischief. Alkalies have been advised from their property of dimin- ishing the tendency of the blood to coagulate; and the borate of soda has been considered by Dr. Copland the most effective agent in prevent- ing the concretion of fibrin, and in dissolving it when concrete. Little or nothing can, however, be expected from them in this affection. Robley Dunglison.] ^ HEART, (RUPTURE OF THE,) [Cardior- rhexis,] may be either complete or partial. The rupture is said to be complete when the walls of the heart are perforated or torn through ; it is said to be partial or incomplete when it is confined to the tendinous chords or fleshy pillars of the heart. Compvetf Rupture.—The immortal discoverer of the circulation was the first to describe this lerion of its central organ. (De circulat sang. exercitat 3.) Morgagni, who himself fell a vic- tim to the disease, and other pathologists, both in this country and on the continent, have since recorded a considerable number of similar cases, and ha»e clearly shown that not a few of the '•ases of sudden death, usually attributed to an apoplectic seizure, are in reality caused by rup- ture of the heart. But although the disease has now in a great measure lost the interest of novelty, yet its investigation has acquired a still stronger claim on the attention of the physician, from the very fact of its occurrence being now no longer a matter of curiosity. We have ourselves wit- nessed two cases of rupture of the heart, occurring within the same year, in the Dublin House of Industry ; and M. Rostan observed three similar cases during the winter of 1816, and two more in the space of a fortnight, in the year 1820.— Still, however, the lesion may be considered as one of comparatively rare occurrence. The table on the opposite page, which we have drawn up from the most accurately reported cases that we have been able U> «lect, may serve to illus- trate some of the most in- cresting points connected with this formidable lesion, such as the relative frequency of its occurrence in the different parts of the heart, the sex and age of the individuals. the causes of the lesion, remote and proximate, and the symptoms which precede and follow the event. From this table it will be seen that the occur- rence of this formidable lesion is almost exclu- sively confined to extreme old age, and that the number of males who fall victims to it is much greater than of females, the proportion being six- teen to nine, or nearly as two to one. As regards the situation of the rupture, it appears that of the twenty-five cases recorded, the lesion occurred nineteen times in the anterior surface of the left ventricle near the apex, three times in the right ventricle, twice in the right auricle, once in the septum, and in two instances there were more ruptures than one. The observations of Bayle likewise confirm these results as to the relative frequency of the rupture in these different situa- tions. Of nineteen cases of rupture of the heart collected by this author, fourteen occupied the left ventricle near its apex, three the right ventricle, one the apex, and one the septum. (Meckel, vol. ii. note.) So that, from his observations as well as our own, it results that the left ventricle near its apex is, beyond all comparison, the part of the heart most frequently ruptured, the right ventricle comes next in order, and lastly the auricles and septum. This difference in the relative frequency of the rupture in their different situations, may, we conceive, be accounted for by referring to those pathological alterations which usually precede and induce the rupture of this organ. We are aware that several cases have been recorded of rupture of the heart caused by some violent mental emo- tion or physical exertion, a remarkable instance of which occurred some years since in Dublin, when a gentleman, on reading in a newspaper the death of his only son at the storming of Bergen- op-Zoom, instantly fell from his chair, and expired without a moan. Still, however, mental emo- tions, however powerful, can scarcely be consid- ered capable of producing so formidable an effect, unless where the heart had been predisposed to rupture by some organic lesion or degeneration of tissue; and therefore, while we do not deny the possibility of rupture of the heart arising in the same way as rupture of the uterus, from the inor- dinate action of its muscular fibres, we believe that Author's Name. Table of Twenty.Jive Cases of Jluplure of the. Heart, collected from various Authors. Adams, in Dublin Hospital Reports Ditto Bertin, Traite des Maladies du Coeur Ditto Bland, in Bibliotheque Medicate Ditto Ditto Ditto Bohnius, De Renunciatione Vul- ~) nerum 3 Ditto Crampton, case unpublished Ferrus, in Archives Generates Harvey, de Circulatione Sanguinis Morgagni, De Causis, etc. Morborum Ditto Ditto Morand, in Mem. de l'Acad. JRoyale Ditto Nichors, in Philos Trans, vol. Iii. Rostan, in Nouveau Journal de Med. Ditto Ditto Ditto Townsend^ in Dublin Hospital Reps. Ditt) Sex. Female Age. 60 Male 64 Ditto Ditto Ditto 86 Ditto 58 Ditto 76 Ditto 80 Ditto Ditto Ditto 80 Ditto 60 Ditto Female 75 Ditto Old Male 65 Ditto Female Old Male 77 Female 70 Ditto 75 Ditto 78 Ditto 74 Ditto 88 Male 84 T M P T O M S Premonitory. Dyspepsia Cerebral apoplexy Not mentioned Previous health good Pain of chest and oppression Dyspepsia Previous health good Ditto Ditto Not mentioned Previous health good C Pain in praecordia ~) £ and Dyspnoea 3 Organic disease of heart Headach and flatulence Palpitations Rheumatic pains Not mentioned Ditto Ditto Organic disease of heart Previous health good Slight catarrh Acute pain in praecordia Previous health good Ditto Consecutive. Sudden death Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto Ditto CAUSE. Proximate. Straining to vomit Straining at stool Leaping out of a window Vomiting after supper Spontaneous Straining to vomit Spontaneous Ditto Ditto Ditto Mental emotions Spontaneous Remote. Ditto Not mentioned Prodigiously fat Ramollissement Ditto Ditto Ditto Not mentioned Ulceration Loaded with fat Ramollisement Situation of Ruptures. Softening and fattiness Anterior wall of left ventricle Ditto Not mentioned Ditto Heart loaded with fat Ditto Ulceration Ditto Ditto Ditto Ramollissement Ditto Ulceration Straining at stool Not mentioned Spontaneous Thinning of the part Ditto Ditto Ditto Ditto Ditto Ditto Ditto C Ramollissement 1 £ and thinning < Ditto Ditto Ditto Right auricle Ditto C Anterior wall of left ventri- C cle near apex Anterior wall of left ventricle Ditto Ditto Ditto Septum ventriculorum Right ventricle Anterior wall of left ventricle Ditto Ditto Ditto Ditto Ditto Right ventricle Ditto Anterior wall of left ventricle Ditto Ditto Ditto Ditto Ditto W d a w w o 1-3 a w 412 HEART, (RUPT URE OF THE) such cases are excessively rare, and that in the great majority of instances which do not arise from external injury, the organic structure of the fibres is diseased before their substance is lacerated. The alterations of structure which usually pre- cede rupture of the heart, are ulceration, softening, or a disproportion in the thickness of the muscular parietes, arising either from atrophy of the part thinned, or hypertrophy of the other parts of the walls of the cavity, or from both these alterations combined. Of these morbid changes, some, as ulceration and softening, may attack any part of the heart external or internal; and accordingly the rup- tures, or rather perforations, which these morbid alterations give rise to, are found to occur with nearly equal frequency in the right and left ven- tricles, and in the auricles, whereas those cases of rupture arising from a disproportion in the thick- ness and strength of the walls of the heart, almost invariably occur in the left ventricle, about half an inch from the septum, and the same distance from the apex. Laennec and Bertin, whose authority ranks deservedly high on such subjects, are both of opinion that perforating ulcers are decidedly the most frequent cause of the heart's rupture, but we cannot reconcile with this opinion the fact that fully three-fourths of the cases of rupture on re- cord have occurred precisely in one determinate point, while the ulcers, which are supposed to precede them, evince no predisposition for that particular part of the heart. It is true that a large proportion of those ruptures which occur in the auricles or in the right ventricle, is caused by per- forating ulcers commencing generally on the in- ternal, occasionally, too, on the external surface of the parietes, and burrowing through their sub- stance ; but in those more numerous instances where the rupture occurs on the anterior surface of the left ventricle near its apex, the lesion is, in most instances, produced by the parietes having been previously rendered thin in that point, while their thickness was increased towards the basis. The reason why this is so may, we conceive, best be understood by considering, that although the parietes of the right ventricle and of the auri- cles are considerably thinner than those of the left ventricle, and consequently the parts which would, a priori, be supposed most liable to rupture, yet as they are nearly of the same uniform thinness throughout, the force of their contractions, as also their power of resistance, is equably divided, and operates equally on every point of their surface ; whereas the walls of the left ventricle are naturally thinner near the apex than towards the basis, and this inequality is occasionally rendered still greater ny disease, especially by that form of hypertrophy Dy no means uncommon in advanced life, in which the walls of the left-ventricle are more or less thickened towards the basis, while they retain their ordinary thinness near the apex, or are even rendered thinner than natural. M. Rostan, who has particularly described this form of hypertrophy, ha* likewise enumerated four cases of rupture arising from it. According to this author, the disproportion is, in some cases, so great that the muscular walls of the left ventricle measure fifteen or even eighteen lines in thickness towards their bases, while near the apex they are scarcely two lines thick. This local thinning of the muscular parietes is frequently accompanied with, and as it were compensated by a thick coating of fat, which is sometimes so considerable as to have arrested the principal attention of several distinguished pa- thologists, who, accordingly, did not hesitate to refer the rupture of the organ to this hypertrophy of the adipose tissue, which, in our opinion, was no otherwise concerned in producing the rupture than as it coincided with the atrophy of the sub- jacent muscular substance. Whenever the disproportion which naturally exists between the thickness of the walls of the left ventricle near the apex and towards the basis is rendered still greater, (as in the form of hyper- trophy just alluded to,) or when, their relative pro- portions remaining unchanged, the force of cohe- sion is generally diminished throughout their mus- cular structure, as in the case of general softening of that organ ;* the apex of the left ventricle being the point which sustains the greatest shock in pro- portion to its powers of resistance, yields to the distending force; and accordingly we find that aneurismal pouches, as well as ruptures, occur most frequently at this very point, namely, at the anterior surface of the left ventricle, about half an inch from the apex, and the same distance from the septum. It is not our intention to enter into a minute description of those morbid changes of structure which we have enumerated as the ordinary pre- cursors of rupture of the heart, as they have al- ready been fully discussed in the respective articles assigned them in this work : for our purpose it is sufficient to observe, that when the heart is pre- disposed to rupture by any of these morbid altera- tions, the slightest exciting cause is often suffi- cient to induce the fatal catastrophe. Of the twenty-five cases we have collected, there were eighteen in which no immediate cause of rupture could be assigned—the ordinary action of the heart being of itself sufficient to overcome its feeble powers of cohesion : of the two cases which fell under our observation, one died suddenly while chatting with his messmates; and the other as instantaneously white telling her beads in chapel. In three of these cases the act of vomiting was sufficient to cause the rupture; and in two in- stances it was occasioned by straining at stool. In one case already alluded to the rupture was caused by violent mental emotion ; and we re- member to have read of a similar event occurring in the person of Philip the Fifth of Spain, on hearing of the loss of the battle of Piacenza ; and lastly, in one of the cases the accident was pro- duced by external violence, the individual having jumped out of a high window. From whatever cause the rupture proceeds, its occurrence is generally followed by immediate death ; but in some rare cases life has been pro- longed for several days after the accident, and the perforation has in these instances, we are informed, * M. Blaud, who has published a highly interesting memoir on this subject, regards the softening of the heart's substance as the result of its prolonged action, and as a frequent, if not a necessary consequence of old age; and this degeneration he considers the essential cause of the ruptures which take place in extreme old age, and proposes to designate by the term of "dechire- menl senile."—Bibl. Midicale. HEART, (RUPT URE- OF THE) 413 been found plugged up with a coagulum of fibrine. We have not ourselves met with an instance of this favourable termination of the lesion, nor have we been able to discover a single case of the kind in the medical annals of this country. Still we are not prepared to deny the possibility of such an occurrence, as the annals of surgery furnish abundant proofs that the heart may be perforated, and yet that the individual may survive the acci- dent for many years. We might quote many cases in point from the works of surgical writers, but prefer confining our observations to cases of spontaneous rupture. M. Cullerier saw an in- stance of rupture of the left ventricle, in which the fissure was plugged up with a firm fibrinous concretion; and M. Rostan relates that a woman, aged seventy-four, who had suffered for fourteen years from palpitations, accompanied with excru- ciating pain in the left side and in the epigastrium, was seized with an attack of indigestion and vomit- ing, during which she expired suddenly, just as she was congratulating herself on getting over the attack. On dissection, the pericardium was found attached to the heart by albuminous bands, in different stages of organization ; an irregular fis- sure, nearly an inch and a half long, was also discovered on the anterior surface of the left ven- tricle, and to the left of this fissure the substance of the heart seemed destroyed for half an inch in length and half a dozen lines in diameter: this loss of substance was replaced by a firm concre- tion, which appeared incorporated with the sur- rounding tissue of the heart. In the neighbour- hood of these changes, the walls of the heart were remarkably thin, and were as remarkable for their thickness every where else. M. Rostan adds, that from the appearance of the cicatrix, he had no doubt that it was the mark of a former rupture, and probably of several years' standing. From these cases and others of a similar char- acter, we are justified in concluding that, in the event of rupture of the heart, there is a possibility of the aperture being closed by a coagulum, and of this coagulum becoming the medium for the formation of a true cicatrix : this favourable event is most likely to occur when the rupture is small, situated obliquely, and traversed by fibres attached to the ruptured surfaces; the cicatrix thus formed would, no doubt, receive additional strength from the formation of adhesions between the heart and pericardium in the immediate neighbourhood of the injury. This favourable termination is un- fortunately of such rare occurrence, that the disease may be reckoned among those which are the most immediately fatal. The premonitory symptoms of this lesion are, as might be expected, as varied as the conditions of the organ which precede its rupture. " Of the individuals," says M. Andral, " who died under my care in consequence of rupture of the heart, some had for a long time previously manifested the usual symptoms of organic disease of that organ; others had never betrayed any symptom of disease, either of the heart or large vessels ; and others again had complained occasionally of un- easiness or pain in the praecordial region, unat- tended with any other morbid symptom." In most instances the attention of the physician is first awakened by the sudden and unexpected 2k* death of the individual ; and in not a few cases it is only on dissection that the true nature of the case is discovered, when on removing the sternum the pericardium is seen presenting a pale bluish tint, and when opened is found more or less dis- tended with blood; most commonly only one rent can be discovered in the heart, but in some cases as many as five or six fissures have been found ; in such cases the ruptures are usually the effects of ulceration. The subject of treatment may, unfortunately, be dismissed in a few words, for as we cannot antici- pate the occurrence of this lesion, or recognize its existence after it has occurred, we cannot, it is evident, know when to apply the appropriate rem- edies ; which should, in the first instance, be di- rected to the removal of those morbid conditions of the heart which predispose it to rupture; and in the second, (after the accident has occurred without producing immediate death,) to support the nervous system under the violent shock it has received, and at the same time to restrain the inordinate action of the heart, with the view of moderating the haemorrhage and favouring the for- mation of a coagulum. Besides the species of rupture just described, the heart is liable to another, which for contradis- tinction has been termed partial or incomplete: in this latter form of the disease the rupture is seated in the chordae tendinae or in the columnae carneae. This species of rupture is, we believe, of more frequent occurrence than the preceding, though, in consequence of its not always causing such violent symptoms during life, or presenting such striking appearances on dissection, its existence is often overlooked. M. Corvisart, who first described this lesion, relates three cases of the chordae ten- dineae being torn across during violent fits of coughing ; a sudden and intense feeling of suffo- cation immediately followed, and terminated in exhibiting all the usual symptoms of disease of the heart. Laennec, Bertin, and Bouillaud, have like- wise published cases of this species of rupture, and a very interesting case of the kind is fully de- tailed by Dr. Cheyne in the Dublin Hospital Re- ports. We have ourselves met with three instances of one or more of the tendinous cords being torn across; in those cases we have seen, the lesion was found in persons labouring under pulmonary consumption. It does not appear that this species of rupture occurs more frequently in one ventricle than in the other. In some instances the tendons appear to be ruptured or torn from their attach- ments by a violent muscular effort, and do not ex- hibit any appearance of previous disease, but more frequently the ruptured extremities present un- equivocal marks of the ulcerative process by which the solution of their continuity was effected ; in two instances we have seen small globular vege- tations attached to the ruptured tendons. The symptoms of this lesion depend, in a great measure, on the extent and seat of the injury : when only one of the tendons is ruptured, the circulation is in general but slightly deranged; we have found two of the tendons severed in theii centre by ulceration where no symptom of any derangement of the heart's action was exhibited during life; the individual was in the last stage of phthisis; but when all the tendons wnich nic 414 HEART, (DISEASES OF THE VALVES OF THE) implanted into one of the valves are ruptured across, the valve, being no longer retained in situ, is allowed to flap backwards and forwards, and its valvular office is consequently destroyed altogether. The following observations, abridged from the case related by Dr. Cheyne, will serve to illustrate the formidable symptoms which are produced by this violent derangement of the heart's action. " A musician, aetat thirty-four, was suddenly seized with acute pain in the region of the heart, so vio- lent as to render him perfectly frantic,—the pain occasionally intermitted for some days. A month after the first attack, the stroke of the heart was indistinct and tremulous, and appeared to extend over the whole of the left side of the chest, from above the clavicle to below the scrobiculus cordis, without being more distinct at any one point than at another. Pulse 148—unequal, irregular, and indistinct—complexion of a leaden colour—coun- tenance bloated—his eyes staring wildly—memory impaired—inability to lie down. The disturbance of the vital functions was wonderfully increased by walking even a few paces, and while the exer- tion increased the dyspnoea, it gave strength and distinctness to the stroke of the artery—death en- sued without a struggle. Besides other morbid appearances, which it is unnecessary to enumerate here, the parietes of the left ventricle were found thickened, their internal surface much inflamed— several irregular excrescences were attached to the mitral and semilunar valves. The chordae tendi- neae, which connected the larger portion of the mitral valve to the wall of the left ventricle, were torn off just at the point of their insertion into the edge of the valve ; four of these ruptured ten- dons hu.ig loose into the ventricle. Between the extensive lesion which occurred in this case, and the formidable symptoms resulting from it, and the rupture of only a single tendon, with its comparatively trifling effect on the heart's performance of its functions, several intermediate degrees of rupture may occur, each of which would, no doubt, be attended with symptoms of proportionate severity. M. Laennec frankly ad- mits that these various kinds of rupture can at most be suspected, but cannot be certainly recog- nized by any positive signs. The only stetho- scopic phenomenon which we could observe in a case of rupture that we had an opportunity of examining, was a confused tremulous pulsation, which it was impossible to analyse; and we have been informed by Dr. Stokes, that a similar kind of pulsation, extending over the whole cardiac region, was the only stethoscopic indication that he could detect in a case where, after death, he found the tendons of the mitral valve ruptured. Richard Townsend. HE ART, (DISEASES OF THE VALVES OF THE)—The valves and chordae tendineae of the heart consist of fibrous tissue interposed be- tween a production and reduplication of the lining membrane of the organ. The fibrous tissue is prolonged from a dense, whitish zone of the same, which encircles each of the orifices of the heart, ind is, as it were, the tendon or point of attach- ment into which the muscular fibres of the organ are inserted. The lining membrane of the heart, according to Bicl 4t, approximates closely in char- acter to serous membranes : the valves, therefore, may be said to consist of fibro-serous tissue. This tissue in general, is remarkable for its prone- ness to cartilaginous and osseous degeneration; whence we derive an explanation of the fact, that the valves and orifices of the heart are frequently affected with these degenerations, while the cavi- ties, where they are invested solely with the lining membrane, are in a great measure exempt. Though disease occupy a valve universally, it stops abruptly where the serous membrane is con- tinued from the circular zone, or the extremities of the chordae tendineae, upon the muscular sub- stance. In a few rare instances it advances far- ther ; but we have never seen it attack the mem- brane on the muscular substance without its being connected with, and apparently propagated from disease of the valves. It would appear that the disease is more de- pendent for its origin on the fibrous, than the serous tissue ; for, where the former is most abun- dant, namely, at the base and the free margin of the valves, cartilaginous and osseous depositions are the most frequent and extensive. The depo- sitions appear, indeed, to originate in the fibrous tissue exclusively; for it is common to find the valves encumbered with large masses of cartilage from which the internal membrane can be peeled off in its natural thin and transparent state. In these cases the surface of the morbid deposition is smooth and equable ; and it is seldom until it be- comes corrugated, rugged, and knotty, that the internal membrane is implicated in the disease. Calcareous depositions in the same way, seem al- ways to commence underneath the membrane. In one case under our care, in which two rings of bone as thick as writing quills encircled the left orifices of the heart respectively, the mem- brane was stretched like a blue film over the whole of the aortic, and the greater part of the mitral ring.* Valvular disease is much more rare on the right, than on the left side of the heart. Bichat indeed, denied its existence at all in the former situation, but his opinion has been fully disproved. Morgagni, Vieussens, Hunauld, Horn, Cruwel, Corvisart, Burns, Bertin, Louis, Laennec, have all met with instances of disease of the right valves. Dr. Latham thinks that in one-third of the cases in which he has seen disease of the left valves, it has existed in the right also. We have notes of eight cases in which it existed in the right, and can recollect several others. In six of the eight the left side was simultaneously affected, and gene- rally to a much greater extent; but the proportion which the whole number mentioned bears to the cases that we have seen of disease on the left side, is less than that indicated by Dr. Latham, not exceeding, wc think, one in four and a-half to five. [In a subsequent work, Dr. Hope thus expresses himself: '■ Since 1831, I have reason to believe, from the examination of a vast number of cases of valvular disease, mostly without, but occasion- ally with dissection, that the proportion of affec- tions on the right side, as compared with the left, * For the lesions of the valves here described, s« " Principles and Illustrations of Morbid Anatomy," by the writer, figs. 65 to 74. HEART, (DISEASES OF THE VALVES OF THE) 415 is very much smaller than I have specified above. I cannot state, numerically, the exact proportion, as I have not leisure at present to analyze 10,000 cases, which I calculate to yield about four per cent, or 400 cases, of valvular disease ; but my general impression is, that, out of the 400, I have not, at the utmost, met with twenty cases of dis- ease of the right valves, — which would only be five per cent, or one in twenty. Dr. Clendenning has met with about one in sixteen, out of 100 cases, as exhibited in the following statement, with which he has obligingly favoured me : Valves of the left side, alone, 92-6 or -£-ths. « « right side, alone, 2-1 or T^th. « both sides, 6-31 or -Uh. 1 c He adds, however, that he neglected to record some instances which might fairly be presumed to have occurred mainly, if not exclusively, under the first head ! This would reduce his proportion below -ptth, and bring it nearer to mine, namely Jrth. I suspect, however, that it will eventually prove to be lower still." (Hope, on Diseases of the Heart: Dr. Pcnnock's edit. p. 343 : Philad. 1842.)] It is remarkable that in all our own cases, and nearly all those of the authors quoted, (with the exception of Dr. Latham, who is silent on this point,) the induration on the right side was merely cartilaginous. When the two sides are affected at once, it very rarely happens that the disease on the ritrht is greater than that on the left: in gene- ral, it is much less, being comparatively slight or incipient The cause of the remarkable difference which the two sides of the heart exhibit in their liability to induration, has not been positively determined. Corvisart attributed it to a more decided fibrous .organization of the left valves, in virtue of which they are more disposed to receive the matter that is to transform them into cartilage, or the calca- reous salts that impart to them an osseous or stony hardness. Bertin has ascribed the differ- ence to the different nature of the blood that traverses the two sides respectively, the left re- ceiving blood of a more vital, more stimulating, more irritating quality than that by which the right cavities are moistened. Laennec does not offer a decisive opinion. We do not pretend to decide which of these two opinions is correct, and whether both causes may not conspire to produce the effect, or whether both may not be groundless. But, in any case, we believe that disease of the left valves is pro- moted by the greater energy of action of the left ventricle, by which these valves are more strained. This opinion is countenanced by the facts, that ossification of the arteries, particularly those of the brain, is a remarkably frequent concomitant of hypertrophy of the left ventricle; and that this affection of the ventricle is generally attended with, or productive of, a thickened state of some of the valves.—(See Arteritis, vol. i.) The characters of valvular induration are some- what different according as the disease occupies the auriculo-ventricular or the arterial valves; the cause of which is to be found in the difference which naturally subsists between the valves them- •elves. We shall therefore describe the degenera- tions of the two classes of valves separately. It may be premised that there is no essential differ- ence but in degree and frequency of occurrence, between the degenerations on the two sides of the heart; consequently, a description drawn from the left will apply to the right. Iwduratiox of the Mitral Valve. — The appearance presented by the indurated mitral valve differs according as the disease occupies the Dase, the margin, or the whole of the valve. When the whole is affected with cartilaginous degeneration, the valve is generally contracted throughout, and what is lost in space appears, as it were, expended in thickening the free border; for this is converted either into a ring, an oval- shaped collar, or a transverse slit like a button- hole. The size of the aperture is various. We have seen it of all sizes from an inch to a quarter of an inch in its longest diameter.* The thick- ness of the border likewise varies. We have seen it equal a writing-quill. When the valve is thus contracted, it generally projects more or less, in a funnel shape, into the cavity of the ventricle. In one case we found it project so far that the co- lumnae carneae were inserted immediately into the ring, the chordae tendineae having disappeared The surface of the induration is smooth, polished, and translucent, until the disease throws out osseous or other excrescences, which, interfering with the integrity of the investing membrane, render it corrugated, rugged, and opaque. Before ossification takes place, the induration described sometimes presents a truly cartilaginous hardness, and sometimes the consistence of fibro-cartilage, or only that of tendon. When divided, the as- pect of the section varies according as the disease is cartilaginous, fibro-cartilaginous, or tendinous. In a more advanced degree, cartilaginous indura- tion is transformed into imperfect bone. It seldom happens, however, that more than a very small proportion of the cartilaginous mass is ossified, and the change takes place sometimes at its sur- face, and sometimes deep in its substance. The bone produced does not exhibit the fibrous struc- ture and peculiar arrangement of natural bone ; though, as it contains a large proportion of carti- lage, it may be presumed to possess more or less vascularity and vitality. There is another species of osseous induration of the valves, which is essentially different from the above, inasmuch as it consists of calcareous matter in great predominance, and, like vesica] calculi, has no vitality. It presents itself under the form of small, polished, and semi-transparent scales; or of minute, yellowish, opaque granules, the agglomeration of which forms concretions of various dimensions, from a mere point to the size of a horse-bean. The deposition commences un- derneath the lining membrane, and generally in a small patch of indurated, cheese-like matter, usu- ally called steatoma, the surrounding parts being healthy. The scales lie flat and superficial under the membrane, while the granules penetrate more or less deeply into the subjacent tissues. When either the scales or the granules enlarge, and their surfaces become rugged or acuminated, they cause * Cases illustrating nearly all the diseases of the valves hereafter described, are detailed in "A Treatise on the Diseases of the Heart," by the writer ?f *his article 416 HEART, (DISEASES OF THE VALVES OF THE) absorption of the internal membrane, and come in immediate contact with the blood. Some authors believe that ossifications of this latter description are natural to old people, be- cause they occur in the majority of those who have attained the age of sixty. Whatever be the character of the ossification, whether it be mixed with cartilage or purely calcareous, to us it ap- pears to be always a morbid production. The circumstance of its occurring in the majority of persons above the age of sixty does not militate against this view ; for, as the elasticity of the ar- terial, as of all the other tissues, is diminished by age, the valves of the heart and the coats of the arteries are, in the aged, less capable of resisting the distending force of the blood, and are there- fore more liable to disease. Nor does the circum- stance of the ossification being more calcareous and less cartilaginous in the old than in the young, prove that in the former it is a natural change. It confirms, indeed, what is proved by every part of the bony tissue ; viz. that in age the ossific tendency is greater ; but it does not, for this rea- son, follow that the tendency is natural when it displays itself in unnatural situations, as in the heart and arteries. Sometimes the membranous portion and free margin of the valve are healthy, while the fibrous zone at the base is cartilaginous, or beset with small calcareous incrustations, or, as sometimes happens, its whole substance is converted into a thick ring of bone. By these depositions at the base of the valve, the orifice is more or less con- tracted, while the valve itself may remain capable of closing. In many cases, again, the base and middle are sound, and the free margin alone is diseased, its conical processes forming adhesions with each other and contracting the circumfer- ence of the valve to such an extent as almost completely to close the orifice. It is not uncom- mon to find the margin studded with small carti- laginous nodules, or roundish calcareous granules, which prevent the accurate adaptation of the edges to each other, and allow regurgitation during the ventricular contraction. Sometimes the cor- dae tendineae are contracted, so as to prevent the valves from completely closing during the ventri- cular systole. This is a lesion perpetually over- looked by those whose attention has never been directed to it: yet, being attended with regurgi- tation, it constitutes one of the worst species of disease of the valves. Much confusion may have been occasioned by such an oversight, the anato- mist pronouncing that the organ was sound, while the most marked symptoms had previously indi- cated its disease. The same formidable effects ensue, and the same remarks are applicable, when, in consequence of dilatation of the orifice, the valves are not large enough to close it; a condi- tion of parts not unfrequent in cases of great dilatation of the heart. Sometimes, the only dis- eased appearance that the valve presents, consists in brittle scales or patches of pure phosphate of lime between the two component layers of the membranous portion, which they occasionally rup- ture, and thus come in immediate contact with the blood Induration of the Aortic Valves.__Indu- ration of the aortic valves, like that of the mitral, is more frequent and extensive at the base and free border than in the intermediate space. At the border it originates more especially in the corpora sesamoidea, and these bodies are some- times enlarged by cartilage to the size of peas. We have seen the margin contracted by the fibro- cartilage into a ring a quarter of an inch in diameter. The valves are sometimes thickened, nodulated, and corrugated by an opaque yellow degeneration, consisting of a mixture of cartilagi- nous and steatomatous matter. We have seen the angles of the valves detached from their bases and partially wasted away by this degeneration; so that, adhering by their centres only, they hung loose into the artery and were destitute of fulcra by which to oppose the retrograde pressure of the aortic blood. In another instance, the same dis- ease had undermined and detached the bases of all the valves throughout nearly their whole length; and, under one of them, it had led to the forma- tion of a canal, as wide as the little finger, be- neath the lining membrane of the heart, leading to an aneurism in the muscular substance of the septum between the left auricle and ventricle. Such are the cartilaginous and steatomatous degenerations of the aortic valves. The osseous, of which we have next to speak, are perhaps even more frequent in the aortic, than in the mitral valve. The ossification may be either pure, or combined with cartilage. In one case under our observation, an irregular, scabrous, and denuded concretion, the size of a pea, occupied the edge of one of the valves and projected into the cavity of the artery. In another case, a similar mass, of a conical shape, sprang from the base between two of the valves, and presented its apex towards the centre of the vessel. Smaller concretions of this description and in this position, are common. M. Bertin saw an ossification of one of the aortic valves which had attained the size of a pigeon's egg. (Obs. liii.) In one of our cases, already alluded to, the fibrous zone encircling the base of the aortic orifice was converted into a ring of bone as thick as a quill. When the ossification is confined to the mar- gin and base, while the middle portion is still healthy over a certain extent, the valve, if its thickening is not very considerable, may still rise and fall, and not offer any marked obstacle to the circulation. But when the ossification pervades the middle portion of the valves, they shrink, be- come soldered together, or curl up upon them- selves, in the direction either of their concavity or their convexity, so as to present a rude represen- tation of certain sea-shells. In this state, they may become immovable. If curled forwards, they remain applied along the walls of the aorta, and oppose no other impediment to the course of the blood than what results from their thickness. If curled, backwards, they remain fixed in the fall- en or shut position, and considerably contract the orifice. Not unfrequently, one of the three valves is curled in an opposite direction to the other two. Corvisart has seen all three ossified in the closed position, and they would only have left an ex- tremely narrow cleft for the passage of the blood, had not one retained sufficient mobility at its base to perform a movement which augmented, by a line or two, the width of the cleft HEART, (DISEASES OF THE VALVES OF THE) 417 IXDTJRATIOV OF THE VALVES OX THE RICHT side of the Heart.—Induration of the right or venous valves is, as already stated, almost always simply cartilaginous or fibro-cartilaginous, and is comparatively rare, not existing in perhaps more than about one case in five of disease in the left valves. It seldom presents itself without being accompanied by disease of the left valves also, and it is, in general, less advanced than the latter. The tricuspid is more frequently affected than the pulmonic valves. We never happen to have seen the latter diseased, but we have once found them incapable of closing the orifice in consequence of dilatation of the artery, and we have seen the orifice contracted to the diameter of a quill, an inch below the valves. M. Bertin has seen the valves themselves contracted into a circular aper- ture only two lines and a half in diameter. As already stated, disease of the right valves, whether cartilaginous or osseous, differs from that of the left only in frequency and extent, its characters being essentially the same. Exciting causes of valvular induration.— These are, first, such as overstrain the valves by increasing the force of the circulation ; namely, violent efforts, hypertrophy, increased action of the heart from nervous, febrile, or inflammatory excitement: secondly, inflammation of the inter- nal membrane of the heart, resulting from cardi- tis, pericarditis—especially rheumatic, from fever or from any other cause. It would be an unne- cessary repetition to dwell on this subject, as wc have treated of it in the article Arteritis. Warty vegetation's of the Valves.— These excrescences bear a close resemblance to venereal warty vegetations on the external organs of generation. Their form is in general irregu- larly spherical, oval, or cylindrical: their size va- ries between that of a small pin's head and a large pea, but when isolated they are occasionally as large as a horse-bean. Their surface is polished, but often lobulated like a raspberry: they are found either isolated, in clusters, or in closely ag- glomerated patches like the surface of a cauliflower. Their number is various; sometimes there are only one or two, and sometimes they pervade the whole of the valves, the tendinous cords, and a great portion of the auricle. Their colour, occa- sionally of a greyish or yellowish white, is more commonly heightened, universally or in parts, with pink or red of greater or less depth. Their texture is fleshy and slightly translucent, like the exuberant granulations of an ulcer. Their con- sistence is variable ; in general they are soft and humid, as if only recently and imperfectly organ- ized : and they can then be easily scraped off with the handle of the scalpel; but sometimes they are firm, and cannot be detached without tearing with the nail or cutting with the edge of the scalpel. Firm vegetations are generally larger and more truly warty than soft. The internal membrane of the part from which vegetations spring, is almost invariably more or less diseased. It is thickened, steatomatous, or cartilaginous, ossified, ulcerated, or ruptured. When vegetations grow from a diseased but un- broken surface, they may be numerous and occur in several parts at once; but when they grow merely from a ruptured or ulcerated edge, they Vol. II___53 are few in number, often not exceeding one or two, are generally confined to that edge exclusively, and attain a larger size than any others. We have seen them exceed a horse-bean, and with a neck two, three, or four lines long. It cannot be doubted that their origin is connected with the broken state of the membrane. The base and the free margin of the valves appear to be parts peculiarly favourable to the growth of warty vegetations. Along these, but especially the latter, they are often arranged in a single row. They occur on both sides of the heart, but less frequently on the right. The aor- tic valves are those most subject to them. Thev are more rare in the auricles than on the valves, especially in the right auricle. We have seen one-third of the left auricle completely covered with them. When situated at the base, or the free margin of a valve, they contract its aperture according to their size and number. Laennec thought it " undubitable that vegeta- tions were nothing more than small polypous or fibrinous concretions, which, being formed on the sides of the valves or auricles, become organized by a process analogous to that which converts albuminous false membranes into adventitious membranes or cellular tissue." This opinion is unsatisfactory ; for as polypi are most common in the right cavities of the heart, vegetations ought to be so likewise,—the reverse of which is the fact. The valves, moreover, being perpetually in mo- tion, would be the last parts to which albumjpous concretions would adhere, as a stagnant state of the blood is most favourable to their formation; yet the valves are the parts most subject to them. It is amidst the intricacies of the columnae carneae, where the blood is more stagnant than elsewhere, that we most commonly find real albuminous con- cretions of small size. Finally, if vegetations were merely fibrinous concretions, instead of be- ing rare, they ought to be frequent; for, as the circumstances which, on this view, lead to their formation, are common to all persons labouring under an obstructed circulation, all, or to say the least, many, should be affected with them. Kreysig attributes their formation to inflamma- tion. MM. Berlin and Bouillaud have espoused the same opinion, resting on the fact that vegeta- tions bear a close analogy to the albuminous gra- nulations occasionally found on serous membranes affected with chronic inflammation. The small and soft vegetations certainly do bear this analogy —a fact of which we have satisfied ourselves by comparing the two as occurring in the same sub- ject ; but the like cannot, in the least degree, be said of the large and more properly wart-like ve- getations ; whence it is to be inferred that inflam- mation alone is not their cause. We are disposed to think that it is inflammation modified by sonic other morbid action dependent either on the con- stitution, or on previous s>;''uctural lesions of the parts affected. The resemblance which the firmer valvular ve getations bear to venereal warts, led Corvisart to think that they might have the same venereal ori gin. This opinion, however, is not tenable, as extensive observation in venereal hospitals has proved that vegetations of the heart are not more common in persons affected with this disease thar U9 HEART, (DISEASES OF THE VALVES OF THE) in others , and i< is certain that they have occur- red in some who had never been in the least de- gree tainted with the disease. Pathological effects of disease of the Valves, and mode of their production.— Diseases of the valves, whatever be their nature, whether osseous, cartilaginous, or warty, have for their common effect to obstruct the orifices of the heart; and this they do, either by contracting the apertures, or by encumbering the valves in such a manner as to prevent them from opening and clos- ing with suitable accuracy and facility. A me- chanical obstacle is thus presented to the circula- tion, and from the obstruction and embarrassment which it occasions, are derived the symptoms of valvular disease. The general symptoms, however, when of an aggravated nature, are seldom dependent on the valvular obstruction exclusively; they are partly attributable to a co-existent disease of the muscu- lar apparatus of the heart. For, so long as the organ remains free from dilatation, hypertrophy, or softening, the valvular disease, according to our observation, is not in general productive of great inconvenience. This opinion is founded on the following grounds. We have seen individuals who were affected in an eminent degree with disease of the valves or of the aorta, maintain for years a very tolerable state of health so long as there was no hypertrophy or dilatation of the heart; but, in proportion as these supervened, the symptoms of valvular obstruction became more and more de- veloped, and eventually assumed their most aggra- vated form. We have reason to believe that, in these cases, the symptoms were attributable in a great mea- sure to the hypertrophy or dilatation ; because we have seen a greater valvular contraction produce less severe symptoms when the hypertrophy or dilatation was less considerable. It might be sup- posed that a great degree of contraction would of itself suffice to produce the symptoms of an ob- structed circulation in their most aggravated form. This is highly probable, but it does not easily admit of demonstrative proof, as a great degree of contraction is perhaps never found, on dissec- tion, without hypertrophy or dilatation. We therefore infer that these affections ensue as con- sequences of valvular contraction, and we be- lieve, for the reasons above assigned, that they play an important part in the production of the symptoms. It is of immense practical importance to keep in view the facts stated, namely, that valvular contraction does not produce formidable symp- toms until it has given rise to hypertrophy or dilatation ; and that it invariably leads to these affections unless the circulation be kept tranquil. We thus know that the most efficacious treat- ment of valvular disease consists in employing such prophylactic measures as are calculated to prevent the supervention of hypertrophy or dila- tation, and in employing them with the same un- compromising strictness before those affections have appeared, as if they actually existed. It remains to be explained how dilatation and hypertrophy aggravate the symptoms of valvular obstruction We have elsewhere shown (See Dilatation of the Heart) that dilatation of the heart, by enfeebling the contractile power of the organ, constitutes as truly an impediment to the circulation as a more direct mechanical ob- stacle. When, therefore, dilatation exists in ad- dition to such mechanical obstacle, it is clear that the symptoms, having a twofold cause, must be doubly severe. Hypertrophy aggravates the symptoms of val- vular obstruction, because the heart, being mor- bidly irritable, struggles against the obstacle, and falls into fits of palpitation ; and as, during these, a greater quantity of blood than natural has to be transmitted through the contracted aperture, the circulation is performed with increased diffi- culty. It is in consequence of these reciprocal reactions of the valvular and the muscular apparatus on each other, that cases thus complicated are more severe than any others. From what has been said here and in the arti- cle Dilatation, the reader will judge how totally some authors have been wrong in referring the ob- struction of the circulation to the valvular contrac- tion exclusively, without allowing that the en- largement of the heart contributed in any degree to the effect. Such a doctrine is not only errone- ous, but dangerous, as it leads to pernicious prac- tice. For, imagining the valvular contraction to be the only formidable part of the complaint, to it alone those authors direct their attention; and, acting on the inaccurate presumption that the con- traction is in all cases caused by, and accompa- nied with, inflammation, they attack it with blood- letting, general and local, abstinence, digitalis, &c; means which cannot remove valvular contraction when once formed, (as must always be the case before the symptoms can exist,) and which are, therefore, a useless expenditure of the patient's strength. It is true, indeed, that measures calcu- lated to diminish the force of the circulation are useful in obviating the supervention of hypertro- phy or dilatation — the paramount source of dan- ger in these cases; — but measures employed for this purpose, and which must be continued for an indefinite length of time, cannot be practised with the same activity as for the purpose of curing an inflammation. We would not he understood by this to mean that valvular disease is never accom- panied by inflammation, and that, when so ac- companied, it should not be treated by antiphlo- gistic measures: but we mean that they should not be employed unless there is reasonable evi- dence of inflammation. Diagnosis. — I. General Signs. — Whether the disease of the valves be cartilaginous, osseous, or consist of vegetations, the general symptoms are the same, if the degree of contraction be equal. Keeping in view the principles developed in the preceding section, we should assign to disease of the valves, as its general symptoms, 1. a greatly aggravated form of the same which have already been assigned to dilatation of the ventricles; 2. certain symptoms of a peculiar and distinctive cha- racter. 1. The general symptoms are cough, iopiou6 watery expectoration, dyspnoea, orthopncea, fright- ful dreams and starting from sleep, oedema of tht lungs, pulmonary apoplexy, passive hemoptysis/ HEART, (DISEASES OF THE VALVES OF THE) •ijy (i. e. sputa stained with dark or grumous blood,) turgescence of the jugular veins, lividity of the face, anasarca, injection of almost all the mucous membranes, passive hemorrhages, especially of the mucous membranes, engorgement of the liver, spleen, &c, and congestion of the brain, with sj mptoms of oppression sometimes amounting to apoplexy. The pulmonary symptoms result from engorge- ment of the pulmonary vessels, when the left valves are obstructed : and, when the obstruction is in the right valves, they result partly from en- gorgement of the bronchial veins, and partly from the quantity of blood transmitted into the lungs not being adequate to their demand — an unna- tural state, which gives rise to dyspnoea, as will be presently shown. In the latter case hemoptysis is more rare. The symptoms affecting the system in general result from retardation of the blood in the venous system. 2. The peculiar and distinctive symptoms of valvular disease are the following. a. When the disease is combined with hyper- trophy or dilatation, as is commonly the case, the symptoms are more severe than those of hypertro- phy or of dilatation alone, the paroxysms of pal- pitation and dyspnoea in particular, being more violent, more obstinate, and more easily excited. b. The action of the heart is irregular. This, it is true, may sometimes be the case in hypertro- phy and in dilatation, but here it is an accidental, not an essential character. The pulse, which we may regard as the representative of the heart's ac- tion, may, in valvular disease, be small, weak, in- termittent, irregular, and unequal; and it may even be small and weak while the heart is giving a violent impulse — a contrast which affords one of the strongest presumptions of valvular disease. The least degree of derangement is intermission ; for in this the rhythm of the heart's action is not subverted, there being either a total omission of one or more ventricular contractions, or one, two, or three feeble contractions audible by the stetho- scope, but scarcely, if at all, sensible in the pulse; yet the next full contraction recurs at the correct interval; that is, supposing the pulse to beat crotchets, the contraction in question recurs at the crotchet. Irregularity is an ulterior degree of de- rangement, for here the rhythm is subverted, the beats recurring at irregular intervals. It is ge- nerally accompanied with inequality, some beats, both of the heart and pulse, being strong, and others weak. The degree to which these charac- ters of the pulse exist, depends on the situation of the valve contracted and the extent of its contrac- tion. We shall, therefore, point out more par- ticularly which of the characters are produced by given states of certain valves; for, this being known, we have a valuable means of ascertaining the situation and extent of the valvular disease. The characters of the pulse just described, are most marked in contraction of the mitral valve, and in states of the valve admitting of regurgita- tion. If either the contraction or the regurgita- tion be great, all the worst characters of the pulse are invariably present: for, in the case of contrac- tion, the left ventricle, not being freely supplied with blood, is not stimulated to contract at the natural intervals and with suitable energy; and, in the case of regurgitation, the ventricle, not be- ing able to disgorge itself through the aorta, for want of the accustomed fulcrum in the mitral valve, labours under a state of more or less con- stant repletion, and therefore contracts languidly and irregularly whenever the stimulus of fulness happens to be greater than usual, or its own ex- hausted irritability allows it to answer the call. In such cases, the pulse is always very soft and feeble — for the obvious reason that the force of the ventricular contraction is determined in a re- trograde, as well as in a forward direction. A slight contraction of the mitral valve (when, for instance, the diameter of the aperture Is not diminished more than a quarter of an inch) does not unnecessarily produce an unsteady pulse, as it still allows of an adequate supply of blood to the ventricle. When, however, the circulation is hur- ried, the pulse generally becomes unsteady. Slight regurgitation, likewise, may not materially affect the pulse. Contraction of the aortic valves must be very great to render the pulse small, weak, intermit- tent, and irregular. We have never seen it pos. sess these characters in any marked degree unless the valves were either soldered together by carti- laginous degeneration, or more or less fixed by ossification in the closed position, so that the aper- ture was only a limited chink. An induration of the size of an ordinary pea, has little effect on the fulness, firmness, and regu- larity of the pulse, and slighter degrees of con- traction appear to have no effect on it whatever. The pulse is less irregular when the valvular contraction is on the right side, than when it is on the left; the action of the heart appearing to be less under the influence of the right ventricle than of the left, — in consequence, perhaps, of the muscular apparatus of the latter being stronger and more irritable. The pulse is not so sinall and weak from a contraction on the right side as on the left, and contraction of the tricuspid valve causes more irregularity than contraction of the valves of the pulmonary artery. c. Pain in the region of the heart is another symptom of disease of the valves. It is true that palpitation may occasion pain though there be no disease of the valves, and we have frequently met With it from this cause in hypertrophy and dilata- tion. It is likewise true that palpitation may oc- casion pain though there be no disease of the heart whatever; we have often found it in hysterical fe- males, and in nervous men. But it is when the valves, the coronary arteries, or the commencement of the aorta, are indurated and inelastic, that pain occurs most frequently and with the greatest se- verity. Sometimes it is little more than an inde- scribable sense of obstruction or oppression in the praecordial region; but, in other cases, it is an in- tense lancinating or tearing pain, felt across the praecordia or scrobiculus cordis, (where it might be mistaken for inflammation of the stomach,; and occasionally extending, with a sense of numb. ness, down the left arm to the elbow and some- times to the fingers. Pain of this description ha, acquired the name of angina pectoris. (See An- gina Pectoris.) We believe this pain to be, in general, occasioned by the inelasticity of the ossified or otherwise indurated parts, which will 420 HEART, (DISEASES OF THE VALVES OF THE) not stretch equally with the other portions of the heart, when the organ is labouring under palpita- tion or disgorgement. When inflammation of the interior of the heart exists, either alone or accompanying disease of the valves, it also occasions pain; but those au- thors have unquestionably been wrong, who have considered inflammation to be the sole cause of pain, and have therefore assumed this symptom as a proof of the inflammatory nature of disease of the valves. The exact time and manner of the fatal termi- nation in valvular disease, as in every other or- ganic affection of the heart, is very uncertain. Sometimes the patient is reduced gradually to an extreme degree of emaciation and debility, and dissolution is duly announced by the usual pre- monitory symptoms. Sometimes he expires sud- denly, after any trifling exertion or emotion, though the malady has made comparatively little inroad on the constitution. Not unfrequently pressure on the brain, whether from serous effusion or ve- nous congestion, is the immediate cause of death, and in this case coma gradually supervenes from three to four days or a week previous to the fatal event. In one case of serous effusion under our care, the patient suddenly uttered a shriek and fell at once into perfect coma. The same occurred in another case, in which there was only a small ef- fusion of blood. Hence, the prognosis must always be general as to time, and, if the case be considerably ad- vanced, it must be guarded with a clause, that the patient is liable to die suddenly and unexpectedly. II. Physical Signs. — Before the discovery of auscultation it was extremely difficult, and in many cases utterly impossible to detect disease of the valves. Corvisart had the merit of discovering, as its signs, certain states of the pulse and a " pe- culiar vibration difficult to describe, sensible to the hand applied to the praecordial region :" — in other words, the cat's purring tremor (fremissement cotaire) of Laennec. But, as these signs may occur under other circumstances, they do not de- note disease of the valves in particular, and are totally insufficient to indicate which is the valve affected. The accession of auscultation to the other means of diagnosis has rendered it possible to distinguish valvular disease with almost com- plete certainty : a certainty, it may be remarked, much greater than was supposed by the illustrious author of auscultation himself; for he did not give their full value to preternatural murmurs as signs of disease of the valves, in consequence of suppos- ing that similar murmurs were produced by a spasmodic contraction of the muscular fibre of the heart and even of the arteries. We have else- where (in a " Treatise on the Diseases of the Heart," p. 47 and 56) attempted to show that it is not the muscular contraction, but the move- ments of the blood, which are in all circumstances the cause of these preternatural murmurs. Laen- nec laboured under another disadvantage : he at- tributed the second sound of the heart to the auri- cular contraction; whereas, according to the ex- periments of the writer, it is referable to the ven- tricular diastole. (Ibid. p. 26 and 36.) The substitution of this view of the heart's action for hat of Laennec, fortunately does not falsify any of his physical signs, except one, viz. that "loud- ness of the second sound indicates dilatation of the auricles ;" it does not, to adduce a single instance, invalidate the fact that murmur of the second sound indicates disease of the auriculo-ventricular valve ; but it affords a rational explanation of all the phenomena noticed by Laennec, and renders various others available as signs, which to him were inexplicable and therefore useless. Bellows—filing—rasping—sowing—andmu- sical or whistling murmurs.—When a valve is contracted, the blood, in passing through it, is thrown into more than ordinary commotion and occasions a morbid murmur. This murmur has a soft character, like that of bellows, when the contraction has a smooth surface which does not greatly break the stream of blood, as when the morbid deposition consists of cartilage, fibro-carti- lage, or vegetations. But the murmur is rougher or more grating, like that of a file or rasp, when the disposition has a rugged, hard surface, as when it is osseous. Murmurs are more hollow when they are deep-seated, as for instance, in the auri- culo-ventricular orifices; and more hissing or whizzing when they are superficial, as in the aortic orifice, more especially in the pulmonary orifice, and the ascending aorta. The hollowness of the sound is referable to its remoteness and its reverberation through the chest. The sawing murmur is almost identical with the filing or rasp- ing ; it is only less grating and on a higher key. The musical bellows-murmur is a perfect note like whistling or cooing. In the case of a patient who applied to us for " a noise in the chest," wc heard it at the distance of two feet In a case precisely similar, which occurred to Dr. Elliotson, there was a very large and long vegetation in the mitral valve. We imagine that this sound is to be accounted for on the same principle that air emitted from the lips in one way produces merely a blowing sound : in another, produces a whistle. We have repeatedly heard the sound in various degrees. Purring tremor is another sign of disease of the valves. It arises from the vibrations into which the blood is thrown during its passage through an obstructed orifice, and is felt in the praecordial region and sometimes in the arteries. We have never felt it in the pulse when the pa- tient was calm, unless hypertrophy was conjoined with obstruction of the aortic orifice or with rough- ness and dilatation of the ascending aorta: but we have felt it during palpitation, though there was neither hypertrophy nor disease of the heart or aorta: whence we infer that it requires for its production in the pulse an increased force or velo- city of the circulation, but not necessarily a valvu- lar or aortic obstruction. In the praecordial region it is more easily produced, and we have found it exist here when there was neither hypertrophy nor palpitation; but it was in cases in which the valvular disease was considerable, and the powei of the heart certainly not deficient. It may be occasioned by disease, not only of the semilunar, but also of the mitral and tricuspid valves, and in the latter cases it may accompany either the first or the second sound. When accompanying the first, it proceeds from regurgitation through the valve; and when accompanying the second, it HEART, (DISEASES OF THE VALVES OF THE) 421 results from the impeded passage of the blood from the auricle into the ventricle during the ven- tricular diastole. It rarely accompanies the second sound ; because, as we conceive, the diastolic cur- rent is seldom strong enough to produce it. When from disease of the mitral valve, it is not percep- tible in the pulse. As purring tremor has the same origin as bel- lows and other murmurs, it often accompanies them; though, as it requires a greater degree of disease for its production, this is not always the case. Having now given an account of the various murmurs and of purring tremor as signs of disease of the heart in general, we proceed to show in what manner they constitute signs of disease of each of the valves in particular ; and it may be premised that, as the sounds of one side of the heart are audible on the other, the sound of the healthy side will partake more or less of the mur- mur of the diseased side, and vice versa. Signs of Disease of the Aortic Valves.—One of the murmurs above described is heard during the ventricular contraction about the middle of the sternum, and is louder here than elsewhere. It is more or less hissing or whizzing, from being super- ficial, and it accordingly conveys the idea of being near to the ear. When a murmur of this kind is louder along the tract of the ascending aorta than opposite to the valves, and is, at the same time, peculiarly superficial and hissing, it proceeds from disease of the aorta itself. As a murmur from this source often extends to the situation of the valves, it might easily lead to the supposition that they also were diseased, and it is sometimes very difficult to ascertain positively that they are not. A murmur may accompany the second sound when there is regurgitation through the aortic valves, and its source may be known by its being louder and more superficial opposite to those valves than elsewhere. We have never found it strong, and we doubt whether it can be so ; as the instan- taneous manner in which the ventricle is refilled by its diastole, must prevent the regurgitation from being considerable. [The writer has been induced to infer, that where a rough sound accompanies the second, it is not owing always to a morbid condition of the semilunar valves, but to the refluent blood passing over the lining membrane of the aorta roughened by ossific deposits. (See an interesting case in Med. Examiner for May 18, 1844.)] Purring tremor generally requires for its pro- duction, by disease of the aortic valves, a consi- derable degree of contraction of a rugged hard nature, with hypertrophy ; especially to produce it in the pulse. Signs of Disease of the Mitral Valve.—When this valve is contracted, the second sound loses, on the left side, its short, flat, and clear character, and becomes a more or less prolonged bellows- murmur. When the valve is permanently pates- cent, admitting of regurgitation, the first sound likewise is attended with a murmur. These mur- murs are louder opposite to the mitral valve, (viz. at the left margin of the sternum, between the third and fourth ribs, i. e. about three or four inches above the point where the apex of the heart heats,) than elsewhere. They are also more hol- low than murmurs of the aortic valves. By these two circumstances the murmur of the first sound may be known to proceed from the mitral, and not from the aortic valves : that of the second pro- ceeds, either from the mitral, or, what is much more rare, from regurgitation through the aortic valves. The means of ascertaining when the lat- ter is its source, have been explained above. With respect to the mitral, the murmur of the second sound is diminished when the contraction of the orifice is extreme; when, for instance, the aper- ture does not exceed two or three lines in diame- ter ; for then the quantity of blood transmitted is not sufficient to create a loud murmur. For the same reason the murmur is diminished when the auricle is obstructed by a polypus; but the dimi- nution under these circumstances is of little im- portance to the diagnosis; as extreme contraction of the mitral, and polypi in the auricle, can be detected by the characters of the pulse, and the assemblage of other signs. Purring tremor may be produced by disease of the mitral valve, especially if the ventricle be hypertrophous and dilated, by which the currents through the valve are rendered stronger. Signs of Disease of the Aortic and Mitral Valve conjointly___The murmurs above described as characteristic of each, exist simultaneously in the situation of each valve. If the murmurs of the first sound be of a different species in the two situations—if, for instance, the murmur of the aortic valves be of the bellows kind, and that of the mitral resemble filing or rasping, it is still easier to determine that both valves are diseased. Signs of Regurgitation through the Mitral Valve.—These signs are, a murmur with the first sound, louder in the situation of this valve than of the aortic ; and a weak pulse, even though the impulse of the heart be violent. It is generally unsteady also. Signs of Disease of the Pulmonic Valves.— The signs are the same as those of disease of the aortic valves, with this difference, that the murmur seems close to the ear, and is equally hi.ssing as in disease of the ascending aorta. Disease of the pulmonic valves is so rare that it ought never to be suspected unless the signs described are ex- tremely well marked, or unless there be pates- cence of the foramen ovale, or some other preter- natural communication between the two sides of the heart:—states, which experience has proved to be in general accompanied with contraction of the pulmonic orifice. Signs of Disease of the Tricuspid Valve.— They are the same as those of disease of the mitral, except that the murmurs are loudest oppo- site to the valve : viz. at the middle part of the sternum, opposite to the inter-space between the third and fourth ribs and a little to the right of the mesial line. As this valve is very seldom affected, the practitioner must be very cautious in pro- nouncing it diseased, especially as the pulse does not afford the same evidence as in contraction of the mitral orifice. Such are the signs which, together with the general signs, are, according to our experience, the best for the detection of disease of the valves. For several years they have never deceived us as to the general fact whether there was, or was not. 422 HEART, (DISEASES OF THE VALVES OF THE) valvular obstruction; and they have seldom failed to indicate, with perhaps more than necessary pre- cision, the situation and nature of the affection. To make the signs available, however, it is ne- cessary to attend to several circumstances which might lead to the deception. Bellows-murmur sometimes exists in the heart, though there be no disease of the valves ; namely, in nervous persons, in cases of reaction from excessive loss of blood, of pericarditis and adhesion of the pericardium, and of hypertrophy with dilatation. Murmur from these causes may easily be distinguished from that of valvular disease by the following cri- teria. When from nervous excitement, very com- mon in hysterical females, it may be known by its being intermittent, ceasing when the nervous ex- acerbation subsides and the action of the heart becomes calm. When from reaction, it subsides with the cessation of that phenomenon. When from pericarditis or adhesion of the pericardium, it may be known by the presence of signs of those affections. When from hypertrophy with dilata- tion, it may be known by its diminishing or ceas- ing when the action of the heart is calmed, as by repose, venesection, abstinence, &c, &c. Contrasted with the above, the distinctive cha- racters of valvular murmur are, that it is not uni- versal over the heart, but confined in a great mea- sure to the part corresponding to the valve affected ; that it persists without intermission for an indefinite length of time, even though the heart be kept in a state of perfect calm; and that it is often of the filing, rasping, or sawing kind; whereas murmurs from other causes have almost always the softness of the bellows sound. [Still, the writer is prepared to say, from his experience, that the diagnosis of valvular disease is at times extremely obscure. Dr. Graves, in- deed, expresses the opinion, that the functional derangements produced by disease of any particu- lar part of the heart are seldom sufficiently cha- racteristic to enable us to make out whether the disease be situate in the auriculo-ventricular or in the semilunar valves; and he frankly owns that it has frequently occurred to him to find that all the symptoms supposed to be indicative of disease of the right side of the heart have been occasioned by disease of the left; and conversely. Some ob- servers place the greatest reliance on the physical signs as means of diagnosis, whilst others regard them as altogether uncertain. It has been affirmed by distinguished observers, (Messrs. Graves and Stokes, cited in American Med. Intelligencer, Nov. 1, 1838,) first, that the physical signs of valvu- lar disease are not fully established ; secondly, that, taken alone, they are in no case sufficient for diag- nosis ; thirdly, that even in organic disease, the nature and situation of murmurs may vary in the course of a few days ; and, fourthly, that organic disease of the valves may exist to a very great degree without any murmur whatsoever.] Cardiac Asthma.—Among the diseases of the heart may be justly reckoned one of the forms of the malady termed in common language asthma. The group of symptoms ordinarily ranged under this name, have been too much regarded as inde- pendent of disease of the heart. It becomes there- fore necessary to notice the subject, formally, in Ibis place, not only for th° r>urpose of showing the magnitude of the error, but of making the reader acquainted with all the habitudes and aspects of a complaint, which is perhaps the mosl distressing in the whole catalogue of human maladies. Corvisart has remarked that the ancients con- founded under the name of asthma, and errone- ously regarded as purely nervous affections, dys- pnoeas resulting from various organic diseases, par- ticularly those of the heart and great vessels. That they were wrong in regarding the latter as purely nervous affections, and especially in confounding them with those forms of dyspnoea that were such, is unquestionable ; but they were, in our opinion, correct in embracing under the general term asthma, cardiac dyspnoea of a cer- tain intensity, and exhibiting certain characters hereafter to be described ; for it is established by the concurrent testimony of all moderns conver- sant with diseases of the heart, that these diseases, no less than those of the lungs themselves, may constitute the organic causes of asthma. A theoretical consideration of the subject leads, in our opinion, to the same conclusion; for, on tracing asthma back to its source, we shall find that, whatever be its proximate cause in different cases, it depends, in all, on the same ultimate cause; namely, inadequate oxygenation of the blood, and the sensation of want of breath resulting from it. In order to render this apparent, it will be neces- sary briefly to analyze the several varieties of asthma, and then compare them with each other. Inadequate oxygenation of the blood results in all ordinary cases from one or more of three proxi- mate causes : viz. 1. Insufficient admission of air into the bronchial tubes and air-vesicles. 2. Insufficient exposure of the blood to the air admitted, in consequence of a less pervious state of the mucous membrane than natural. 3. Insufficient admission of blood into the lungs. It will be found that to one or more of these causes, all the varieties of dyspnoea and asthma are referable. All the varieties of asthma—to give an approxi- mative statement probably very near the truth- are comprised under the following heads:— 1. From chronic dry catarrh, and the emphy- sema resulting from it. 2. From pituitary catarrh, (humoral asthma,) whether acute or chronic, but more especially the latter, and the pulmonary cedenia resulting from it. 3. From mucous catarrh, especially chronic. 4. From organic disease of the heart. 5. From purely spasmodic constriction of the bronchial tubes. We do not include amongst the varieties, one from the compression of the lungs by hydrothorax, by tumours, by imperfect descent of the diaphragm, &c, because these rarely occasion what can strictly be called asthma. 1. Chronic Dry Catarrh is attended with in- tumescence of the internal membrane of the bronchial tubes. The intumescence exists princi- pally in the smaller tubes, which are sometimes completely obstructed by it; but it is also found in the larger. Andral has seen the bronchial trunk of a lung so contracted by this intumescence, that the air could scarcely enter; and in another case, HEART, (DISEASES OF the third and fourth bronchial divisions were con- tracted by the same cause. (Clinique Med. se- conde partie, obs. ii. et iii.) Further, the tubes are more or less obstructed by an exceedingly vis- cous mucus, often as dense as the vitreous humour of the eye; and when the dry catarrh is universal or even very extensive, it is almost invariably pro- ductive of emphysema. 2. Pituitary Catarrh is attended with moderate intumescence, slight softening, and partial redness of the pulmonary mucous membrane—a state inter- mediate between sanguineous and serous conges- tion, but partaking more of the latter. The quan- tity of phlegm expectorated, always considerable, is sometimes enormous, amounting to from four losix pints of thin glairy fluid in twenty-four hours. The air-passages being obstructed partly by the intumescence of their mucous membrane and partly by this fluid, it necessarily follows that there is an insufficient admission of air into the lungs. 3. Mucous Catarrh is accompanied with more or less tumefaction of the bronchial membrane and obstruction of the calibre of the tubes. The ex- pectoration, though less copious, and different in quality from that of pituitary catarrh, is, notwith- standing, frequently abundant, amounting to one or two pints or more in the day. Consiquently, there is au insufficient ingress of air into the lungs. In all the cases now mentioned, the second cause of inadequate oxygenation of the blood is, likewise, for the most part, in operation, viz. the mucous membrane being thickened, it is less per- vious to air; and its mucus, the natural function of which is to expedite the combination of oxygen with the blood, probably discharges this function less perfectly, in consequence of an alteration in its chemical qualities. 4. Disease of the Heart.—Sometimes, from this cause, blood exists in the lungs in excess ; as is the case when the right ventricle is hypertrophous, or the left side of the heart obstructed; or still more, when these two affections coexist: also when the circulation is merely accelerated, as by palpitation, running, or by slighter efforts in cor- pulent persons. Now, under all these circumstances, there is inadequate oxygenation of the blood: or, in other words, there is an excess of venous blood in the lungs; first, because the quantity of blood admitted exceeds its due proportion to the air in the organ ; secondly, because the overloaded ves- sels do not transmit the fluid with natural celerity; thirdly, because the engorgement of the mucous membrane on which the blood ramifies, constricts the bronchial passages, and prevents the free in- gress of air, as proved by the feebleness of the respiratory murmur. Hence the sensation of want of breath is a necessary consequence of an excess of blood in the lungs. Soini'iimcs blcod does not enter the lungs in sufficient quantity, constituting the third cause of inadequate oxygenation; and this may arise from the weak ness of the right ventricle, from an ob- struction in its mouth, or from increased resistance on the part of the lungs; as, for instance, during sleep, when the respirative function is less active. Hence results the sensation of want of breath, and dyspnoea. Cases exemplifying this will shortly be adduced ; meanwhile, it may be illustrated by a simple physiological experiment, viz. by making J THE VALVES OF THE) 423 and sustaining a full expiration. This is attended, not only with a deficiency of air, but also with a deficient influx of blood into the lungs, as is proved by the lividity of the face which ensues, by the elevation of the fontanel in infants, by the rise of blood in a tube inserted into the jugular vein, and, lastly, by experiment; for we have demonstrated, in the treatise already referred to, that, on suspend- ing artificial respiration in a rabbit, the heart in- stantly became gorged, of a black colour, and dis- tended to nearly double its natural size—a pheno- menon which renders it sufficiently manifest that, when the lungs are exhausted of air, the blood does not freely enter them. Now, the sensation of want of breath experienced on making a full expiration is familiar to every one, and it becomes intolerable if the expiration be long sustained. 5. Spasmodic Constriction of the Bronchial Tubes—This is presumed to exist, first, because, according to the researches of Reisseissen and others, the bronchial tubes are provided with mus- cular fibres, and all muscles are liable to spasm ; secondly, because asthma is occasionally found to occur without any organic cause (so far, at least, as our senses enable us to judge) sufficient to ac- count for it: thirdly, because every form of organic disease above described, both of the lungs and the heart, may exist without causing dyspnoea of such intensity and of such a character as to constitute asthma properly so called. Thus, many have j intense catarrhs, acute or chronic, and profuse ex- pectoration, without any asthmatic dyspnoea; and we have known a patient with a contraction of the mitral orifice to the size of a small pea, and likewise with dilatation and softening of the heart and profuse expectoration, pass through a period of ten years to her grave, without ever experiencing a paroxysm of asthma, though a few steps across the room were sufficient to excite dyspnoea. Hence we apprehend that whatever be the or- ganic cause of asthma, it requires, for the produc- tion of the fit, the super-addition of a state of the nervous system leading to spasmodic constriction of the bronchial tubes. Admitting that the spasmodic constriction of the bronchial tubes does take place, it is obvious that it will more or less close these tubes against the ingress of air; and this closure, again, by pre- venting the free expansion of the lungs, will im- pede the influx of blood : whence there is a double cause for the inadequate oxygenation of the blood, and, consequently, for the production and mainte- nance of the asthmatic paroxysm. From all that has been said, we are now led to the resulting inquiry ;—what is the essential differ- ence between asthma from disease of the heart and that from disease of the lungs? Putting aside that variety of asthma, which, as not being ,i. tended with any visible organic derangement, (though it is, notwithstanding, highly probable that one exists,) may be regarded as mainly, if not wholly spasmodic, there does not appear to be any essential difference between the remaining varieties. The organic causes are diversified, but they all ultimately produce the same effect, and it is the effect which constitutes the essence of the disease. This effect is inadequate oxygenation of the blood. which causes the sensation of want of breath ; and this, when there exists more than what niav 424 HEART, (DISEASES OF THE VALVES OF THE) lie called mere dyspnoea, occasions spasmodic con- striction of the bronchial tubes, and its consequence, the asthmatic paroxysm. We now proceed to a more particular consider- ation of asthma from disease of the heart: a va- riety which comprises, according to our observa- tions, by far the greater proportion of the most severe and fatal cases of asthma. Until the discovery of auscultation had in some degree dissipated the deep obscurity of the affec- tions of this organ, the fact that they were a cause of asthma was scarcely known ; and even at the present day, there are few errors more common than that of attributing asthma to other causes, when it originates solely in the heart. For instance, a theory of this description which has, within the last half century, been more widely disseminated than perhaps any other, consists in ascribing asth- ma to a spasmodic or convulsive contraction of the external muscles of respiration, much dependent on habit. Now, the action of these muscles, so far from being morbid or dependent on habit, is a natural, instinctive, and salutary effort to prevent suffoca- tion, the stimulus to which effort consists in an exaggeration of that which excites the muscles in ordinary respiration,—namely, as above explained, the sensation of want of breath, from inadequate oxygenation of the blood. Nothing is more com- mon, for instance, than to see a patient with dis- eased heart, while sleeping tranquilly, start up and begin to respire with violence. Here it is obvious that the necessity for violent respiration preceded the act; and the necessity depends on impeded transmission of blood through the heart and lungs ; for starting is invariably accompanied by palpita- tion, and preceded by frightful dreams or some sensation of praecordial distress, indicating an ob- structed circulation. We have frequently examined the heart and lungs by auscultation immediately before the supervention of a paroxysm of dyspnoea, and have always found that the heart began either to palpitate or to act in that irregular, confused, and, as it were, struggling manner, which denotes its engorgement. We, were, therefore, enabled to tell the patient that difficulty of breathing was coming on, to which, with some astonishment, he would reply in the affirmative, being himself fore- warned of the approaching accession by a feeling of anxiety and straitness in the praecordia. This fact is so universally true, that any one may satisfy himself of it by entering an hospital, and gently placing a patient with orthopnoea from disease of the heart in a rather uneasy position, when the series of phenomena described will become ma- nifest. Dr. Burrows communicated to us the particu- lars of a case, under his observation, in which the respiration was alternately violent and tranquil under the following circumstances. The patient dozed for a few minutes at a time, during which his complexion became livid, and his pulse more and more feeble, oppressed, and irregular. He then started up, and, after a few violent wheezing respirations, relapsed into the same calm doze. fn this case the mitral orifice was contracted to the size of a pea. Now there can be little doubt lhat, as, during sleep, the sensation of want of »reath is less felt, and tl.e muscles of respiration are, consequently, less stimulated by it—in simple language, as the respiration is more feeble during sleep,* the lungs were not, in the present case, kept sufficiently expanded to admit of an adequate circulation of blood through them; whence ensued engorgement of the heart and venous system of the body, with insufficient arterialization of the blood in the lungs, and the sensation of a necessity for breathing resulting from it: which series of phenomena was relieved by the succeeding violent respirations. We have frequently* observed this series of phe- nomena in a greater or less degree. In one case, violent gasping and wheezing respiration, lasting from a few seconds to two or three minutes, oc- curred at intervals of four or five minutes, during which the patient dozed, even though sitting erect on a s,tool and undergoing a stethoscopic exami- nation ; and this series of actions continued so long as the patient remained disposed to sleep in that situation. (Med. Gazette.) In all these cases it is manifest that the action of the muscles of respiration was consecutive to the obstruction of the circulation, and that it was not dependent on any spasm of those muscles, but simply on the necessity for breathing, which instinctively excited them to a salutary preserva- tive effort. Asthma from disease of the heart often imitates the characters of the other varieties; and this perhaps for a very simple reason; that the lungs are in much the same state as in those varieties. Thus, the asthma is humid or humoral, when there is permanent engorgement of the lungs, causing copious sero-mucous effusion into the air- passages, as in cases of contraction of the mitral valve. It is dry when the engorgement is only transitory, as in cases of pure hypertrophy. It is continued when there is a permanent obstruction to the circulation ; and any of the varieties may be convulsive when the heart has sufficient power to palpitate violently. The worst cases of convul- sive asthma from disease of the heart are those of hypertrophy with dilatation, together with a val- vular or aortic obstruction. We shall now examine the state of a patient labouring under severe cardiac asthma, and then take a more strictly medical view of the nature and progress of the paroxysm. The respiration, always short, becomes hurried and laborious on the slightest exertion or mental emotion. The effort of ascending a staircase is peculiarly distressing. The patient stops abruptly, grasps at the first object that presents itself, and fixing the upper extremities in order to afford a fulcrum for the muscles of respiration, gasps with an aspect of extreme distress. Incapable of lying down, he is seen for weeks, and even for months together, either reclining in the semi-erect posture supported by pillows, or sitting with the trunk bent forwards and the elbows or fore-arms resting on the drawn-up knees. The latter position he asumes when at- tacked by a paroxysm of dyspnoea—sometimes, * As the respirations are slower, they might be sup- posed deeper; but with the exception of those deep in- spirations that are taken occasionally durin" and more particularly at the breaks of sleep, the expansion of the lungs during sleep will be found by auscultation to be less than at other times. HEART, (DISEASES OF however, extending the arms against the bed on either side, to afford a firmer fulcrum for the mus- cles of respiration. With eyes widely expanded and starting, eye-brows raised, nostrils dilated, a ghastly and haggard countenance, and the head thrown back at every inspiration, he casts round a hurried, distracted look, expressive at once of fright, agony, and supplication; now imploring, in plaintive moans, or quick, broken accents and half-stifled voice, the assistance already often lavished in vain; now upbraiding the impotency of medicine; and now, in a fit of despair, droop- ing his head on his chest, and muttering a fervent invocation for death to put a period to his suffer- ings. For a few hours—perhaps only for a few minutes—he tastes an interval of delicious respite, yvhich cheers him with the hope that the worst is over and that his recovery is at hand. Soon that hope vanishes. From a slumber fraught with the horrors of a hideous dream, he starts up with a wild exclamation that "it is returning." At length, after reiterated recurrences of the same attacks, the muscles of respiration, subdued by efforts of which the instinct of self-preservation alone renders them capable, participate in the general exhaustion and refuse to perform their function. The patient gasps, sinks, and expires. Such are the sufferings, in their worst form, of an asthmatic from disease of the heart. We have now to take a more strictly medical view of the nature and progress of the asthmatic paroxysm. If about to be severe, it is generally preceded by certain premonitory symptoms, which, though not so marked as in ordinary asthma, are much of the same nature—probably because derange- ment of the circulation and imperfect oxygenation of the blood are present in both. In cardiac asthma, however, many of the nervous symptoms, which characterize the ordinary varieties, are often deficient. One of the most common and efficient exciting causes of cardiac, as of all other asthmas, is derangement of the stomach, the irritation of which extends to the heart, and stimulates it to inordinate action. The irritation, according to the theory of Sir Charles Bell, is propa- gated through the medium of the par vagum, by which nerves the stomach and heart are closely associated as parts of the respiratory system. Accordingly, after a feeling of acidity, flatulence, or a load on the stomach from undigested food, often accompanied with abdominal distension, the patient experiences pain, weight and constriction in the forehead and over the eyes, accompanied (if the case be one of hypertrophy of the left ven- tricle) with throbbing of the temples and the sound of rushing waters. He feels a sensation, scarcely to be denned, of oppression, tightness and anxiety about the praecordia, frequently with slight palpitation. Sometimes the patient is drowsy, listless, restless, irritable, and impatient not only of society but of the attention of friends: these symptoms, however, are,, in general, more preva- lent in ordinary asthma. The signs described afford the experienced asthmatic well-known as- surance of the approaching attack, They gradually become worse and worse, espe- cially after a meal, and eventually burst into a paroxysm. The time of the accession is less regular than in ordinary asthma, being more Vol. II. —54 2l* THE VALVES OF THE) 425 dependent on the state of the heart, which is liable to accidental excitement, from a variety of causes, at any moment. The fit, however, as in ordinary asthma, is, on the whole, more apt to supervene during the evening or early part of the night; and this, as appears to us, for two reasons : 1st. The recumbent position is unfavourable to respiration, the diaphragm being pressed upwards by the abdominal viscera, and the expansion of the chest being opposed by its own weight: 2d. During sleep respiration is not assisted by the will, which, during the wakeful state, from the sensation of want of breath being more acutely felt, is ever ready to maintain the body in the position most favourable to breathing. From the co-operation of these two causes, therefore, tbe circulation becomes so far embarrassed before the patient is aroused to a sense of his condition, that it can only be relieved by those violent efforts which accompany the asthmatic paroxysm. He accordingly awakes, generally with a start, in a fit of dyspnoea, accompanied either with violent palpitation, or a distressing sense of anxiety in the praecordia and great constriction of the chest, as if it were tightly bound. He is compelled to assume a more erect posture, and intensely desires fresh, cool air; the respiration is wheezing and performed with violent efforts of all the muscles of respiration both ordinary and auxiliary. The inspirations are high and accompanied with ap- parently little descent of the diaphragm, and the expirations are short and imperfect. The surface is chilly, the extremities are cold, and the face is pale and sometimes livid. In cases in which the pulmonary congestion is only temporary, as in hypertrophy, either simple or with dilatation, there is no cough beyond a few slight and ineffectual efforts, producing little 01 no expectoration ; and in such cases the fit sub- sides as soon as the engorgement of the heart and great vessels is relieved, which nature generally effects in two or three hours or less, by determin- ing the blood to the surface and creating diapho- resis. In some instances we have known this termination to be regularly accompanied with a copious secretion of pale urine and a purging alvine evacuation. The pulse, though at first full, strong, and bounding, may, during the worst of the paroxysm, become feeble and small, and the sound and im- pulse of the heart may be diminished ; and this in cases even of hypertrophy ; for the organ, being gorged to excess, is incapable of adequately contracting on its contents. Such is the nature of an asthmatic fit when the pulmonary congestion is only temporary : the case is different when it is permanent, as in valvular disease and in some extreme cases of dilatation. For, then, there is often violent cough in suffocative paroxysms, accompanied, at first, with difficult and scanty expectoration of viscid mucus, but ending gradually in a copious and free discharge of thin, transparent, frothy fluid, occasionally intermixed with blood. This evacu- ation by disgorging the pulmonary capillaries, affords great relief to the cough and dyspnoea. As, however, the transudation of the matter to be expectorated into the air-p:issages, and its final elimination, are slow processes, paroxysms of this 426 HEART, (DISEASES OF^ description are much more protracted than those of dry asthma from hypertrophy. They frequently last "five or six hours, and we have known them persist, with only occasional remissions, for two, three, or more days. During the attack, the pulse is quick, small, and weak, often irregular and in- termittent In other forms of asthma the circula- tion through the heart is sometimes little disturb- ed ; but this is always incorrect in reference to asthma from disease of the heart. As the paroxysm subsides, the anxiety and constriction decrease, the respiration becomes less frequent, high, and laborious, and the pulse be- comes slower, fuller, and more regular. But some degree of wheezing and tightness of the chest remains, and the paroxysm is very apt to return for two or three nights successively, and sometimes for a much longer period, until the lungs are freely unloaded by copious expectora- tion. It may, indeed, continue to recur at brief intervals for an indefinite period, or the patient may never be wholly exempt from some degree of asthmatic dyspnoea. A severe asthmatic attack from disease of the heart is in general far more injurious in its con- sequences than one from an affection of the lungs. Treatment of Disease of the Valves.— According to the foregoing principles, the ex- citing causes of valvular disease are, 1. over-ten- sion of the valves by the force of the circulation; and, 2. inflammation, generally of the chronic kind. If it were possible to ascertain that these causes were in operation before they had actually occasioned an organic change, it would most probably be possible, in many cases at least, to counteract their effects and to prevent the forma- tion of the disease. But, unfortunately, there are no positive signs of the latent mischief but what result from the disease already formed,—from the obstruction itself: and as, in the present state of our knowledge, we are not acquainted with any means of removing a valvular obstruction, the indications of treatment in this disease are, to pre- vent its increase, to counteract its tendency to induce hypertrophy and dilatation, and to relieve the symptoms of an obstructed circulation. The remedies calculated to answer these indi- cations are, in general terms, such as diminish the force and activity of the circulation, namely, occa- sional venesection to a moderate extent, an un- stimulating and rather spare, though sufficiently nutritious diet, a tranquil life, with respect both to the body and the mind, and a good state of the digestive organs and alimentary canal. If there be distinct signs of inflammation of the valves, to the above remedies may be added cup- ping or leeching on the praecordial region, with counter-irritants, as blisters, setons, issues, and the tartrate of antimony in the form either of ointment, or plaister with the empl. picis comp., and one- fourth of bees'-wax. We have also found digi- talis very useful under these circumstances. The extent to which any remedy must be car- ried can only be determined by the particular cir- cumstances of each case. If, for instance, the pa- lient be robust and pletnoric, depletory measures may be pursued to a greater extent, and vice versa. In general, if the valvular obstruction be ii--»* very considerable, and there be no hypertrophy THE VALVES OF THE) or dilatation, and no tendency to plethora, an tb- stemious, light diet, and a scrupulously tranquil life, with an open state of the bowels, constitute all the prophylactic treatment that is necessary; and it is satisfactory to know that, by these means, danger may in many instances be completely averted. We have several times known patients with a moderate—even with a rather considerable valvular obstruction, attain the age of sixty, seventy, and even eighty, though the symptoms, judging from their account, had commenced in early life. On the other hand, if precautionary measures be neglected, and hypertrophy or dilatation be su- perinduced, there is no organic disease of the heart, except adhesion of the pericardium, which tends more rapidly to its fatal termination. Hence the great importance of detecting and attending to disease of the valves in its earliest stage. When the obstruction has become very consid- erable, has produced hypertrophy or dilatation, and is attended with dyspnoea, orthopncea, and dropsy, the case is one of the most difficult that the practitioner can encounter. The most urgent symptoms, however, generally admit of being re- moved for a time; and the amelioration which takes place is sometimes truly astonishing. But, unhappily, the complaint seldom fails to return with greater or less promptitude. If the patient be youthful and of a robust constitution, the re- lapse may not occur for several months, especi- ally if he has not been affected with dropsy, or after the first attack; but if he be of a shattered constitution, and have previously had severe at- tacks, the symptoms commonly return the moment he resumes any active occupations. In an ulte- rior deigree of the disease, no sooner are the symp- toms dispersed than they return, though the pa- tient does not commit any indiscretion. When this is the case, the fatal event is never far remote, and may occur suddenly at any moment. The remedies suitable for the treatment of the cases described are, abstractions of blood, purga- tives, diuretics, sedatives, revulsives, a spare diet, and, what is paramount in importance to all, com- plete repose. These remedies, however, are not to be employed at random : so used, they might not only be unavailing, but directly destructive. It is only by adapting them to the character of the organic cause of the disease—only, in short, by a sound diagnosis, that they can be administered safely and effectively. It is necessary, therefore, to enter into further particulars relative to their nature and mode of application, and this may be most conveniently done by adverting separately to each. Bloodletting.—When, with the valvular ob- struction, there is hypertrophy or hypertrophy with dilatation, bleeding is generally necessary and may be repeated in small quantities, two, three, or more times, according to the strength of the patient and the urgency of the palpitation and dyspnoea. Some have recommended that bloodletting be practised in valvular disease in the unsparing manner of Albertini and Valsalva. The results of our own experience lead us to dissent entirely from this doctrine. Excessive bleeding cannot re- move the valvular obstruction—cannot, therefore, cure the disease; consequently, its employment HEART, (DISEASE OF THE VALVES OF THE) 427 with this object is inappropriate. It is, moreover, directly injurious; as it reduces the patient to a state of debility which renders his circulation more liable to be embarrassed by the valvular obstruc- tion, and his constitution more susceptible of the inroads of the malady. We have always ob- served bloodletting to be most serviceable in val- vular disease when carried only just so far as to relieve the existing urgent symptoms without en- croaching on the constitutional powers. It is ad- vantageous to draw from four to eight ounces of blood occasionally during the intervals of the at- tacks, whenever dyspnoea becomes urgent and the heart's impulse more than ordinarily strong. If, instead of hypertrophy, dilatation, either sim- ple or attenuated, be conjoined with valvular dis- ease, bloodletting is less necessary, and is more injurious if carried to excess. It should be re- sorted to reluctantly; only when imperiously de- manded by excessive dyspnoea, which other means have failed to relieve; the least quantity that suffices to afford relief should be drawn; and the depletion should not be repeated if it can possibly be avoided. Attention to these rules is still more necessary in the aged. The greater the valvular obstruction, the greater is likely to be the embar- rassment of the circulation, if the power of the heart and system be reduced below a certain point. Of this we feel satisfied from reiterated observation. Diuretics.—When there is dropsy and a scanty secretion of high-coloured urine, remedies of this class are of the greatest utility. In most cases, in- deed, the dyspnoea, palpitation, cough, &c. de- crease in the same proportion as the urine in- creases and the dropsy disappears. Nor is it only when dropsy has actually appeared, that diuretics are useful. They are remarkably beneficial in an anterior stage of the disease ; for, by drawing off the serous portion of the blood, they diminish the quantity, without deteriorating the quality of that fluid, and thus relieve palpitation and dyspnoea and obviate infiltration, without materially redu- cing the patient. Diuretics are very variable in their effect, a weaker sometimes answering perfectly after a stronger has failed. When, therefore, one does not speedily produce the effect, another should be tried. The surest way is to employ several at once. A pill consisting of three grains of blue pill, one of pulv. scillae, and one or half of one of puh. digitalis, given three or four times a day, seldom fails; or it may be given once or twice a day with a draught of tr. scillae, mxx. sp. aetheris nit. and sp. junip. C. comp. aa.. gss. ad gi, in dec. spartii. giss. twice or thrice a day. We have sometimes found all these fail until Sfii or ^iii of infusion of digitalis were added to the draught. Its effect, however, must be carefully watched. Bupertartrate of potass is always a valuable aux- iliary, and may be given to the extent of 5jii or Jiii in twenty-four hours, either in the form of a drink, of electuary, or in the above draughts. Sometimes diuretics cannot be made to produce any effect: it is then necessary to resort to pur- gatives, as will presently be explained. In very feeble and reduced patients, dropsy should not be too rapidly evacuated ; as the pro- cess is attended with a degree of exhaustion, which is often fatal. The period, indeed, imme- diately succeeding the disappearance of dropsy is, on this account, one of the most critical. The older physicians were aware of this, and ascribed it to the accumulation of the fluid in the internal cavities. Such, however, is not always the cause ; for, in cases terminating fatally at the period allu- ded to, we have frequently ascertained, both by auscultation, percussion, and post-mortem exami- nation, that the internal and external dropsy dis- appeared simultaneously. Purgatives.—When diuretics do not remove dropsy, purgatives will frequently produce that effect. The two classes of remedies may, indeed, be combined with great advantage, when the pa- tient is strong enough to bear them. The drastic hydragogue purgatives are the most efficacious, as tinct. jalapae, elaterium, &c. The effects of the latter are sometimes truly astonishing. We have seen an extreme universal anasarca removed by it in three or four days. The remedy is apt, how- ever, to be excessively violent in its operation, and should, therefore, only be given to strong subjects. As its effect varies in different individuals, it should be tried at first in small doses, as from one-eighth to one-fourth of a grain. With caution it may be carried to two grains. We generally give it in the form of pills with pulv. capsici, which obviates its griping effect; sometimes we add a grain or two of calomel. A single pill should produce six or eight watery evacuations, and it may be given two or three mornings successively, or every se- cond or third morning, according to the strength of the patient. All the other purgatives may bo useful, especially such as produce watery evacua- tions. A very good one is, the infusion of senna, with tinct. jalapae gi, and tartrat or acetat. po- tass, gii. An occasional purgative is sometimes very ben- eficial though there be no dropsy ; as, for instance, when an attack of palpitation or asthma has ap- peared to be induced by an excess of bile, by undigested food, or by acrid or long detained faeces in the intestines. Under such circumstances a purgative often alleviates, and sometimes termi- nates the attack. Except with a view of remov- ing dropsy, or plethora in cases where hypertrophy is superadded to valvular disease, frequent, syste- matic purging should be avoided on the same prin- ciple as bloodletting : viz. lest it should too much reduce the system. Diaphoretics.—When there is anasarca, cuta- neous transpiration contributes very powerfully to remove it. A lady, lately under our care, anO subject to frequent attacks of anasarca, often found the swelling disappear in twenty-four hours with copious perspiration. Strong stimulating sudori- fics, however, should be avoided, as they are both too debilitating and too exciting to the circulation. Gentle saline diaphoretics are the host, and their effect may be promoted by warm clothing, hot di- luents, and the occasional use of the warm bath to keep the skin soft and open. When there is no anasarca, and no permanent pulmonary en- gorgement and expectoration, diaphoretics, beyond warm clothing, are of little use, except occasion- ally, to relieve asthmatic attacks. For the latter purpose we have generally found them of great utility ; but, as internal remedies of this class «!•» 428 HEART, (DISEASES OF THE VALVES OF THE) rIow in their operation, they should be resisted by fomenting the hands and feet, or immersing them in warm water, at the same time keeping the trunk covered. If perspiration can thus be gently elicit- ed without heating and stimulating the patient, it is one of the most effectual means of curtailing a paroxysm. Nature herself indicates the reme- dy ; as a paroxysm of asthmatic palpitation often terminates with profuse spontaneous diaphoresis. Emetics.—These are extremely useful or ex- tremely pernicious according as they are judi- ciously given, or the reverse; and it is only by a sound diagnosis that the practitioner is enabled to judge whether they can be safely administered or not. When there is an undigested, bilious, or acid load on the stomach, exciting a fit of palpita- tion, its removal by an emetic often affords instan- taneous relief. But the medicine should be one which simply evacuates the stomach without much shaking the system, as ipecacuan with sulphate of copper or of zinc, but by no means tartrate of antimony. If the disease of the heart and the em- barrassment of the circulation be great, even such an emetic as the above cannot be given without danger of aggravating all the symptoms. We have seen emetics, administered under these cir- cumstances, exasperate and prolong the paroxysm, increase the frequency of its recurrence, and speed- ily bring the patient to his grave. They may even cause death during the paroxysm. Their dan^eious effect consists in their increasing en- gorgement of the heart and the obstruction of the circulation. For this reason they should not be ventured upon in disease of the heart simply for the object of promoting expectoration—an object which may be much more safely and effectually accomplished by other means. In ordinary varie- ties of asthma, especially that from pituitary ca- tarrh, they are peculiarly beneficial by promoting the expectoration of the immense accumulations which take place in the lungs. Hence the im- portance of carefully distinguishing between these two classes of cases. (See Asthma.) Though emetics are objectionable except for the purpose of evacuating the stomach, small doses of ipecacuan or tartrate of antimony are useful as diaphoretics and expectorants. When the ob- struction of the circulation is great, they cannot safely be carried to nausea, as this state is apt to bring on a languor of the circulation which leads to the formation of polypi in the heart In the case of a lady under our care, and affected with extreme contraction of the mitral valve, nausea came on unexpectedly at the moment when she had just been relieved of an excessive dropsy, and was followed by suffocating dyspnoea, an imper- ceptible pulse, and other symptoms indicating the formation of a polypus in the heart. She died in a week, and the polypus was found. Puncturing. — When dropsy has failed to be relieved by other means, and the cutaneous ten- sion has become intolerable, the practitioner is compelled to resort to puncturing. We say com- pelled, because the remedy is a last and dangerous resource. The danger, however, may be conside- rably diminished by making small punctures with a grooved needle, and allowing the fluid to ooze till antacids appear to have failed. To give tone to the stomach, bitters are very useful. Infusions should be employed during an asthmatic paroxysm, as tinctures are too stimu- lating; but after the second or third day, when the patient begins to amend, either the one or the other may be used. The bitters may be conve- niently conjoined with the antacids, acids, &c. Griffith's mixture is very beneficial in debilitated subjects, in the intervals between the fits. Tonics.—When disease of the heart is of the hypertrophic kind with increased activity of the circulation, tonics are obviously inappropriate: when it is of the dilated kind, with languor of the circulation and atony of the system, they are re- medies of the greatest value, and it is mainly by them that a complete cure can be effected. All 430 HEART, (DISEASES OF THE VALVES OF THE) the tonics, of which the preparations of iron are the best, may be used according to the discretion of the practitioner. Of the advantages of bracing air and exercise and of the shower-bath, we have spoken in the article Dilatatiox. A discreet use of the cold bath also is highly beneficial. (See Asthma.) Such are the remedies to be used in the treat- ment of organic disease of the heart. It cannot be too strongly inculcated on the practitioner, that the disease, when remediable, is not to be cured by relieving the paroxysm, but by preventing its occurrence. Every attack gives the patient much ground to retrace; a single attack may undo the progress of a year, and death may result from the indiscretion of a day. Great firmness is necessary on the part of the physician to impress this strongly on the mind of the patient; for the latter, when his feelings are easy, can seldom—very seldom— be made to comprehend that the necessity for his rigid adherence to medical, regiminal, and dietetic discipline is equally imperative. The practitioner, however, is not the less to study the means of relieving the paroxysm; not only because in it he has perhaps the greatest of human sufferings to alleviate, but because by cur- tailing the attack he increases the chances of an 'lltimate cure. [See on all this subject, Hope on Diseases of 'le Heart, edit. cit. p. 341. , XT J. Hope. HECTIC FEVER. (See Feter.Hectic) HEMERALGIA. (See Nyctalopia.) HEMICRANIA. (See Heauach.) HEMIPLEGIA. (See Paralysis.)] HEMORRHAGE, (alpop'payla, from alpa, san- guis, and pfiyvvjii, rumpo,) loss of blood. The purpose of this article is to present a summary view of the knowledge we possess, and of the doctrines now generally received, concerning in- ternal hemorrhage. The term is here employed in its most comprehensive sense, as signifying the passage of the blood beyond its natural channels— beyond or out of the vessels that are appointed to contain and convey it in the healthy living body. Under this definition it is indifferent whether the extravasated blood remains pent up within the body or not. The epithet internal is however prefixed, in order to limit the subject to those forms of hemor- rhage which/fall within the province of the physi- cian, and to exclude all consideration of those cases which, whether they are the result of disease, or of accidental injury, or of surgical operation, are capable of relief by mechanical expedients only. These latter cases are sometimes, though not perhaps with much propriety of language, com- prised under the general title of surgical hemor- rhage, in contradistinction to the former, which are then classed as being medical. In what has been called surgical hemorrhage the blood proceeds from some large vessel, situated within the reach of the eye and the finger. The principles upon which the loss of blood in such cases is arrested or prevented are well understood ; and in no par* of the rapid progress of modern surgery has the union of well-contrived observa- tion with sound reasoning been productive of more admirable results. With a few remarkable excep- tions, such as the protection afforded against small- pox by vaccination, or against sea-scurvy by the use of lemon-juice, there is not perhaps any single improvement in the art of healing by which so many lives are saved, and so much human suffer- ing is relieved or averted, as by the scientific appli- cation of the ligature upon the larger blood-vessels. That kind of hemorrhage which falls to the care of the physician is less perfectly understood, and is controllable with less certainty. It comprehends, however, a large and very formidable class of dis- eases. In some of these the effusion of blood is an accidental symptom only; of many it forms the principal sign or circumstance; and there are others in which it may be considered, in reference to our united means of investigation, as constitut- ing the whole disease. The accidental injuries to which the animal frame is continually exposed must have furnished mankind, from the earliest times, with frequent illustrations of the striking fact that the mere loss of blood, when it exceeds a certain amount, implies also the loss of life. They who have seen their fellow-men bleed rapidly to death from external wounds would be strongly impressed with the great importance of the fluid, the removal of which from the body led to an event so appalling; and they would look with interest and alarm upon the rarer instances which might occur of bleeding from in- ternal and unseen parts. A natural but deceptive analogy, uncorrected by pathological knowledge, would almost unavoidably lead them to this further inference, that all hemorrhage—hemorrhage, the source of which they could not see, as well as that the source of which they were able to examine and appreciate,—proceeded from an opening in the sides of some one (or more) considerable blood- vessel. It is true that some hemorrhages, of which the origin is, during life, beyond our vision and means of inquiry, do result from the rupture of vessels of a certain magnitude; but it is no less true that in the greater number of instances of bleeding from the interior of the body, there is no lesion, capable of being detected by dissection, either of the veins or the arteries ; but the blood is poured out by what is called exhalation, and proceeds from those ultimate ramifications of the minuter blood-vessels which constitute the capillary system This remarkable and important piece of know- ledge was ascertained long since by Morgagni; it was more formally and completely demonstrated by Bichat; and it has been so amply illustrated by subsequent observation that it may seem to be a fact almost too trite to dwell upon. Yet, judging from the writings and language even of medical men, it does not appear to be so generally known or acknowledged as it ought to be among them; and among unprofessional persons the old errors upon this subject prevail almost universally. To break or burst a blood-vessel, in the most literal meaning of those words, is thought by the public, and by some at least of the profession, to be a misfortune of very common occurrence; yet rela- tively to the frequency of hemorrhage, it is certainly a very rare one. Bichat explicitly propounds the doctrine that in certain hemorrhages the blood escapes from the HEMORRHAGE. 431 capillary vessels by a process which, in pursuance of his example and to avoid circumlocution, we shall call that of exhalation. He rests this opinion upon several distinct considerations, some of which are perhaps more curious than conclusive. Thus he states that if the uterus of a female who has died during the menstrual period, be care- fully examined, no erosion of its inner surface or of its blood-vessels can be seen, nor any of those numerous cicatriculae which, he argues, must have been formed, if each occurrence of the catamenial discharge had resulted from a rupture of those vessels. The rupture which he here supposes is the simultaneous laceration of numberless capillary blood-vessels. Such laceration, if it took place, would indeed account for the discharge; and it has been assumed in explanation of some morbid hemorrhages. It is by no means certain, however, that it would give occasion, especially on a mucous surface, to visible scars. Punctures, even of the skin, made by fine needles which would wound the blood-vessels, do not, we imagine, however numerous they may be, leave any such traces of their former presence. He adds, that if we submit the same uterus to pressure, and mark closely what happens, we see minute drops of a red fluid exude from its inner surface; and if we then wipe these drops away, the membrane whence they proceeded appears to be perfectly entire. Whatever weight this argument may possess is strengthened by the actual observation of the pro- cess of menstruation in the living uterus. Dr. James Hamilton of Edinburgh is in the habit of relating, in his lectures, the case of a patient who was once under his care, and whose complaint appeared to him so instructive upon this very point, that he sent her into the clinical wards of the infirmary, that the students might have an opportunity of witnessing it. This woman was afflicted with enlargement and complete prolapsus of the uterus. The professor describes the inverted womb as having hung down between her thighs like a quart bottle; it could not be replaced; and it was tense and hard, except during the period of menstruation, which took place regularly. At those times it became soft and flexible, and the menstrual discharge was seen, by numbers of me- dical men and of students, to issue guttatim from the exposed surface. As, however, the process of menstruation cannot be looked upon as a morbid process ; as, in the unpregnant female, during a certain portion of her life, it is not only consistent with perfect health but actually essential to it; and as the fluid so poured out is not strictly blood ; the analogical argument drawn from the preceding facts in favour of he- morrhage by exhalation, though it may afford a strong presumption, is not decisive. But the deficiency here noticed is supplied by what is observed in those cases (rare indeed, yet well authenticated) of actual cutaneous hemor- rhage, where a dew of blood appears upon some portion of the *kin, is wiped away, and re-appears, with no perceptible alteration of the affected sur- face beyond some occasional variation in its colour. Another of the arguments advanced against the possibility of rupture or laceration in such cases is drawn from the well-known fact that the flow of blood, or of the catamenia, will sometimes continue for a few moments, then cease, and again recur; and that these alternate changes may happen se- veral times in the course of a single day; so that, upon the supposition against which Bichat is con- tending, the wounds of vessels must heal and re- open at every change. This reasoning is obviously both inconclusive and erroneous. We know that the cessation of hemorrhage from a torn, vessel may and often does result from other causes than cicatrization ; that even when the vessel is of considerable size, and the laceration extensive, the bleeding may occur, and pause, and occur again, and that repeatedly, within a short space of time. Bichat did not overlook that species of evidence by which alone, after all, the existence of hemor- rhage, independent of any rupture of vessels, can be satisfactorily established. He states that he had frequently dissected the bodies of persons who had died from hemorrhage; that he had examined, ac- cording to the nature of the case, the surfaces of the bronchi, the stomach, the intestines, or the uterus ; and that, although he took the precaution of washing them clean, and even of submitting them to maceration before he inspected them with a microscope, he never could detect the slightest appearance of erosion. Numerous and conclusive observations of the same kind have been accumulated by the zealous pursuit of morbid anatomy for which the present age is so remarkable ; and in this way direct proof has been obtained, not only that internal hemorr rhage may take place from the surfaces of mem- branes by exhalation, but that this is the mode in which it most commonly happens ; that the effu sion of blood by any of the natural outlets of the body can seldom, excepting in the cases of aneu- rismal disease, be explained by the detection of a broken blood-vessel. Where hemorrhage, for example, has occurred so profusely from the stomach or bowels that the death which ensued has been sufficiently accounted for by the mere loss of blood, the whole tract of the alimentary canal has been diligently scrutinized, and has exhibited no breach of surface, nor any perceptible alteration of texture. Sometimes its mucous membrane appears, here and there, of a red colour, and as it were charged with blood; sometimes it is pale and transparent, while the vascular network visible immediately beneath it is gorged and turgid; sometimes the whole is colourless, the same network of vessels having been completely emptied by the previous hemor- rhage ; and sometimes again (and this is very illustrative of the mode by which the blood has issued) vast numbers of small dark coloured masses, like grains of fine sand, can be made to start from the surface of the membrane by slight pressure. There can be no doubt that these are minute portions of blood, which had remained and coagulated in the vessels or apertures forming the ultimate channels of the hemorrhage. These views receive an indirect but strong sup- port and illustration from the well-known circum- stance, that certain hemorrhages are preceded and followed by an increased efflux of the fluids which belong to the surface concerned. In hemorrhages 432 HEMORRHAGE. from the mucous membranes this succession of events is in some persons habitual. First, there is an augmented flow of mucus alone, then of mucus tinged with blood, then of blood alone; and the hemorrhage ceases by a similar but inverse gradation towards a mucous drain, which itself at length decreases and disappears. In such cases (there being no manifest erosion or organic change) it is apparent that the blood proceeds from the same vessels or apertures, which in health pour out the natural fluids of the part—mucus, serum, or sweat. There seems no more necessity, under the action of disease, for a rupture of vessels to give exit to the blood than to give exit to these fluids. What the vessels or outlets to which we give the name of exhalants really are—how they are distributed and arranged—in what manner they are connected with the ordinary capillary cir- culation of red blood—or under what influences they are placed—are points concerning which we have little or no certain knowledge. We know, indeed, that such channels must exist, though we cannot demonstrate or see them ; and that, whilst the health is entire, they do not allow the blood, as such, to pass through them. Several kinds of hemorrhage by exhalation have been enumerated by pathologists, according to the different morbid conditions with which the efflux of blood is associated. The chief distinc- tions of any importance may, however, be almost all comprised within the two general classes of idiopathic and symptomatic hemorrhage. Idiopathic hemorrhage is that which occurs without any discoverable change of texture, either \n the part from which the blood proceeds, or in any other part capable of influencing the circula- tion in the former, by reason of some intelligible connection of structure, or function, or mutual relation. The epistaxis of young persons affords an example of this kind of hemorrhage, to which the terms spontaneous and essential are also some- times applied. Symptomatic hemorrhage, on me other hand, is that which depends upon some notable organic disease. It comprehends all cases of hemorrhage by exhalation not embraced by the definition just given of idiopathic hemorrhage. It may be said to be primary when the organic disease upon which it depends is situated in the very part which gives issue to the blood; secondary, when the | organic disease is situated in some other part more or less distant from the former. We have instances of the primary species in hemorrhage from the stomach, or from the uterus, dependent upon incipient scirrhus of those organs; from the pleurse or peritoneum, under violent in- flammation ; from the mucous membrane of the air-passages in intense bronchitis. Examples of the secondary species occur in hemorrhages from the bronchial membrane in con- sequence of the presence of crude tubercles in the lungs, or of organic disease of the heart; and in hemorrhages from the mucous membrane of the stomach and bowels in consequence of disease obstructing the circulation through the spleen or liver. The proximate cause (as it is called) of idiopa- thic hemorrhage — or the essential condition of the facts concerned in its production — is involved in much obscurity. There appears good reason for believing that it is different in different cases. It is certain that in very many instances the he- morrhage is preceded and accompanied by an un- usual accumulation of blood in the capillary vessels of the part. In the secondary species of symp- tomatic hemorrhage this kind of sanguine conges- tion is also almost always present, and is then owing to some mechanical impediment of the venous circulation. The causes of such conges- tion antecedent to idiopathic hemorrhage are less obvious, especially when the congestion is partial, Since the time of Stahl and his disciples, the existence of local plethora has been fully recog- nised as constituting a frequent element of disease, Some of the distinctions introduced by him were doubtless fanciful: it is certain, however, not only that local congestion is of common occurrence, but also that this unequal distribution of the blood in the capillary vessels may happen in several ways, and from various causes, easily distinguish- able from each other. M. Andral, the most recent, and probably the most able writer on this subject, describes three different conditions under which local plethora (or, to use his own convenient though somewhat uncouth phraseology, hypere- mia) may occur in the living body. One of these conditions has been already ad- verted to, that, namely, in which the return of the blood from the capillary vessels towards the heart is impeded by some mechanical obstacle. Hy- peraemia of this kind may be strictly local. It may be confined to a single limb when the princi- pal venous trunk belonging to that limb is com- pressed, or otherwise diminished in size. If there be disease of the liver, of such a nature as to pre- vent a free passage of the blood through that organ, congestion will take place in all those parts of the capillary system from which the blood is conveyed by the veins that ultimately combine to form the vena portae. The force of gravity alone will be sufficient to induce venous congestion in parts of the body in which, under ordinary circumstances, the circulation through the veins is aided instead of being opposed by that force. If the head, for instance, be suffered to hang downwards for a certain time, we see the unequivocal signs of such congestion in the tumid condition and the purplish colour of the lips, cheeks, and eyelids. When an impediment to the free transmission of blood exists in the heart itself, a tendency to stagnation is pro- duced, first in the venae cavae, then in the smaller ramifications by which these veins are fed, and at length in the general system of capillary vessels; and thus general hyperaemia from a physical cause will ensue, the parts which are the most vascular being also the most readily and the most com- pletely gorged. The two other forms in which local plethora or hyperaemia may present itself are called respective- ly active or sthenic hyperaemia, and passive or asthenic. The first of these proceeds from some irritation or stimulus, either applied to the part itself, or in- fluencing that portion of the nervous system, by which the vital actions of the part are regulated. The irregular distributions of blood which fall under this head are not always morbid. In a HEMORRHAGE. 433 certain degree and for a certain time they may consist with the most perfect health. The deep flushing of the cheeks and forehead under strong mental emotion, and the general redness of the skin produced by violent exercise, are familiar il- lustrations of this healthy congestion of capillary vessels. A similar congestion may be produced at will upon the surface of the body by mechani- cal or chemical stimuli—by friction for example, or the application of heat. If these causes of the local accumulation of blood be intense in degree, or continue to be applied for a certain time, the congestion is accompanied by disturbance of the functions of the part—by pain, or by other well- known changes. But local congestion of this active kind, and essentially morbid in its character, is of frequent occurrence in various organs of the body ; and in many of these cases there is no obvious exciting cause of such an unequal distribution of the blood. We have evidence, indeed, in the blush of shame or anger, and in the paleness of fear, that the capillary blood-vessels may be filled to excess, or completely emptied, by causes operating through the brain and nerves; and it seems probable that morbid congestions, which are sometimes separated from those consistent with health by shades of difference not easily discriminated, may also be occasioned through the agency of the same ner- vous system. Local hyperaemia of the active kind seems in many instances to form a part, or rather to be an effect, of a plethoric condition of the whole body. To understand precisely what is meant by a state of general plethora, it is necessary to remember the physiological doctrine that the whole vascular system is constantly distended beyond the size of the vessels when free from any distending force. When the arteries are in any way emptied of their contents, their diameter diminishes, and fre- quently they become even impervious. The gen- eral notion of plethora is that this state of disten- sion is greater than what is ordinary or natural. It is easy to conceive that in persons who live fully, lead an inactive life, and sleep much, there should be a greater quantity of blood formed, and consequently a preternatural distension of the vessels. Fulness of habit and a florid complexion are marks of the existence of general plethora; of superfluous blood being partly expended in the formation of that substance which is the least ne- cessary in the animal economy, namely, fat, the capillary vessels of the face partaking of the general fulness or vascular distension present in all parts of the system. We trace the existence of general plethora also in the character of the diseases most prevalent in those who are the subjects of it, in the tendency especially which they evince to hemorrhage and to inflammation. A state of general plethora is, however, by no means essential to the production of local conges- tion, which, on the contrary, is of frequent occur- rence in persons who are pale, spare, and defi- cient in blood. Nay, a remarkable proclivity to an unequal distribution of blood in the capillaries, has been observed in those who, from accident or disease, have already lost large quantities of that fluid. The general symptoms, however, which accompany local hyperaemia in these two opposite Vol. II. — 55 2 m conditions of the system, undergo proportional modifications. The simple existence of local congestion of the active kind, and independent of any mechanical impediment, is sufficient to show that the blood, after it has entered the capillary system, is no longer under the sole influence of the heart's im- pulse; but that its subsequent motion is mainly determined by a power of contraction belonging to the smaller blood-vessels themselves. It is upon a supposed defect of such power—a diminished tonicity of the vessels, that the doctrine of asthenic or passive hyperaemia is founded. The efficacy of the assigned cause in the pro- duction of hyperaemia is perhaps less obvious here than in the cases which have just been considered. The following are some of the observed facts from which its actual operation has been presumed. In persons enfeebled by age or by disease, the lower parts of the legs, the ankles, and insteps, and the skin which forms the surface of old scars, are often habitually purplish or violet-coloured. This cannot be owing to the mere influence of gravity, because that remains constant at all ages and in all conditions of the system. The peculiar colour, denoting a sanguine congestion of the part in which it is visible, may indeed be diminished sometimes by placing the limb in the horizontal position, whereby the weight of the blood in op- posing its own return from the capillary vessels being removed, the action of the vessels themselves again suffices for its propulsion. But the conges- tion in these cases often disappears upon the em- ployment of friction, or of stimulating application, which would be powerless against any mechanical obstacle in the larger veins, and which would tend to increase the afflux and accumulation of blood in active hyperaemia. In the same way, the large, flabby, and livid granulations which often appear on the surface of indolent ulcers, are made to contract, and to as- sume a more healthy and florid hue by local sti- mulants, which quicken the previously languid circulation by exciting (it is supposed) the vita! action of the minute blood-vessels. There is no part of the body which affords more striking and unquestionable evidence that blood may accumulate unequally in the smaller vessels, than the eye. The conjunctiva and sclerotica, through which, while healthy, colourless fluids alone circulate, are traversed, under various forms of disease, by innumerable vessels bearing red blood. It is notorious that in certain cases the application of any stimulant to the surface of the organ will increase the existing redness, multiply the number of visible vessels, and aggravate the disease. These are cases of active hyperaemia, dependent upon irritation which is still subsisting, It is equally well known that the same vessels arc liable to congestion under very opposite circum stances. They are then seen to be distended with blood, tortuous, and varicose; and the redness is browner, and less vivid than before. In this kind or stage of vascular fulness, emollient application!* do harm rather than good ; while strongly astrin- gent and even highly irritant substances will often promptly dissipate the vascularity. There are, again, cases illustrative of hyperaemia of the asthenic kind The strong topical irritants restore the feeble ano 434 HEMORRHAGE. relaxed vessels to their natural elasticity, stimu- late them to contract upon their contents, and to force onwards the blood, which they cease to ad- mit from the arteries, and the redness disappears. In the examples here touched upon, the asthenic character of the local congestion is denoted by the peculiar aspect of the altered parts; by the cir- cumstances under which the congestion happens; and, above all, by the nature of the measures which conduce to its removal. The doctrine of asthenic hyperaemia admits of extensive and most important application, in regard to various inter- nal morbid conditions of the body. But any fur- ther prosecution of this part of the subject, would be irrelevant to the present inquiry. The pre- ceding observations have been made with the view of demonstrating or of rendering probable certain differences in respect to the manner in which the capillary blood-vessels may become unequally loaded, and of elucidating thereby some of the modes of hemorrhage; of showing in particular, that a predisposition to hemorrhage may arise under very different conditions; that it is far from being always of one and the same character, or susceptible of relief by the same kind of treat- ment The fact, then, which is beyond dispute, of the frequent pre-existence of local engorgement and distension in the capillary circulation, gives support to the hypothesis that (in certain cases at least) the issue of blood results from pressure, whereby the blood in substance is urged through passages naturally impermeable by its red particles, but now mechanically dilated in consequence of the vis a tergo. Although the dilatation cannot be made sensible to the eye, this seems the sim- plest and most obvious explanation applicable to some forms of idiopathic hemorrhage, and to the secondary species of that which is symptomatic. That blood may be thus exhaled, independently of any disease in the vessels themselves, we know from experiments made on animals, and from the observation of what sometimes occurs in the healthy human body. Boerhauve produced hemor- rhage into the intestinal canal of a living dog, by placing a ligature on the vena portae. An extreme turgescence of the whole venous system is one of the results of sudden strangulation. Dr. Yelloly accordingly found such turgescence conspicuous in the bodies of five criminals who had recently suffered death by hanging; and in two of these instances, blood in considerable quantity had ex- uded from, and coagulated upon, the mucous mem- brane of the stomach. Hemorrhage has been ascribed also to some alteration (other than that which we may conceive to be produced by the distension of plethora) in the vessels or apertures through which the healthy exhalations are transmitted. The change is con- sidered as being of the nature of morbid debility nr relaxation. That such a state may sometimes exist is not unlikely; but as we are altogether ignorant of the natural condition of these outlets, it is difficult to reason about the alterations to fvhich they may be liable in disease. This hypo- thesis derives its principal support from the occa- sional efficacy of astringent substances (either locally applied, or taken into the system) in check- ing the effas'op of blood, when artificial bleeding has failed Another mode in which the occurrence of hemorrhage has been explained, supposes an al- teration in the consistence or composition of the blood itself, which thus becomes attenuated, and capable of passing through channels or orifices that healthy blood cannot penetrate. In defence of this supposition are adduced the facts that hemorrhages are known to occur where the blood is obviously more thin, pate, and serous than com- mon ; and still more remarkably where that fluid has undergone a demonstrable change in its chem- ical nature, or is even visibly altered in its sensible qualities; as, for example, in certain cases of purpura and of sea-scurvy. These hypothetical attempts to explain the pro- cesses by which hemorrhage may take place de- serve, perhaps, more attention than has sometimes been paid to them. The views which they in- volve can scarcely be regarded as mere specula- tive refinements ; for they often exercise a real, though perhaps an unacknowledged influence upon our practice. At any rate, if they do not, prior to experience, justify certain modes of treat- ment, they accord wpnderfully with what expe- rience has taught concerning the means by which hemorrhage may sometimes be stayed or prevented. In some cases we succeed by measures which tend to abate the general force of the heart and arteries and to lessen general plethora, or by diverting partial plethora and restoring the disturbed balance of the circulation, or by directly emptying the turgid capillary vessels. In other cases we rely chiefly upon expedients which we believed to have the effect of constringing the extreme vessels, styptics to the bleeding part, cold to the surface of the body, producing a sympathetic shrinking in other related membranes; or internal medi- cines, which use has shown to have the property of restraining the natural exhalations when in excess. And, finally, there are cases where we seek, and not in vain, to repair the blood, to re- store it to its natural condition by improvements in diet, or by food of a peculiar kind, such as the juice of lemons; and thus the tendency to hemor- rhage is cured. Whether the hypotheses originated from a con- templation of symptoms, or whether they were suggested by the apparent effects of remedies, may be doubted ; but it is well worthy of remark how in the several cases they accord with both these classes of observed facts. Certainly hemorrhage is a prominent symptom in several morbid condi- tions, differing greatly from each other; and there is nothing inconsistent in sometimes attempting its explanation in one way, and sometimes in another. One observation yet remains, in regard to this doctrine of a preceding turgescence of the minute blood-vessels; namely, that it applies not only to certain kinds of hemorrhage, but also to inflam- mation, of which indeed it appears to be a constant and necessary element. Why, in one instance, the congestion terminates in that complex and variable process, or why, in another, it is relieved by an effusion of blood, we hitherto know not; but the fact that the same condition of capillary plethora is inceptive sometimes of the one form of disease, and sometimes of the other, supplies a rational ground for the analogy which has often HEMOR RHAGE. 435 been traced between hemorrhage and inflamma- tion ; and, what is of no less importance, it points out also the boundaries within which that analogy should be limited. There is a very ancient division of hemorrhage (into active and passive) drawn, not so much from the nature of supposed proximate causes, as from the assemblage of circumstances in connection with which the efflux of blood takes place. The distinctive characters of these two forms of hemorrhage are, in well-marked cases, sufficiently broad and decided. Active hemorrhage occurs in persons who are young and robust, who live fully, and lead indo- lent lives, and are subject to the influence of those causes which tend to generate plethora. Occa- sionally the hemorrhage can be traced to some exciting cause, such as exposure to heat, strong mental emotion, or violent exercise. More fre- quently, however, it seems to be the consequence of the predisposing causes merely. It is some- times announced by a set of symptoms expressive of what has been called the molimen hemorrhagi- cum. The patient experiences a general feeling of indisposition, with wandering and obscure pains that gradually settle in the part from which the blood is about to be discharged. A series of local symptoms, such as a sensation of weight, or of tension, or of heat and tingling, sometimes a slight degree of turgescence and redness, and a visible fulness of the larger veins, indicate the afflux of blood towards the labouring organ and the parts in its vicinity ; while chilliness, paleness, and shrinking of distant parts, and especially of the feet and hands, denote an opposite state of the circulation in them. The blood commonly escapes with-rapidity, is of a florid colour, proceeds from a single organ, and readily coagulates, though it seldom separates distinctly into serum and crassamentum. While it is flowing, the signs of local hyperaemia dimin- ish and disappear, warmth returns to the extremi- ties, and the pulse regains its natural strength and frequency. The patient becomes conscious of a sensible relief, and feels stronger and more lively than before. This kind of hemorrhage is in some sort its own remedy; it ceases in virtue of the dis- charge of a certain quantity of blood, and it is followed by morbid consequences only when that quantity has been excessive. Passive hemorrhage is characterized by circum- stances of an exactly contrary nature. It occurs in those who are naturally feeble, or who have been debilitated by disease, fatigue, insufficient nourishment, great evacuations, or the depressing passions. It is not, in general, announced by any precursory symptoms, nor attended by any re- action. The effused blood is of a dark colour, serous, and but little disposed to coagulate; and it often ia poured forth from several parts of the body at the same time. If the quantity lost be at all considerable, the natural debility of the patient u rapidly augmented ; his face becomes pale, and his body loses its heat. The hemorrhage leaves him in a worse condition than that in which it found him. The flow of a certain quantity of Wood is noi, as in the cases of active hemorrhage, »Hspensive of its further effusion; frequently, in- deed, passive hemorrhage resists the means op- posed to it the more in proportion as it has con- tinued longer, or been more profuse. If every case of hemorrhage could be accurately referred to the one or the other of these forms, this distinction would be of the greatest impor- tance and value. The truth is, however, that the majority of cases cannot be said to possess deci- dedly either an active or a passive character. The flow of blood is not preceded by any notable ex- citement or exhaustion, is not announced by any precursory symptoms, and is neither followed by any sensible improvement, nor (unless it exceed a certain limit as to quantity) by any marked de- bility. May not this indefinite character of the majo- rity of cases be accounted for by the consideration that most hemorrhages are in fact merely symp- toms, and derive their character from that of the disease of which they form a part! Does it not appear that the distinction of active and passive applies chiefly to the smaller class of idiopathic hemorrhages, those that are active being allied to the active form of hyperaemia, and bearing a close analogy to inflammation, both as regards the symptoms which accompany them, the description of persons in whom they principally happen, and their remarkable tendency to recur 1 whilst the passive belong to that condition of the body which is attended with some morbid change in the blood ; a circumstance which would of itself go far, per- haps, towards explaining their simultaneous oc- currence from various organs 1 However this may be, that hemorrhages are sometimes what is called active, and sometimes what is called passive, is a valuable fact, apart from all hypothesis. And concerning these morbid effusions of blood, there are several other 'well-ascertained general facts, with which it imports the physician to be acquainted, but of which the limits of this work will allow of a cursory enumeration only. In the first place, hemorrhage by exhalation, of whatever kind, takes place much more fre- quently and readily from some tissues of the body than from others, and most especially of all, from the mucous membranes. Upon this important fact have arisen questions which, although not without interest in them- selves, do not admit, in the present state of our knowledge, of positive solution. Has it any rela- tion to the manner in which these membranes, and the tissues subjacent to them, are supplied with a capillary circulation 1 or to their laxity of attachment, which facilitates and favours the accu- mulation of blood therein ? Again, has the density or consistence of their natural exhalations any thing to do with this disposition to hemorrhage in the mucous membranes] May we suppose that the vessels or orifices appointed to exhale mucus afford a more ready passage to the blood than those which give egress to thinner fluids- serum for example, or the cutaneous perspiration / Hemorrhage is also liable to occur, but much more rarely, from the serous membranes; from the skin ; into the cellular tissue of various parts of the body; and into the substance of the several viscera. Another important fact in regard to these he- morrhages is, that they proceed more frequentlv 436 HEMORRHAGE. from certain parts of the body than others, accord- ing to differences of age. Thus, in childhood they are most common from the membrane that lines the nasal cavities ; in youth from the mu- cous membrane of the lungs and bronchi; in the middle years of life, and towards its decline, from the rectum, uterus, and urinary passages ; and in old age from the blood-vessels of the brain. There are persons (and the case is far from being an uncommon one) who are subject, during the greater part of their lives, to certain hemor- rhages, which occur again and again, without any notable detriment of the general health, indepen- dently of any obvious exciting cause, and (as it would seem) from some inherent necessity of the system. Habitual hemorrhage of this kind is said to be constitutional; it takes place more com- monly from the rectum than from any other part, although cases are recorded of its occurrence from the mucous membrane of the bladder, of the bronchi, and of the nasal cavities. Linked, in some inexplicable manner, with the original con- stitution of the body, this disposition to hemor- rhage, as might be expected, is sometimes observ- ed to be hereditary. It differs from ordinary hemorrhage of the active kind, by affecting, indis- criminately, those who are feeble and those who are robust, but most remarkably by its recurrence at periods more or less regular. The celebrated Gall used strenuously to main- tain the doctrine of a periodic movement in the male system analogous to that which returns monthly in the female, and marked by signs which all might observe who would take the pains to look for them. That the analogy really obtains in many points, and more distinctly in some indi- viduals than in others, there can be no doubt. It has been incidentally noticed indeed by several writers; and Chomel has given the following clear summary of the principal features of the resemblance. "The primary appearance of these constitu- tional hemorrhages is sometimes preceded by a state of general indisposition, more rarely by slight febrile disturbance, and even, acording to some observers, by a sort of chlorosis analogous to that which affects young girls in whom the menstrual evacuation is delayed or suspended. The hemor- rhage sometimes recurs at precisely regular inter- vals, and by monthly periods more commonly than any other; being announced, on each occa- sion, by the same preludes, proceeding from the same part, continuing for the same space of time, and furnishing always about the same quantity of blood. Its accidental interruption is almost uniformly the cause or the effect of some derange- ment of the health. It is furthermore remarkable that these habitual hemorrhages, like the catame- nia, do not ordinarily occupy the whole course of life; in most individuals they do not commence before the period of adolescence or youth, and they cease altogether, or recur at distant intervals only, in declining age. When they become ex- cessive, they also (like hemorrhage from the Uterus) enter the exclusive domain of pathology." One of the most singular facts relating to hemorrhages is that they are, not unfrequently, vicarious or supplemental—sometimes of each other—but more often, in the female, of the men- strual discharge, between which and the constitu- tional hemorrhages of men there has just been shown to be some degree of analogy. Bleedings from the bladder and from the mouth sometimes follow upon the suppression of constitutional he- morrhoids ; from the lungs, stomach, or rectum, upon the suspension of the menses. These he- morrhagic deviations, as they are sometimes called, take place commonly by the same organ on each occasion, sometimes by different organs in succes- sion. It is almost always in this supplementary manner that the rarer forms of hemorrhage occur, and those of the skin in particular. This peculiarity in regard to hemorrhage seems calculated to throw some light upon the obscure doctrine of revulsion,- a doctrine which, though very imperfectly understood, is of continual avail in the practice of physic. The symptoms which accompany internal hemorrhage are modified by various circum- stances ; and the degree of certainty which they impart to the diagnosis differs much in different cases. If the part into which the blood is directly ex- travasated communicates with the exterior of the body, the expulsion of some of that fluid sooner or later demonstrates the case to be one of hemor- rhage. The particular symptoms will have some relation to the functions of the organ that furnishes the blood, and to the time that intervenes between its extravasation and its ultimate expulsion; and certain characters will often be derived from the parts traversed by the blood before it reaches the surface. It is even difficult sometimes to deter- mine whether the blood proceeds from a certain organ, or from those parts that lie between it and the natural outlet by which it ultimately escapes. The blood itself will be generally more fluid and brighter in proportion as it is effused in greater quantity, and near the surface; more in clots and darker in colour, in proportion to the length of time that it has remained within the body after its escape from its proper vessels: and this length of time may depend upon the smallness of the quantity of blood effused, and the conse- quent tolerance of the organs through which it may have passed ; or upon the actual space tra- versed. If the locus of the hemorrhage does not com- municate with the external air, we are without that certainty which results from the actual spec- tacle of the blood. But we are then assisted by local signs, which spring from the pressure on, or the laceration or distension of the suffering viscus, or of the parts contiguous to it; and by general signs, many of which are the same whether the extravasated blood reach the exterior or not. These general signs again are modified according to several circumstances. They principally vary according to the quantity of blood poured out, and to the rapidity of its effusion; something also will depend upon the particular organ, and much (when the quantity is the same) upon the age and strength of the patient. Besides the symptoms which are observable at the very time of the bleeding, there are others, cf much interest, which occur more remotely. These may sometimes result from a single profuse he- morrhage, but more commonly they are owiugi HEMOR RHAGE. 437 not so much to one large bleeding, as to a repeti- tion of such as have scarcely any immediate per- ceptible influence on the system. Some of the general symptoms,—such as pale- ness of the face, feebleness of the pulse, coldness of the extremities, and a tendency to syncope, which have been observed to ensue upon the eruption of the blood, have been ascribed to the alarm and sense of danger which the sight of that fluid is calculated to produce in the mind of the patient. This is probably true to a certain extent; but the explanation does not apply to those cases in which the hemorrhage is strictly confined to the interior of the body, yet in which the symp- toms just alluded to are often strongly marked. For the method of treatment applicable to internal hemorrhages, the reader is referred to the several articles in which the different forms and varieties of hemorrhage are practically discussed. A very cursory notice only can here be taken of the general means which are found most effectual in restraining the actual efflux of the blood. A preliminary question, however, of some im- portance, here presents itself. Is it in all cases of hemorrhage proper or safe to attempt to stop the bleeding ? Without going into detail, it may be stated as a rule that constitutional hemorrhages ought not to be interfered with, so long as they have no perceptible injurious influence upon the health, and proceed (as they mostly do) from parts of which the structure is not likely to be spoiled, nor the function impaired, by the passage of the blood. The most common seat of these constitutional hemorrhages is the rectum, to which the condi- tions just mentioned are, fortunately, both of them applicable. Epistaxis supplies a less frequent example of the same kind. When these habitual hemorrhages deviate from their usual channel, and are (as it were) transferred to some more import- ant organ, it will generally be right, among other remedial measures, to endeavour to recall the original hemorrhage. It is very seldom that the metastasis takes place for the better, from a part where the bleeding is attended with danger, to one where it is comparatively harmless. Again, it will seldom be proper to employ direct expedients for stanching the flow of blood in the small class of idiopathic and active hemorrhages, unless the quantity lost is so great as to endanger the safety of the patient. Such hemorrhages have commonly a tendency to cure themselves, by relieving the local or general plethora on which they depend. Nor may we venture to use direct means for checking most of those hemorrhages which result from present inflammation. With these exceptions, it will generally be right to arrest the effusion of blood as speedily as may be; though in some of the symptomatic hemorrhages this may even be of secondary im- portance. To this end the patient is to be surrounded as much as possible with cool fresh air, and kept in a state of absolute quiet. All motion of the body, and emotion of the mind, all kinds of stimulating food or drink—every thing in short which has a tendency to hurry the circulation, should be dili- gently avoided; and that position of the body | 2m* should be chosen which is the least favourable to the afflux of blood towards the part affected. The horizontal posture will be proper in hemorrhage from the bowels, the uterus, or the urinary organs. In epistaxis and in cerebral hemorrhage, the head should be raised. Of the actual remedies used for checking the further escape of the blood, one of the most im- portant is venesection. The objects of artificial bloodletting are, to diminish the force of the heart and arteries, to lessen general plethora, to remove local congestion, and to divert the current of the blood from the suffering organ. The method, and the amount, and the repetition of the bloodletting must of course be regulated by the circumstances of each particular case. The same objects may sometimes be effected by other modes of general depletion, and especially by the use of purgative medicines. Next to bloodletting, astringents constitute the great resource against hemorrhage; and of these cold is one of the chief. It may be placed in di- rect contact with the bleeding surface, as when ice is swallowed to restrain haematemesis; or cold water injected into the rectum in hemorrhoids, or into the vagina in flooding from the uterus; or it may be applied to the surface of the body, as near as possible to the seat of the hemorrhage, as to the nose and forehead in epistaxis; to the epigas- trium in hemorrhage from the stomach; to the lower part of the abdomen, or to the perineum, in hemorrhage from the intestines, uterus, or urinary organs. But the influence of cold in constringing the smaller vessels is not confined to the part with which it is in contact: it will stop hemorrhage by the sympathetic shrinking which it produces in distant parts. Epistaxis, for example, has often been arrested by the sudden apposition of cold water to the neck, back, or genital organs. Of its even mischievous power in this way we have con- tinual illustration in the suppression of the cata- menia by cold applied to the feet. There is a long catalogue of medicinal sub- stances, which are esteemed to possess more or less of a specific virtue, when taken internally, in arresting the flow of blood. Most of these are of an astringent nature, and some of them are essen- tially useful. The binacetate of lead enjoys in this country a higher character perhaps than any other of these substances. Many vegetable matters, and some artificial compounds, frequently employed in internal he- morrhages, seem to owe their astringent and styp- tic properties to the gallic acid [and the tannic acid] which enters into their composition. Such are the rhatany root, uva ursi, bistort, tormentil, the pomegranate, kino, caiechu, the several pre- parations of gall-nuts, [oak bark, monesia, &c] and the nostrum called Ruspini's styptic [creasote]. The power of arresting internal hemorrhage has also been confidently ascribed by different persons to nitre given in large doses, to the mineral acids, to the muriated tincture of iron, to alum, to the oil of turpentine, [See Astringents,] to the se- cale cornutum, and to various other substances, a more particular account of which may be found in other parts of this work, under the head of tha individual hemorrhages. Thomas Watson. 438 H E M O R1 HEMORRHOIDS, hxmorrhois. — The term hemorrhoids, from the Greek, ai,xa, sanguis, and pcu.fiuo, signifying simply a blood-flux, is not adapted to convey any correct idea of the nature of the various affections to be treated of under this head, some of which are not even attended, with a discharge of blood. Custom, however, has sanctioned and established its use in a particular sense, viz. as synonymous with piles, and to custom we think it right to con- form, it being our duty to furnish practical in- formation rather than to enter into an etymological disquisition. The meaning of the word hemorrhoids is now, by common consent, so entirely limited to certain affections of the rectum that no inconvenience can arise from its adoption. But this has not been the case always, for we find that very many au- thors, modern as well as ancient, have employed it in its literal sense, and under the epithet hemor- rhoids have described discharges of blood from the bladder, the uterus, and other organs, as well as from the rectum. Among others, Celsus, in treat- ing hemorrhoids, says —" Idque (vitium) etiam in ore vulvae faeminarum incidere consuevit." (Lib. vi. cap. xviii.) Notwithstanding this and the many other ex- ceptions alluded to, the majority of authors, begin- ning with Hippocrates, have restricted the mean- ing of hemorrhoids to those diseases of the rectum which form the subject of the present article. By hemorrhoids, then, are to be understood, first, a flux of blood from the rectum without any tumours internal or external; secondly, a flux of blood from the rectum with internal or external tumours; thirdly, tumours internal or external without flux of blood. The distinctive characters of these tumours and of the blood-flux will be de- scribed hereafter. When it is remembered how very common he- morrhoidal affections are, how great the sufferings they occasion, and how frequently they fall under our observation and treatment, we naturally con- clude that every particular relating to them has been fully investigated and satisfactorily made out; vet the reverse is the fact; and, innumerable as are the dissertations and other publications on he- morrhoids, we have sought in vain for acccurate information of their anatomical characters and pa- thology ; nor have we been able to find it in the museums of morbid anatomy of this metropolis preparations illustrative of the various kinds of hemorrhoids. The deficiency of information on this subject may in part be ascribed to the few deaths which occur absolutely from hemorrhoids ; for, excepting the cases which prove fatal after an operation, the individuals affected with hemorrhoids die usually of some other complaint, which, being urgent and prominent, while perhaps the hemorrhoids have ceased to be troublesome, engrosses the attention during life and at the post-mortem examination. That this is the case at our large hospitals, all who are in the habit of witnessing the post-mortem examinations will acknowledge, the condition of the rectum seldom forming a part of the investi- gations ; an omission not to be ascribed to negli- gence, but arising from the attention not having IHOIDS. been attracted to this organ during the latter part of the patient's life. 1. State of the rectum.—The anatomical cha- racters of the rectum, which we have discovered by dissection, independent of the hemorrhoidal tumours, are an enlargement of the hemorrhoidal veins and hypertrophy of the submucous tissue. The enlarged veins are seen through and lying immediately under the mucous membrane, taking a perpendicular course almost parallel to each other for seven or eight inches, their trunks being as large as a crow-quill, and formed from innume- rable small arborescent veins at the anal extremity of the rectum, which render the bowel intensely vascular. The same vascularity and lesion of these veins have been described by Dr. Colles; (Dublin Hospital Reports, vol. v. p. 152,) and Morgagni mentions an instance of extraordinary enlargement of the hemorrhoidal vein, <• interna haemorrhoidalis vena sub coli intestini fine et tota recti longitudine pollicis fere crassitiem aequaret." (De Sedibus et Causis Morhorum, lib. iii. p. 38.) 2. Anatomical characters of the hemorrhoidal tumours.—These tumours are generally regarded as arising from a varicose state of the hemorrhoidal veins: " haemorrhoides autem nihil aliud essequam varices venarum ani." (Morgagni, De Sedibus et Causis, lib. iii. p. 38.) By Sir Astley Cooper they are described as being found in two states; " a varicose enlargement of a vein ; or an excres- cence arising from its adhesion and organization," a description not very intelligible. (Lectures, by Tyrrell, voi. ii. p. 335.) By others they are dis- tinguished into such as discharge blood, bleeding piles : and into such as are not attended with he- morrhage, blind piles : " hemorrhoidum verd alia sunt caecse, aliae apertae : caecae sunt quae omni tem- pore inflatae sunt, et nihil excernunt: apertae verd sunt quae per tempora sanguinem effundunh" (Aetii Tetr. Sermo ii. cap. v.) By Sauvages it is proposed to call the bleeding tumours, haemor- rhois ; and the blind, mariscae; " tumores illi (sine ullo sanguinis effluxu) muriscx vocari de- bent, et fluxus cruoris, hxmorrhois multd aptius vocatur." (Nosologia Methodica, vol. ii. p. 323.) Such are the notions usually entertained of these tumours, notions which give us very little insight into their exact nature, seeing, as we shall presently do, that they differ so materially in their structure as to justify the division of them into the several following kinds. The first kind (which may be called varicose) is that which arises from a varicose state of the hemorrhoidal veins, or from the accidental dilata- tion of a small vein at a particular point, by which a cyst distended with venous blood is formed with- out rupture of the coats of the vessel, and is cov- ered only by the mucous membrane of the bowel; a manner of formation which appears to have struck Celsus, who describes hemorrhoids as " ora venarum tanquam ex capitalibus quibus sergentia quae saepe sanguinem effundunt" (Lib. vi. cap. xviii.) These tumours form within the gut, and are eventually extruded from causes hereafter to be described. They may be recognised when exter- nal, as consisting of a rounded tense elastic nu- cleus, the size of a pea, covered by the intestinal mucous membrane which moves easily upon it, HEMORRHOIDS. and may be pinched up separately, its adhesion to the distended or varicose vein, the nucleus, being by the submucous cellular tissue in its natural Btate of tenuity. Should this tumour remain ex- truded, the blood in the distended or varicose vein, being as it were out of the circulation, coagulates, thus converting the nucleus into a solid clot, still covered by the original mucous membrane of the rectum, which after exposure becomes transformed more or less perfectly into skin. This coagulum sometimes becomes organized, and the exterior covering strongly adherent from attacks of inflam- mation, in consequence of which the whole tumour is rendered solid and vascular. These tumours constitute one variety of bleeding piles. The second kind of hemorrhoidal tumours, which may be be called erectile, present all the charac- ters of an erectile tissue : they are cellular, spongy, full of blood, intensely vascular, and bleed profusely from innumerable points on their surface ; a fine example of which is furnished by Sir James Earle, in the case of a young lady, in whom " the tu- mour was about nine inches in circumference, sep- arable into several lobes, and altogether like a piece of sponge, bleeding from every pore. It was, however, of a healthy appearance, soft, and compressible." (Observations on Haemorrhoidal Excrescences, p. 23.) The vascular character of this kind of tumour has been ascertained by dissection. " I had an opportunity," says Dr. Colles, " of examining the structure of these tumours in a patient who died of another disease. On slitting up the rectum I saw three bloodvessels, each as large as a crow- quill, running for some way down the intestine, and then dividing into a number of branches; these vessels ramified very profusely, and each seemed by interweaving of its branches to form one of these tumours. The trunks and branches were covered only by the lining membrane of the intestine." (Dublin Hospital Reports, vol. i. p. 152.) The supply of blood to these tumours is not therefore by one large trunk, but by numerous minute vessels. Tumours of this description com- mence within the gut, afterwards descend ; and they constitute another variety of bleeding piles. The third kind of hemorrhoidal tumours con- sist wholly of dense, thickened, or hypertrophied cellular tissue covered by the intestinal mucous membrane, and are from their earliest formation external. At their origin each is merely a small fold of mucous membrane, which with its submu- cous tissue has been forced through the anus by efforts at the closet or other causes, and being pinched by the contraction of the sphincter is pre- vented from returning within the bowel. Ex- posed thus to friction and other sources of irrita- tion, these tumours are liable to inflammation and consequent thickening and induration of the sub- mucous tissue above described; while the mu- cous membrane continuing to be exposed gradually changes its character, is transformed into skin, and its organic sensibility being in this manner dimin- ished, the whole tumour becomes a chronic pile more or less flaccid and insensible until inflamma- tion is a-ain excited in it, when it tumefies, grows red, hard, and extremely painful, but does not bleed. By continued irritation from friction and want of cleanliness, these tumours often increase to a large size, become excessively indurated, and assume, from the pressure of the nates, a flattened oblong form with a thick rounded irregular edge ; and from the same causes the opposing surfaces of these piles become abraded, ulcerated ; and fis- sures and rhagades are produced from which a thin purulent discharge takes place. Tumours of this description constitute the mariscx or blind piles. All the kinds of hemorrhoidal tumours »bove described vary much in form and colour. When inflamed or highly congested they will be red or purple, and tense and hard ; and when in an in- dolent condition they will be more or less pale and flaccid. Generally they have a broad base: sometimes they are pedunculated. The hemorrhoidal flux.—Nothing is more va- rious than this hemorrhage, either as relates to quantity or to the circumstances under which it takes place. The most simple form occurs with- out any sign or premonition, without hemorrhoidal tumour, without lesion of any kind, if we except a determination of blood to the rectum ; and here the hemorrhage, it may reasonably be conjectured, is the product of a vital exhalation from the capil- laries of the mucous membrane. Several ounces of pure red blood may be lost at the closet from the rectum, the patient having experienced no un- easiness, no pain either previous or subsequent to the discharge, and without previous or subsequent hemorrhage; or patients subject to bleeding piles at intervals of a week, a month, or longer, may lose blood unconsciously, and in place of stool, to the amount sometimes of half a pint. On some occasions the hemorrhage will recur so frequently and in such quantity as to induce an alarming debility and anaemia, without any at- tendant local symptoms ; while at other times the excessive discharge will be accompanied with signs of internal hemorrhoids and of great deter- mination of blood to the bowel. It may occur in quantities to endanger life from external tumours of the erectile kind, as happened in the example quoted from Sir James Earle's Observations: or the hemorrhage may be small in quantity, not ex- ceeding a tea or table-spoonful, taking place after every dejection and for many days, then ceasing, and returning at uncertain and rather distant pe- riods, attended always with internal or external hemorrhoidal tumours : or the hemorrhage may assume a periodical character, more or less irregu- lar nevertheless, but occurring once in six or seven weeks, or in three or four months, preceded by an abdominal congestion, which is immediately re- lieved by the discharge. Very many persons who live freely are liable to this kind of flux, a happy resource of nature to unload the system when too plethoric, and so to preserve their health. Expe- rience teaches them that this periodical loss of blood, when not too copious, is beneficial, and they regard its return wuh satisfaction. If this accustomed discharge ceases, a determination of blood to another organ will ensue, and apoplexy, diseased liver, or some other very serious organic affection be the result. There are instances in which the hemorrhoidal flux will go on without the individual being aware of its extent or of its effects on the system, the loss not being great at any one time, but continuing day after day and 440 HEMORR HOIDS. week after week, until it exhausts the strength, blanches the face, and, if he is advanced in years, brings about debility under which he sinks, or from which he recovers slowly and with difficulty. The source of the hemorrhoidal flux is un- questionably various; yet it is the prevailing opinion that it issues from a rupture or bursting of the varicose hemorrhoidal veins. That this opinion is well founded, and that the varicose or dilated veins are the true source of the blood in the majority of cases, there can, we think, be little doubt. The facts that the hemorrhage occurs very frequently in a stream, while the patient is straining at the closet, the stream being interrupted as the straining is suspended, and returning as the efforts are repeated, form strong presumptive evidence, consistent with the anatomical peculiari- ties of these veins. It has been stated that the hemorrhoidal veins take a perpendicular course from the anus up the rectum, and as they, like nearly all the veins of the portal system, are not provided with valves, hemorrhage from a rupture of one of these veins when varicose or dilated, in a stream interrupted, as the efforts at the closest are continued or suspended, is probable and intel- ligible ; and it may take place to a prodigious amount Another source of the hemorrhoidal flux is from the capillaries of the rectum by vital exhalation or exudation, in cases of determination of blood to the mucous lining, a form of hemorrhage similar in every respect to that which is known to pro- ceed from the mucous membrane of the small in- testines in hepatic obstructions. A third source is by exudation from the sur- face of the erectile tumours, internal or external, where the blood may be seen to issue from every pore, as stated by Sir James Earle in the case al- ready quoted. A fourth source of hemorrhage may be lacera- tion of the congested mucous membrane by hard scybala forced through the sphincter by great effort, the body being much constipated. Here the he- morrhage is exceedingly trifling, and attended with pain, such as might be supposed to occur under the circumstances related. The Diagnosis of the hemorrhoidal flux has been explicitly pointed out by Actuarius; " Ve- rum ille (sanguis) qui ab altioribus locis emanat et aliquamdiu in corpore est moratus, nigrior est: hie vero purus, sincerus, et qualis ex jam ccecis hostiis profluit" (Med. sive de Meth. Med. lib. i. cap. 20.) The blood from piles is fluid and florid, may be discharged before or after a dejection, may cover, but is never mixed with the faeces; whereas hemorrhage from the intestines higher up is manifest by the blood being black and coagu- lated. Where the hemorrhage arises from dysen- tery, it is mixed with mucus, which gives it the characteristic appearance of portions of flesh ; and where it is produced by various kinds of ulcera- tion, it is confounded with the faeces. The Causes of hemorrhoids are hereditary pre- disposition, habitual constipation, free living, obe- sity, a sedentary mode of life, and aloetic and sther irritating purgatives. Hereditary pre-dispo- sition to hemorrhoids is marked in many persons, hut of all the causes which operate in the produc- tion of piles, habitual constipation is the most frequent. By habitual constipation the residual alimentary matter is delayed in the colon, becomes hard and knotty, and a source of great irritation to the large intestines, particularly to the rectum. This irritation induces a determination of blood to the lower bowel, this again congestion and gradual dilatation and varicose lesion of the he- morrhoidal veins, which eventually form tumours, burst or rupture, and give rise to hemorrhage; consequences all favoured by the anatomical pe- culiarities of the portal system, and accelerated by the efforts at the closet:—thus are bleeding piles formed. Habitual constipation is perhaps also the only cause of the blind piles or mariscae. When the bowels are costive, the sphincter is always tight and rigid, so that by its contraction the pro- truded membrane is prevented from returning, and being in some degree strangulated and exposed to irritation from friction, it inflames, indurates, and constitutes piles which do not bleed. By free living as a cause of homorrhage, we do not mean gluttony and drunkenness merely, but also that generous system of diet and indulgence at the table which prevails throughout society. The habitual liberal use of fermented liquors and of animal food produces a plethoric state not only of the whole system, but especially of the abdom- inal viscera concerned in digestion, the veins of which viscera constitute the portal system, and concur to form the vena portae itself. A fulness of the portal system, unprovided as it is with valves, must necessarily determine a congestion of the hemorrhoidal veins; and congestion of these veins from any cause will, as we have seen, pro- duce the hemorrhoidal flux and tumors. It is in persons who have hemorrhoids from living freely, that we have observed the flux to be most regular and periodical, and most decidedly salutary ; and there can be no doubt that it proves a great pre- ventive of visceral disease, to which these persons would otherwise be very liable. The suppression of the periodical flux is always attended with in- convenience. A sedentary mode of life tends to produce hemorrhoids, by favouring a sluggish circulation in the portal system, which leads to hemorrhoidal congestion and its consequences: the pressure accruing from obesity leads to the same results. Symptoms.—The symptoms are such as arise from the determination of blood to the rectum and congestion of blood in the hemorrhoidal vessels, and such as arise from the tumours whether in- dolent or in a state of irritation and inflammation. The hemorrhoidal flux is not always rendered cognizable by symptoms, examples of which have been already mentioned. On the other hand, the determination of blood to the rectum, which pre- cedes the hemorrhage, will be marked by dull pain about the back and loins, a sense of weight and heat about the sacrum and rectum, scanty and high-coloured urine, heaviness of the head, and disturbance of the digestive functions ; signs which persist for several days, when the flux supervenes and entirely relieves the patient. These symp- toms are most manifest where the flux is periodi- cal. In those who have hemorrhoids from habitual constipation, there will be weight and heat, and a sense of fulness about the rectum very constantly, HEMOR] an obscure tenesmus, frequent micturition from sympathetic irritation of the bladder, and leucor- rhaea, from a similar irritation of the vagina and uterus; all of which are temporarily alleviated by the discharge of blood, but are never entirely re- moved, the cause remaining. The symptoms arising from the henorrhoidal tumours are those of irritation and inflammation. Tumours situated without the sphincter are per- petually irritated by the friction of the parts in the ordinary motion and erect position of the body, and moreover they are irritated to a painful degree during the period of the evacuation of the bowels. The irritation is much aggravated by want of clean- liness, and soothed by regular ablution. Many persons affected by hemorrhoidal tumours experi- ence pain from sitting, aggravated to a great de- gree when they travel in a carriage or take horse exercise. The irritation will frequently produce accessions of inflammation, in which the tumours will become congested, swollen, red or purple, and excessively painful, so as to oblige the patient to keep his bed for many days. The Treatment of hemorrhoids must be con- sidered in reference to the flux and to the tumours. In considering the treatment of bleeding piles, the first step should be an inquiry into the influ- ence of the flux on the health; next into the cause and the practicability of removing it. If the cause of hemorrhoids is free living, and the flux salutary, and if the individual subject to the flux will persist in his mode of life, it would be unwise to interfere. It is only in the event of the flux being profuse that means to restrain it should be contemplated. It may happen, how- ever, that a person subject to a salutary periodical flux may be so harrassed by hemorrhoidal tumours as to render their extirpation unavoidable; and should their removal suppress the flux, either the patient must change his habits to those of great temperance, or must lose blood from time to time by an artificial outlet in order to guard against disease ; for pathological congestions will other- wise most assuredly occur. It was proposed by the older writers to leave one pile as a safety-valve ; " Quare quum plures sint haemorrhoides unam relinquere oportet, purgationis gratia," (Pauli -Eginaiae de Re Medica, lib. iii. cap. lix.^ a sug- gestion not to be altogether slighted. The hemor- rhage, however, may proceed within the bowel, and, therefore, not be suppressed by the removal of the outward tumours, in which case there can be no hesitation in deciding upon the operation. In all persons affected with hemorrhoids, except those above mentioned who are sensible of deriving benefit from the flux, there is an anxiety to be free from the hemorrhage and from the tumours ; and if sufficient attention is given to the various causes operating in the production of the flux and tumours, there can be no reason why measures to restrain the one and remove the other should not be put in practice. The influence of habitual constipation in the production, aggravation and continuance of hemorrhoids, should never be over- looked ; the obviating this cause by regulating the bowels by suitable aperients, will frequently cure the patient either of the bleeding or of the blind piles; and the restoration of the natural action of the bowels is certainly essential to prevent a re- Vol. II.—56 LHOIDS. 441 currence of the hemorrhoids, however effectual •» they have been suppressed by medicine or removed by operation. In the treatment of hemorrhoids of all descrip- tions, the regulating the bowels by suitable aperi- ents is a most essential point : all irritating and drastic purgatives, as aloes and colocynth, are in- admissible, our choice must be directed to those which act efficiently but mildly and without irri- tation of the lower bowel. Of these, senna, sul- phur, castor-oil, and the neutral salts are the most eligible, and should be prescribed in doses adapted to the constitution of the patient. The confection of senna combined with sulphur and magnesia, is in general use, and is perhaps the most desirable form of aperient that can be employed. A point of immense consequence to be insisted on is that the aperient should be so administered as to act upon the bowels in the evening. Persons afflicted with hemorrhoids will be dis- tressed through the day if their bowels are acted upon in the morning, because of the erect position which they are obliged to sustain in their ordinary avocations, all which distress is obviated if their bowels are not evacuated till the evening, the hori- zontal position of the night removing all incon- venience, and allowing the day to be passed in comparative comfort. Again, the seat of the closet being inclined instead of horizontal is a means of rendering the exoneration of the bowels less pain- ful ; and where prolapsus of the gut co-exists with piles, the observance of the horizontal position during the action of the bowels, is a great pre- ventive of suffering as it is a great aid in the cure. Injections of warm water and other ingredients daily administered with a view to regulate the bowels and to relieve hemorrhoids are very objec- tionable ; they give a momentary relief, but they aggravate the symptoms they are intended to re- move. An injection of half-a-pint of cold water daily has, however, been found highly serviceable. In order to restrain the hemorrhage where it is profuse or its continuance is injurious, we can confidently recommend turpentine, half-a-drachm of which may be mixed with yolk of egg, or given in a table-spoonful of gruel once or twice a day. The hemorrhage is often effectually arrested by the first dose; and where the body is already ex- sangueous, and the discharges of blood are fre- quent and great, the turpentine is an invaluable remedy. We have been informed by a patient who suf- fered and was seriously debilitated from bleeding piles, that, after having tried almost every other remedy, the copaiba was successfully administered, and at once and permanently cured the hemor- rhage. And although our own experience does not furnish us with facts in favour of the secale cornutum, we have every reason to believe from the testimony of others and from the influence which the secale exerts on hemorrhage from the womb, that it would prove a very efficacious rem- edy in the hemorrhoidal flux. It may be admin- istered in the dose of ten grains twice or thrice a day, in the form of decoction or infusion. [When the hemorrhage becomes dangerou from quantity, the most efficacious of the mineral and vegetable astringents may be prescribed,—care being taken that they are not used of such strength 442 HEMORI as to condense and corrugate the parts so much as to endanger the supervention of inflammation. The iodide of iron and creasote form valuable haemastatic injections. When the discharge is very copious and colliquative, the rectum must be examined carefully, in order, if possible, to ascer- tain the spot whence the hemorrhage proceeds. In such cases, powdered alum, or tincture of creasote, or the tampon, or caustic, or even the actual cau- tery may be demanded. The case then becomes one of surgery.] However objectionable aloetic and other irritat- ing aperients may be in the treatment of hemor- rhoids, stimulants of certain kinds given internally are notoriously beneficial; Ward's paste, which is justly celebrated for the cure of piles, is highly stimulating; as also is a similar preparation, the confectio piperis nigri. Great assistance is afforded in the cure of piles by external applications whenever the condition of the tumours admits of relief without an operation. The application in common use is an ointment composed of the pulvis gallae and adeps: we our- selves employ an ointment of black hellebore in preference, and find it a remarkably efficacious, though a painful remedy. The proportions are pulv. hellebori nigri ^i, adipis %i M., with which the tumours and anus are to be anointed night and morning. The pain caused by the hellebore is intense for half an hour, but it then subsides, and proportionate relief follows. We are in the habit of prescribing it when patients complain of blind or bleeding piles, which are painful, and which do not yield to the senna and sulphur. The use of the bougie in the treatment of he- morrhoids is too much overlooked and neglected. Judiciously employed, we believe it would obviate the necessity of an operation in many instances. Its influence in relaxing the rigid sphincter muscle, facilitating the return of blood from the tumours, as well as the. replacement of the extruded mucous membrane, is greater than might be supposed; besides, it is found to be a»means of inducing a natural action of the bowel and of procuring solid figured dejections; objects very desirable, and which, when attained, facilitate and often effect a perfect cure. Removal of the Hemorrhoidal Tumours.—The actual cautery was a favourite remedy with Hippo- crates : " Urere enim oportet; et nullum haemor- rhoidem sine ustione sinere, sed omnes exurere. (De Haemorrhoidibus.) The moderns have relin- quished the use of the cautery in this and in almost every operation, perhaps indeed too uni- versally, it being a less painful and less barbarous remedy than at first sight is supposed, while un- doubtedly it is a safe and valuable one in many states of disease. In the removal of hemorrhoids, surgeons are in general agreed on the superior advantage of the ligature over excision; excision being frequent- ly followed by dangerous and in some instances fatal hemorrhage. « For excision," says Sir Ast- ley Cooper, "in the early part of my surgical career I was a strong advocate, for I found it a less painful operation than ligature, and it ap- pea'-ed to me not dangerous; but as my experience .ncreased 1 was induced to change my opinion, sad 10 considar excision as not divested of danger." I RHOIDS. (Lectures, by Tyrrell, vol. ii. p. 342.) Besides disastrous hemorrhage, the excision of piles has been succeeded by a fatal inflammation of the peri- toneum. To the authority of Sir Astley Cooper in favour of the ligature, may be added that of Mr. Copeland and of very many others. Excision may be practised in some of the he- morrhoidal tumours, as the mariscae or blind piles, for these are exempt from danger of hemorrhage; but all internal piles and the external tumours of the erectile character should certainly be removed by ligature. The mode of applying the ligature to internal hemorrhoids recommended by Sir Astley Cooper, is " to draw down the pile with forceps or a tena- culum, and tie a piece of waxed silk around it, draw the knot until the patient complains severely, then tie a second, cut off the ligature a little way from the knot, and return the intestine and pile." (The Lectures by Tyrrell, vol. ii. p. 345.) Some precaution and judgment should be exercised in drawing the ligature where the base of the tumour is small or pedunculated, lest it should be cut through and hemorrhage supervene. Mr. Mayo, operating on a child having a small internal pile upon a long narrow pedicle, drew the ligature too tightly, the thread cut through the part, and the pile came away at once. " No disposition to bleed showed itself at the time; but the following night the child lost a profuse quantity of blood." (On Diseases of the Rectum, p. 75.) This con- veys a warning not to make use of too fine a liga- ture. In cases where the pile to be removed is very large, it should be transfixed at its base with a needle armed with a double ligature; the needle being cut off, leaves the two ligatures, each of which should be tied round the corresponding half of the pile. The operation, then, for the removal of hemor rhoidal tumours, whether by excision or by Iiga ture, is simple and easily accomplished; but a point of no mean importance is to determine when the patient, both as regards the state of the tumours and of his constitution, is in a favourable condition to undergo the operation. We have seen a person die of sympathetic adynamic fever in four days after the removal of piles by a most accomplished surgeon ; the nervous system of this patient, prior to the operation, was disturbed, and the shock of the operation itself excited delirium and high febrile movement, which soon terminated in dissolution. In proportion as the mucous mem- brane covering the tumour to be removed retains its natural organic sensibility and structure, so should precaution be observed; and this remark applies, of course, in an especial manner to internal piles. In proportion as the mucous covering has been transformed into skin, which can be the case only with external tumours, so is the operation free from the risk of tetanus, of depression of the vital powers, of inflammation and other consequences which are known to follow injury of this tissue. The treatment of the patient preparatory to an operation should have for its objects the diminish- ing the determination of blood to the rectum, the appeasing any irritable state of the tumours, and the removal of any inflammatory disposition in the constitution. Moreover, the natural tempera- ment should not be altogether overlooked, the HEREDITARY TRANS] hazard of an operation being greater in nervous and irritable persons. To effect these objects, ab- Btinence from all fermented liquors and a moderate diet should be enjoined for some weeks; the bowels should be most carefully regulated, and the determination of blood to the rectum dimin- ished by cupping over the sacrum once or twice to the amount of six or eight ounces ; and the irrita- table condition of the tumours will be much ap- peased by ablutions and fomentations. We would insist strongly on the propriety and necessity of these preparatory measures, believing as we do that they would disarm the operation, simple in itself, of the disastrous consequences which too frequently ensue. There is another consequence of this operation which, although it does not affect the life of the individual, affects his comfort materially ; it is the incomplete healing of the wound. We have known the trifling wound caused by snipping off a small pedunculated tumour in the rectum, or a small pile from the verge of the anus, remain open for many months, and cause such acute suf- fering whenever the bowels acted as to render life miserable. [In the form of hemorrhoids to which the term vascular tumour has been applied, and which Dr. Houston, of Dublin, (Dublin Journ. of Med. Science, March 1823; or Braithwaite's Retrospect of Practical Medicine and Surgery, vol. 7, Jan. to June, 1843,) regards as an affection of the mucous membrane and submucous tissues exclu- sively, having for its base a knuckle or bunch of varicose veins, or else as being a distinct and in- dependent growth, the result of some other irrita- tion in that region, but giving rise ultimately to the formation of a varicose condition of the dis- eased part, that gentleman has recently found great benefit from the application of nitric acid, of the specific gravity of 1-500. He directs the patient to strain, as at the night-chair, so as to bring the tumours full into view ; and whilst they are down, he lets him either lean over the back of a chair, or lie down, in the bent posture, on the side on which the disease exists, with the nates over the edge of the bed. When the patient is thus placed, a piece of wood, cut into the shape of a dressing-case spatula, is dipped in the acid, and then, with as much of the acid adhering to it as it will carry without dripping, it is rubbed on the tumour to the extent desired,—its effects being exhibited by the colour of the part being changed to a grayish white. One or more applications of the acid are needed, according to the depth of the slough required, after which the whole is smeared with olive oil, which destroys the farther escharo- tic action. The prolapsed parts are then pushed back within the sphincter, the patient is put to bed, and an opiate administered; the pain is at first sharp and burning, but it goes off in two or three hours, and does not return in the same form. A general uneasiness about the anus, on motion, to- gether with a slight sense of heat, fulness, and throbbing, are felt for a few days, and there may be some feverishness; but the symptoms following the application are usually so mild as not abso- lutely to require confinement to bed for more than a few hours, although such confinement may often be desirable. On the third or fourth day, Dr. 1ISSION OF DISEASE. 443 Houston prescribes a cathartic draught, which is found to act generally without either pain or pro- lapsus of the rectum. After this the improvement is rapid, and free from any dangerous accompani- ments.] T t-, J John Burne. HEPATITIS. (See Liter, Inflammation of) HEREDITARY TRANSMISSION OF DIS- EASE.—The cases are rare in which a disease under which the patient labours displays itself in the offspring at birth, or so recently after it, that it can be supposed to be directly transmitted. Small- pox and syphilis are the diseases most frequently referred to as furnishing examples of direct trans- mission. Small-pox has been discovered in infants at birth, as was proved by Mr. John Hunter, and instances of marks of this disease on still-born in- fants are not infrequent; but those who attend scrupulously to the niceties of language consider these as examples rather of communication by contagion than of transmission by inheritance. The same distinction, if not in any case over-re- fined, may be drawn in cases of the communica- tion of infantile syphilis; but as a good deal of controversy has arisen on this especial case of he- reditary reception, we shall bestow a few remarks upon it. Until the period when Mr. Hunter endeavoured to give greater precision to our ideas respecting lues, many diseases, particularly scrofula, were ascribed to a syphilitic taint This opinion was certainly too vague, and was adopted on very in- sufficient evidence, or rather on no evidence at all. Since the period mintioned, there has existed an unwillingness to admit the possibility of the com- munication of this disease to the fcetus in utero ; and the nature of any indications of it which ap- pear soon after birth is either questioned, or the disease is supposed to have been communicated by direct contagion from ulcers existing in the genitals of the mother. Many persons have questioned the validity of these objections, and among others the late Mr. Hey of Leeds, whose accuracy will not be doubted. This gentleman relates cases of infantile syphilis which could not have occurred in the manner adverted to, the disease never having existed in the genitals of the mother, but having been communicated to the nipples whilst the breasts were drawn in a previous confinement by a person habitually employed in this way, and who had contracted it by the mouth in performing the same operation on an infected female. (Medico-Chirur- gical Transactions, vol. vii. part ii.) The writer can add his experience to that of Mr. Hey on this point, having seen many cases of what appeared to be infantile syphilis occurring speedily after birth, though at the time of delivery the mother was entirely exempt from ulcers of the pudenda. If the identity of the disease is questioned, it may be urged that the eruption is of the characteristic copper colour, the throat is very generally affected, in some cases ulceration of the genitals exists ; in short that it has all the symptoms of syphilis, and is speedily remediable by mercury. A singular circumstance connected with these cases is, that they occasionally occur in infants whote parents do not labour under manifest symptoms of the disease, either at the time of generation or during 444 pregnancy; but they are never observed in the offspring of those who have not, either one or both, more commonly both, previously laboured under it. These two diseases and tubercles, which have been discovered in the lungs of still-born infants, furnish perhaps the only examples of direct here- ditary transmission. Other diseases, for instance deafness and blindness, are connate, and are fre- quently observed to occur in members of the same family; but these individuals will generally be found to have sprung from parents who did not labour under the same privation. It is true that persons born deaf or blind rarely marry, so that much opportunity is not afforded of observing how far this family peculiarity, however acquired, is transmissible : but the same fact may be adduced as an argument that it is not received by inheri- tance. Of one hundred and forty-eight scholars at one time on the foundation of the Deaf and Dumb Institution in London, one was of a family in which there were five deaf and dumb; one in which there were four; eleven in which there were three ; and nineteen in which there were two. Of the scholars, fifty-seven were girls, and the rest boys; and none of them were the children of deaf and dumb parents. The gentleman who superintended the manufactories, and who consequently had the best opportunity of tracing the subsequent history of his scholars, stated that some of them were married and had children, all of whom were per- fect in the organ of hearing. One instance oc- curred in which both parents had been born deaf, yet the children possessed the faculty of hearing. (A Treatise on the supposed hereditary properties of Diseases, by Joseph Adams, M. D. &c. p. 66.) Cataract is frequently observed as a congenital disease in members of the same family; but in this case it is found not to appear in successive gene- rations as if it were at once connate and hereditary. Hydrocephalus, too, is connate, and members of the same family are born with it; but being in the adult a rapidly fatal disease, it cannot of course be received by inheritance. Though nature is thus sparing of the direct transmission of disease from parents to offspring, she is not equally so of morbid tendencies; and what are commonly called hereditary diseases are so merely by predisposition. That children inherit the outward bodily configuration and manifest pe- culiarities of one or other of their parents, is well known; and that they likewise derive from them that more hidden weakness of certain organs by which these are prone to take on diseased action, is proved by the experience of ages. The here- ditary predisposition to scrofula, consumption, gout, and insanity, is so essentially a part of the medical creed, that a professional man called to a case supposed to belong to any of these disorders im- mediately endeavours to strengthen his diagnosis by information gathered from the family history. But besides these very common examples, various other diseases, such as asthma, angina pectoris, a general hemorrhagic disposition, apoplexy, epilepsy, and various nervous disorders, blindness and deafness, not congenital, and, according to Dr. Adams, ele- phantiasis, are transmitted in predisposition from generation to generation. To this sufficiently "ormidable list, some persons are disposed to add MISSION OF DISEASE. goitre and cretinism, though this can be regarded as a mere speculative opinion ; but an affection closely allied to the latter, idiocy, is unquestionably hereditary. Of this Halter presents us striking examples in two noble families, into which it had been introduced above a century before the time he wrote, and where it was still manifesting itself in some individuals of the fourth and fifth gene- rations. Certain idiosyncrasies too, which, like idiocy, cannot be regarded as diseases, are observ- able in successive generations of the same family; for instance, a peculiar susceptibility to the effect of certain remedies, such as mercury and opium. Of transmissible diseases, some have appeared in several individuals at a certain period of life, and such members of the family as have escaped at this critical period have remained exempt from the affection. All the members of the family of the Le Comptes saw clearly till about the age of sixteen or eighteen; at that age some of them, without any apparent cause, became dim-sighted, and grew gradually more so till total blindness ensued : such has been the case for three genera- tions with a certain number in each race; but such as have escaped at that critical age have re- tained their sight through life. (Baltimore Med. and Phys. Reg. 1809.) In the family of Mr. Bass, at Peterborough, deafness has observed a similar course. (Adams, ubi supra, p. 19.) Hy- drocephalus, the disposition to which exists in certain familes, though it cannot be regarded as an hereditary disease, has often attacked individuals of the same race at the same age; and those who have then escaped have continued free from the complaint. The same observation has been made of elephantiasis, angina pectoris, and other diseases. Like other family peculiarities, hereditary pre- disposition to disease may cease in one generation to appear in a subsequent one; or, though mani- festing itself in each generation, it may pass to the subsequent one through an individual who has escaped it. Of this mode of transmission an ex- traordinary example occurs in the relation of cases of hereditary hemorrhage by Dr. Riecken. (Me- dicinische-Chirurgische Zeitung, Nov. 1830, and Edinburgh Med. and Surg. Journal, No. 108.) These cases occurred in the principality of Birken- field in Oldenburg. The parents had never been subject to hemorrhage, and the father, Ernest P., was living in good health in his eighty-sixth year at the time of the publication of the narrative. The couple had twelve children, five sons and seven daughters, of whom three boys and one girl died of hemorrhage. Their youngest daughter, who never suffered from the disease, married a stout healthy man and had six children, four boys and two girls, of whom three boys died of hemorrhage. There is no trace of any member of the family, either on the male or female side, anterior to the children of Ernest P., being affected with the dis- ease. How the hemorrhagic disposition arose in the second generation of Ernest P.'s family we know not; but in certain cases the first appearance of an hereditary disease in an individual can be traced to an assignable cause. The natives of the warmer regions of the earth become affected in colder lati- tudes with scrofula and consumption ; and the latter disease manifests itself under such circura- HEREDITARY TRANS HEREDITARY TRANS) stances even in inferior animals, as in the monkey tribe. Certain modes of living engender gout; and elephantiasis appears to be produced by a peculiar climatorial influence. It has never been observed that these diseases, when introduced by manifest causes, have not partaken of the property of transmission to suc- ceeding generations. If they do indeed possess this property, (and there seems no reason at pre- sent to doubt it,) nature would appear to have instituted laws for the transmission of disease on two points, the opposite of those established re- garding hereditary varieties in manifest structure. The laws in the latter case are, as illustrated in Dr. Prichard's very elaborate and ingenious work, that connate varieties are apt to appear in the progeny; but that changes produced by external causes terminate with the individual, and have no influence on his descendants. (Researches into the Physical History of Man. 2d edit. vol. ii. p. 536, et seq.) It will have been remarked that congenital blindness and deafness, though family diseases, or apt to prevail in members of the same generation of the same fami.'y, are rarely if ever hereditary. Dr. Adams suggests, that though congenital peculiarities and redundancies are hereditary, connate privations are not so, and that deafness and blindness belong to the latter class; and in this way, provided it is ascertained that connate privations do not descend to offspring, the discrepancy in the law may be reconciled. Dr. Prichard endeavours to adjust the other dif- ference by supposing that the exciting causes of diseases act upon an existing predisposition laid by nature in the original stamina and habit of the body, and that the occurrence of a malady from their application is no proof that it is engendered by them, but that they are the mere occasion on which a congenital weakness previously hidden is rendered manifest This view he illustrates by the example of gout; but were other instances chosen, such as those of scrofula and consumption occurring in the natives of warm when removed to cold climates, it appears questionable whether the doctrine would be found to apply invariably ; whether it would not rather be proved that a morbid peculiarity may be strictly engendered by an external cause, and, being thus engendered, may be transmissible to posterity. Perhaps, too, the rule that acquired peculiarities in general are not hereditary is laid down too absolutely. The writer has in many instances observed in the case of individuals whose complexion and general ap- pearance has been modified by residence in hot climates, that children born to them subsequently to such residence have resembled them rather in their acquired than primary mien. It is natural to inquire whether we derive any useful inference from our knowledge of the here- ditary property of certain diseases ? The most important and practical inference that can be de- duced is, that the descendants of those who labour under any hereditary disease should be shielded as far as possible from its exciting causes; for the predisposition is of various degrees, in some so intense that at a certain period the disease occurs by the spontaneous act of the constitution ; but in others so slight, that the co-operation of nox- ious agents is required to render it manifest. 2s ISSION OF DISEASE. 445 Hence the descendants of the gouty should ob- serve the most rigid temperance ; certain climates should be selected, if possible, till a certain period of life, for those of the consumptive; the offspring of the maniacal should be guarded as much as possible from mental irritation, and from all habits of life calculated to call their inherent tendency into action ; whilst a nutritious and invigorating regimen and warmth should be appropriated to those who, there is reason to think, have derived the scrofulous diathesis from their ancestors. Another practical inference which might be deduced is, the propriety of avoiding matrimonial alliances between families possessing the same hereditary taint; and, generally, of forbidding all such alliances between kindred families, for few are perhaps free from some congenital weakness or susceptibility, and, to use the phrase of the cattle-breeders, all predispositions to disease are rendered more intense in families by breeding in [HERMAPHRODISM. —See Sex, (Doubt- ful)] HERPES, from the Greek Sp-tiv, to creep. Syn. Cytisma herpes ( Young) ; Lepidosis herpes (Good); Neshr (Arabic) ; Zittermahl; die Flechte (German) ; Dartre (French) ; Vesicular tetter. Herpes is an inflammatory disease of the skin, terminating in the discharge of a quantity of thin fluid sufficient to elevate the cuticle into small irregular vesicles, which appear in groups or cir- cumscribed patches of various forms, on an in- flamed base, the skin in the intervals retaining its healthy aspect. The disease, which is non-con- tagious, generally passes through a regular course " of increase, maturation, and decline, and termi- nates in about ten, twelve, or fourteen days." (Bateman's Practical Synopsis; 7th edit. p. 319.) Biett and Rayer assert that it is rarely preceded by fever, and unless when it proves critical of some other disease, that it cannot be referred to any appreciable cause. Our own experience, however, accords with that of Bateman, that it is frequently preceded by considerable constitutional disorder. At first the vesicles are filled with a colourless pellucid fluid, which gradually becomes opaque and of a yellowish hue, but not purulent; after which it forms crusts, which droop off', ex- cept when ulceration occurs. The eruption is attended with tingling; sometimes with lanci- nating pains, as if hot needles were run into the part. In some of the forms of the disease, as the vesicles concrete and the crusts fall off in one part, fresh patches arise in the immediate vicinity, and thus the disease creeps over a considerable portion of the skin. Herpes is distinguished from pompholyx by the vesicles appearing in groups or patches on an in- flamed base; and from erysipelas, by the vesicles not being preceded by redness and tumefaction; by their distinct yet clustered character, and the state of the skin between the clusters. It is scarcely possible to confound it with eczema or impetigo, neither of which assume the purely vesicular form, nor run the same regular progress within a limited period ; and both of which form 446 HERPES. thin plates or semi-pellucid crusts, from under which a thin acrid fluid exudes, instead of the dry harsh scab which characterizes herpes. In Bateman's synopsis we find the various ap- pearances of herpes constituting six distinct spe- cies ; and in this view of the subject he is followed by Rayer. (Traite Theorique et Pratique des Maladies de la Peau, tome i. p. 226.) Biett, on the contrary, considers every form of herpes a variety of one species, phlyctxnodes, differing only in the seat of the eruption, or in the figure of the clusters of vesicles. Thus he regards herpes labialis and herpes prxputialis as varieties of herpes phlyctxnodes, distinguished from it only by having a determined site; while herpes zoster, herpes circinatus, and herpes iris, are regarded equally as varieties, differing merely in the.form of the vesicular patches. In the view which an extensive experience has led us to take of the generic disease, we feel authorized in dividing it into two distinct species, herpes phlyctxnodes and herpes iris, the characteristics of which are well defined : all the other forms, generally regarded as species, will be found to be mere varieties of herpes phlyctxnodes, however they may differ in the figure of the clusters, or in the parts on which they appear: indeed the modifications which both herpes labialis and herpes prxputialis display de- pend on circumstances connected altogether with the parts on which they appear. Taking this view of the general disease, we are of opinion that all its forms are comprehended in the follow- ing arrangement:— Species 1. H. phlyctxnodes. Var. a. H. zoster. — b. H. circinatus. — c. H. labialis. — d. H. praeputialis. ------- 2. H. iris. Species 1. Herpes Phetctjenobes. — This species appears in irregular agglomerated groups of small, transparent, globular vesicles, not larger than a millet-seed. It is usually preceded by one or more slight febrile attacks, accompanied by thirst, heat of stomach, and flatulence, which are not immediately relieved by the appearance of the eruption, but on the contrary are sometimes aggravated by the heat and tingling in the patches of vesicles as they continue successively to appear. The clusters rise in various parts of the body; the cheeks, the forehead, the neck, the trunk, and the extremities being indiscriminately the seat of the eruption. The vesicles differ greatly in size, but the smaller are comparatively the most nu- merous ; and when the disease spreads exten- sively, the clusters are chiefly made up of small vesicles. On the spo\, where each cluster appears, a sen- sation of heat and tingling is felt; at which time, says Biett, minute red points may be detected, very closely grouped, and over these on the fol- lowing day the vesicles display themselves on an inflamed base, resisting compression, and varying m size, from that of a small millet-seed to that of a pea. We have never observed the previous state here described, although its existence is highly probable: in general we have seen the spots, which afterwards became gToups of vesi- ries, appearing as simple red blotches, which feel rough when the finger is passed over them. Rayer states that the number of vesicles in each group varies from twelve to fifteen or more. (Op. cit. p. 227.) Several of these groups rise to- gether, forming clusters, in which the intervening skin retains its natural colour; although within, and for a small space beyond each group, it is red. The fluid in the vesicles is at first generally colour- less, but occasionally of a brownish hue ; it gradu- ally thickens, probably owing to the absorption of the watery part, and in ten or twelve hours ac- quires opacity and looks milky or pus-like; some- times in the larger vesicles it appears bloody. About the fourth day the larger vesicles break and discharge their fluid ; the inflamed surface ac- quires a dull purple hue; and while many of the smaller vesicles flatten and disappear, the larger dry and change into irregular yellow or brownish crusts, which fall off about the eighth or tenth day, although sometimes not until the fifteenth or twentieth. The skin for a considerable time re- tains a reddish hue, indicating the seat of the previous eruption. In this manner the successive clusters run their course. Authors agree that the causes of herpes phlyc- txnodes are very obscure. In almost every in- stance which we have seen, the immediate or ex- citing cause appears to be derangement of the digestive organs accompanied by a highly irritable state of the system. It has appeared also occa- sionally to proceed from catarrhal or other inflam- matory febrile affections, in which the eruption may be regarded as a translation of diseased action from the mucous membrane of the skin. The continental writers have laboured to marl the symptoms which distinguish herpes phlyctx- nodes from pemphigus. In our opinion it is scarcely possible to confound them; in the one the eruption consists of distinct solitary bullae, in the other of clusters of vesicles upon isolated sur- faces. With respect to the treatment of herpes phlyc- txnodes, as this differs little from that which is requisite in the varieties, the notice of it may be deferred until these shall have been described. Var. a. Herpes Zoster (shingles) differs from herpesphlyctxnodes chiefly in the size of the vesi- cles forming the groups, in the seat of the disease, and the manner in which the clusters successively appear and extend over the body. The vesicles, however closely agglomerated, are from the first distinct: they generally enlarge in twenty-four hours to the size of pearls ; are perfectly transpa- rent and filled with a limpid fluid : the inflamed base of the pustules, which are considerably larger and more irregular than those of herpes phlyctse- nodes, extends some distance beyond the vesicles. The most frequent seat of this variety is the trunk of the body, and as the patches of vesicles succes- sively appear, they extend either round the waist in an oblique direction, like a sword belt, or across the shoulders, or from the shoulder they extend to the arms, or from the nates down the thighs, in an oblique direction to the knee. A perpendiculai position of the clusters is very rare : Rayer men- tions having seen it on the thigh: he also de- scribes a case in which it extended from the face into the mouth. « La moitie gauche de la langue est tumifiee, epaisse, rouge, et couverte de plaques HERPES. 447 blanches, moltes, irregulieres. Les unes ont les volumes des vesicules de la peau, les autres se mpprochent des bulles par leur granite dimension. L'epaisseur de ces plaques est egale a celle d'une feuille de papier, &c. La salive, secretee en abondance, est filante ; l'haleine est fetide, mais n'a point l'odeur particuliere qui s'exhale de la bouche chez les personnes qui ont abuse des pre- parations mericurielles." (Traite des Maladies de la Peau, tome i. p. 230.) The most frequent seat of the clusters is the lower part of the thorax ; the right side is more frequently attacked than the left: the eruption never appears on both sides at the same time. Rayer has placed this variety among the bullae, although he regards it as holding an intermediate place between bullae and vesicular inflammation.* The eruption of shingles appears to be an affection solely of the reticular web of the cuticle, and never extends, like erysipelas, to the subcutaneous cellular tissue. The premonitory symptoms in shingles are languor, loss of appetite, febrile rigors, headach, a quickened but small pulse, sometimes sickness, pains darting across the chest and epigastrium, and a sensation of scalding heat or deep-seated pain in the spot where the first patches of erup- tion are likely to appear. In old persons, and in those of delicate habits, this feeling of local heat and pain often continues for a week or more pre- vious to the appearance of the eruption, by the coining out of which it is almost instantly relieved. It is sometimes so severe, that it has been mis- taken for pleurisy, and treated by venesection and other depletory means. At other times the pre- cursory fever is so slight, that the first notice which the patient receives of the presence of the disease is a sensation of heat and tingling on some part of the trunk, where he finds on examination patches of shining, pearly, or silvery vesicles, already formed. Sometimes the patches appear at the opposite extremities of the zone, and join by the successive patches extending towards the centre. The vesicles in the separate clusters attain their greatest size, which seldom exceeds that of a pea, in three or four days; and at this time the inflammation of the base of the patch is at its height, of a vivid redness, becoming fainter as it extends beyond the limits of the cluster of vesicles. Generally before the fourth day, while the new clusters begin to appear, the lymph in the first set of vesicles becomes opaque, acquires a milky or yellowish hue, and approaches in some instances almost to *he state of pus. The inflam- mation of the bas<. now changes to a bluish or livid hue, and the vesicles flatten or subside: some, however, break, and either spontaneously or from friction discharge their fluid, which con- cretes in dark-coloured scabs. These crusts harden and adhere firmly for ten or twelve days, and then fall off, leaving the skin red and tender; and when the vesicles have been rubbed and become ulcerated, cicatrices or pits sometimes remain. These symptoms vary according to circumstances; thus in old people, or those enfeebled by want, the vesicles enlarge almost into bullae, break soon, * Cette maladie forme r^ellement 1'anneau interme- iitue. entre les inflammations bulleuses et les inflamma- tions vcsiculeuses. Tome i. p. 202. and almost always ulcerate; and even, according to Biett, occasionally have been followed by gan- grene. Yet the same physician has never seen the disease attended with much fever or general derangement of the system. The febrile symptoms which we have observed, generally subsided when the eruption was com- plete, but not always ; and we have seen cases in which the uncomfortable feelings seemed rather augmented than diminished during the whole progress of the eruption ; and more especially the deep-seated pain described by Bateman, which, he says, «continues to the latter stages of the disease, and is not easily allayed by anodynes." Shingles is not a contagious disorder, and may occur several times in the same individual. In the greater number of instances it appears towards the termination of some acute disease. It occurs most frequently in persons between twelve and twenty-five years of age, although occasionally the aged suffer severely from it. Those who have a delicate and irritable skin are most liable to its attacks. It prevails more in summer and autumn than in spring and winter. It is scarcely possible to mistake shingles for any other vesicular disease, unless in its early stage, when it resembles in some degree herpes phlyctxnodes; but it may be distinguished by the appearance of the red patches on which new clusters of vesicles are about to appear. The absence of swelling of the skin, and of the disap- pearance of redness on pressure, readily distin- guish it from erysipelas. The general treatment of shingles is the same as that of the other varieties of herpes phlyctx- nodes, and therefore need not be detailed here. With respect to local applications, a gently stimu- lant spirituous lotion to the inflamed clusters, to which a portion of tincture of opium may be added when the pain and irritation are severe, may be employed. By these means the vesicles are prevented from breaking; but when this occurs, nothing is so serviceable as the oxide of zinc ointment. Var. b. Herpes Circinatus* Ringworm.— This variety of herpes phlyctxnodes is of very fre- quent occurrence ; and being unaccompanied with any constitutional affection, is of little moment. The vesicles are small, and form in a circle, inclosing a portion of the skin seemingly unaffect- ed, while a red inflammatory blush extends to some distance around the cuticle of the circle of vesicles. The fluid contained in the vesicles is generally discharged in a few days; after which dark prominent crusts concrete over them ; and at this time the centre, which seemed free from dis- ease, becomes rough and exfoliates. The eruption of the vesicle is preceded by a red spot of various sizes, from half an inch to two inches in diameter: it is generally circular, but occasionally oval. In a very short time after the redness appears, the vesicles, minute and globular, can be traced by the aid of a glass, filled with a transparent fluid, which becomes opaque beforo they burst. Sometimes the fluid is absorbed , in which case the vesicles shrink, and exfoliate al- most imperceptibly. The period in which each circle runs its course is from eight to ten days; but the circles appear in succession, and as earh 448 HERPES. requires a period of eight or ten days to be per- fected and desquamate, the disease is thus pro- tracted to two or three weeks or longer. When the crusts fall off, they leave a redness which remains for some time; but no other inconve- nience attends the eruption. 'In some instances, instead of the regular circle, the whole central spot is covered with minute vesicles, which enlarge sometimes to a considerable size, and are accom- panied with much heat, pain, and irritation. When this form of disease occurs, the clusters rapidly spread and pass over the great part of the arms, the places on which this variety generally shows itself. The feverish state does not at once abate after the eruption appears; it contines to increase for five or six days; and about the ninth day the vesicles break, and the fever suddenly ceases. The vesicular circles most commonly appear on the arms, the shoulders, the chest, the neck, and the face; and in young girls of a delicate frame of body, with a thin and irritable skin, the circles frequently display themselves on the chin. The disease is very frequent among children, and is commonly but erroneously supposed to be contagious. Its exciting causes are obscure ; and it is ushered in merely by a sensation of slight tingling and itching. This variety of herpes, if it appear on the fore- head and at the roots of the hair, may be mistaken for porrigo scutulata,- but the vesicular character of the eruption, the regular course which it runs, and the hair not falling off, very easily enable us to- distinguish it from the contagious ringworm of the scalp, as porrigo scutulata is termed. No internal treatment is required : lotions con- taining either of the mineral alkalies, or sulphate of zinc, or alum, may be applied with advantage. Black writing-ink is a domestic application which has proved as beneficial as any that has been suggested. Var. c. Herpes L,all>ialis. Herpes of the Lips.—This variety differs only in the situation which it occupies. It sometimes extends round the whole mouth, sometimes its seat is the upper, sometimes only the lower lip. When it does not surround the mouth, it is not unusually confined to the angles : wherever it appears it rarely at- tacks the true lips, but frequently impinges upon the line of union between these and me skin, and at the same time patches of the eruption rise on the cheeks and alae of the nose. The vesicles, like those of the other varieties, at first contain a transparent lymph, which in twenty-four hours assumes a purulent aspect, and in three or four days becomes more yellow than that usually found in pustules, few crusts forming. The lips, as the disease advances, swell, become hard, sore, stiff, and painful, with a sensation of great heat in the affected parts. After the crusts fall, the surface lemains red, harsh, and painful; cracking every time the patient laughs or opens the mouth wider than usual. Herpes labialis is more decidedly the sequel of a distinct febrile state of the system than any of the other varieties. This febrile state is often of a catarrhal kind, and not unfrequently results from •udden alternations of heat and cold, particularly sudden exposure to damp cold air, after having been confined in a hot or crowded room. The febrile affection is manifested by rigors, headach, pains in the limbs, anorexia, lassitude, and lan- guor. This variety of herpes is often a critical eruption,appearing on thedecline of acute diseases, which rapidly disappear as soon as the vesicles, or the inflamed bases on which they rise, show themselves. Severe catarrhs often terminate in this manner; and the appearance of this vesicular disease is considered a favourable symptom in affections of the bowels, and in the latter stages of remittent and low malignant fevers. It occa- sionally becomes chronic. In general this variety requires no particular treatment; successive crops of the eruption rarely appearing, so that it runs its course in three or four days, and spontaneously disappears. To allay the heat and itching, diluted alcohol or a solution of zinc proves serviceable. When it be- comes chronic, (and in this state it is almost always symptomatic of some deranged state of the digestive organs,) the hydrargyrum cum creta, combined with James's powder in the proportion of ten grains of the former and four of the latter, may be administered every night at bed-time; and during the day the liquor potassae, in full doses, taken in the decoction of the root of the rumex acutus or obtusifolius, rarely fails in affording re- lief. The decoction should be made at first with not more than an ounce of the sliced root to a quart of water, and reduced by boiling to a third; but if the disease do not soon yield, double this strength will be required. The diet should be light, and consist chiefly of milk and farinaceous matters. The diluted ointment of nitrate of mer- cury is the best topical application in this chronic form of herpes labialis. Var. d. Herpes prccputialis. Herpes of the prepuce. — Although this variety of herpes is not uncommon, yet until Dr. Willan pointed it out as an herpetic eruption, and Bateman accu- rately described it, it was often confounded with syphilis and treated as such. It more nearly re- sembles the last variety, herpes labialis, than any of the others. It appears on both the external and internal surface of the prepuce, and not un- frequently on the glans penis. The eruption of vesicles is preceded by a teasing itching and ting- ling in the prepuce, which appears slightly swol- len and inflamed, and covered with two or three red patches, on which, when closely examined, minute vesicles may be observed rising nearly in a circle. These rapidly increase in size; the lymph loses its transparency and assumes a milky hue; and in another day they are coherent and almost pustular. If the vesicles be not disturbed, they sometimes do not break, but the lymph is absorbed, and the shrunk vesicles desquamate; but at other times they break, and form ulcers covered with a whitish fur, and having an elevated base, not unlike the aspect which chancre assumes; and when they are rubbed, or improperly managed by caustic or acrid applications, a tedious state of ulceration sometimes supervenes. When the vesi- cular patches are situated on the internal surface of the prepuce and on the glans penis, the inflam- mation is more severe than when the exterior of the organ is the seat of the disease. In some in- stances the itching and tingling which accompany HERPES. 449 the eruption are so severe as to prevent sleep. On the exterior, the vesicles terminate about the fifth or sixth day, forming small, hard, acuminated scabs, under which the healing process is carried on; and about the ninth or tenth day the scabs fall and leave the surface slightly indented. In many instances the disease does not run this regu- lar course, but yields to very simple means in forty-eight hours. This variety of herpes is rarely observed in young men ; on the contrary, persons in the de- cline of life are most subject to it, and it not un- frequently accompanies stricture of the urethra, or an irritable state of this canal. It is also some- times produced by an acrid state of the secretion at the root of the glans; and we have seen its approach checked by keeping the part between the glans and the prepuce clean with soap and hot water, and afterwards introducing a small piece of clean dry lint to absorb the acrid fluid. Dr. Bateman properly rejects the idea of Mr. Pearson, that it is caused by mercury. The most severe case of the disease which we have seen occurred in a gentleman who had never taken mer- cury. We cannot, however, agree with the opinion that it is altogether independent of stricture, or at least of irritable urethra : we think that we have also observed it sympathizing with derangements of the chylopoietic viscera. It is more liable to recur than any of the other forms of herpes. As all these different descriptions of herpetic eruptions are mere varieties of one genus, the gene- ral treatmentrequired is nearly the same in all; and this is regulated chiefly by the nature and degree of the fever which precedes and accompanies the eruption. This is seldom so severe as to require the use of the lancet, unless the patient labours under some acute disease of which the herpatic affection may be regarded as symptomatic. More frequently herpes about the mouth and occa- sionally on the ears occurs as a salutary crisis of fevers, and ought not to be interfered with. If the digestive organs be much deranged, and the erup- tion can be / aced to that source, an emetic will prove usefr' n clearing away the superabounding acid which generally prevails, and is undoubtedly one cause of the irritation of the intestinal mem- brane with which the skin sympathizes. No class of medicines so effectually fulfil the indication to be answered in herpes as mild pur- gatives, especially those containing magnesia, as they carry off a large portion of the existing acid, whilst the magnesia allays the morbid irritability of the gastric surface. Neither calomel nor any of the very active cathartics are in general re- quired. Diaphoretics are not indicated; and even when much heat of skin exists, more advantage is derived from the free use of diluents than from antimonials or any medicines of that class. One of the most distressing symptoms in se- vere cases of shingles is the deep-seated pain which often occurs about the thorax, and when 'he pulse is at the same time quick and hard, it 'las, as already stated, led to the supposition that pleurisy is present. The lancet brings no relief in this case; but much comfort is afforded, and sleep secured, by a combination of colchicum, magnesia, and an opiate. The following form is that which we have found most serviceable : Vol. II. — 57 2 s* R Magnesiae J}i- Vini colchici seminum m xlviii. Tincturae opii m xxx. Misturae camphorae f-gxi. M. Sit haustus hori somni sumendus. In the chronic state of herpes labialis the treat- ment we have already described is commonly suc- cessful; but when the disease is obstinate, it is necessary to place the patient under a course of hydrargyrum cum creta, with decoction of sarsa- parilla or of elm bark. Upon the whole, although we cannot refuse to accord with the opinions of most writers on affections of the skin, that herpes requires less of the medici diligentia than almost any other of the numerous list of cutaneous erup- tions, yet the young practitioner will feel frequent disappointments if he expects all cases of herpes to run so favourable a course. It is only when they are critical of some acute disease that he may altogether disregard them : on the contrary he will sometimes find the most acute suffering precede the eruption, and a degree of general derangement of the system often so obscure as to complicate and restrain the efforts of the physician. In such cases the first object is to gain an accurate know- ledge of the state of the stomach and bowels, that of the liver and the chest; and if the nervous sys- tem which is often the case, be involved in the general derangement, to ascertain how far this de- pends on mental causes, as many cases of herpes, in all its varieties, may be clearly traced to grief, anxiety, and other mental sources. Species 2. Herpes iris. — This species dif- fers materially in all its characteristics from the former. It was first announced as a herpetic af- fection by Dr. Willan, and afterwards accurately described by Bateman. Its usual seat is on the back of the hands ; but it has appeared en all parts of the body; most commonly, however, where there is little fleshy substance. It first dis- plays itself in small Ted spots, which, as they change colour, are sui rounded by fresh circles of inflammation, which become vesicular. The patch- es gradually extend until they attain the size of a shilling, the circumference assuming a radiated or star-like appearance. In the description of Bate- man we are told that the first circle, surrounding the central vesicle which is yellowish, " is of a dark or brownish red colour ; the second is nearly of the same colour as the centre ; the third, which is narrower than the rest, is of a dark red colour; the fourth and outer ring, or areola, does not ap- pear until the seventh, eighth, or ninth day, and is of a light red hue, which is gradually lost in the or- dinary colour of the skin." (Bateman's Synop. p. 340.) The variously coloured rings so well defined in this description are, however, rarely observed. This species of herpes most frequently appears in children and fair women; but neither the pre- disposing nor the exciting causes are very obvious. Like some of the varieties of herpes phlyctxnodes, it has occasionally occurred as a critical eruption. In some individuals, according to Bateman, it has recurred several times, « occupying the same parts, and going through its course in the same periods of time." It is scarcely possible to confound herpes i~i» with any other disease. There is one species of roseola which extends in successive cirdes. but i< 450 HERPES —HICCUP. wants the vesicles, which are sufficient to charac- terize the herpetic disease. With regard to the treatment of this species of herpes little requires to be said : no internal me- dicines are required; nor do we know any local applications likely to prove serviceable in shorten- ing the disease. The warm bath employed only for twenty minutes, and exercise taken immedi- ately after it, has appeared to be useful. Rayer recommends decoctions of linseed to be employed as fomentations: we have had no experience of their use, so that we are not authorised to give an opinion on the subject. Moderate bloodletting, gentle aperient medicines, and a combination of the solution of arsenic and of pure potassa, with the decoction of the rumex obtusifolius, have been productive of more benefit than any other means which we have employed. A small piece of soap- plaster laid over the parts affected, has occasion- ally been productive of much benefit. [It may be proper to add, that in regard to the local treatment of the different varieties of herpes, differ- ence of opinion has existed. Whilst some restrict it to washing the parts with tepid milk and water, or with mucilage, others recommend oleaginous and other applications, possessed more or less of astrin- gent or excitant properties. Chlorinated lime; chlo- rine; hydrocyanic acid; creasote, in solution or oint- ment ; soot; cyanuret of mercury; red iodide of mercury; tincture of iodine pencilled over the parts, especially in herpes circinatus; iodide of po- tassium ; cod-liver oil, used externally and inter- nally, have all been employed. Very obstinate casus may require, also, the external use of the 'preparations of iodine, combined with syrup, to modify the condition of the circulating fluid, and thr>ugh it that of the system of nutrition. It has been recommended to open the vesicles early, and apply an emollient catiplasm over them; and it is affirmed, that in herpes zoster, where the pain is very severe, the best effects result from the application of a dozen leeches to the inflamed part If done early, before many vesicles have appeared, the farther progress of the disease, according to Dr. Mackintosh, (Principles of Pathology and Practice of Physic, 2d Amer, edit. ii. 286, Philad. 1837,) may be stopped. Small blisters, applied o the inflamed skin, in the vicinity of the vesi- cles, it is said, check their extension, and produce a shrivelling of those already formed.] A. T. Thomson. HICCUP. — Hiccup or kickup, sometimes vritten hiccough, apparently from a mistaken no- tion of the etymology of the word. It may have been immediately derived to us from the Danish; but its origin in that as well as in some other lan- guages was most probably an attempt to imitate the peculiar sound which it denotes. It corres- ponds with the French hoquet, and the German schlucken,- but the Greek Auvf or \vypis, and the Latin singultus, though applied to this affection, seem also to have designated the somewhat analo- gous one which we call sobbing. The phenomena of hiccup, as observed by a by-stander, may be described to consist in a sud- den, rapid, and brief inspiration (such as may pro- perly be called convulsive), instantly followed by expiration; each of these movements being ac- companied by a noise not heard in common re- spiration, and these noises following each other in quick succession, produce that peculiar dissyllabic sound by which the affection is characterized. The convulsive movements return at short inter- vals, commonly varying from half a minute to a minute, but sometimes of longer duration, and are attended by an uneasy sensation at the praecordia, which, when the hiccup is violent and often re- peated, amounts even to pain. Such are the phenomena presented by this af- fection, apart from any attempt to explain its mi- chanism. What this is has been the subject of much conjecture. The oldest opinion seems to have been that it consisted in a convulsive move- ment of the stomach; an opinion which, in the then very imperfect state of physiology, was not an Unnatural inference from the well-known fict that the exciting cause is commonly some impres- sion directly made upon that organ. Since, how- ever, the functions of the stomach and neighbour- ing parts have been more accurately investigated, most authors have concurred in referring the mo- tions which constitute hiccup chiefly to the mus- cles employed in respiration, and particularly to the diaphragm. That causes acting upon the sto- mach are adequate to excite these muscles to vio- lent and irregular contractions is familiarly known. Fits of coughing (especially in the hooping-cough) and of spasmodic asthma are often produced in this way ; and whatever difference of opinion may still exist as to the particular combination of mus- cular actions by which vomiting is effected, it car scarcely be doubtful, especially since the expel ments of Magendie, that the expulsion of the con- tents of the stomach is ordinarily in great measurj produced by the agency of some of the respiraton muscles. If, however, two phenomena, so widely differing in their results as vomiting and hiccup, are referred chiefly to the same mechanical pow- ers, some other cause of their difference must ex- ist. It is probably owing to an inverted action of the muscular fibres of the stomach and gullet co-operating with the other agents in the former, and not in the latter, that the rejection of the contents of the stomach takes place in the one, but does not happen in the other. The modern opinion, which ascribes hiccup chiefly to the respiratory muscles, rests upon the following among other arguments.—1. The phe- nomena of the affection, as above described, appear to consist chiefly in a convulsive act of respira- tion. 2. The researches of physiologists have clearly shown that the muscles in question, or at least some of them, are capable of movements cor- responding with those of hiccup in rapidity and violence. 3. We are without any satisfactory evidence that such motions are ever performed by the muscular fibres of the stomach. 4. A con- sideration of two popular methods of preventing the recurrence of hiccup, namely, holding in the breath for a considerable time, and making a pro- tracted deglutition by sipping liquids; both of which seem to owe their efficacy to the power of the will over the respiratory muscles. Some writers, while they admit the agency of the diaphragm in producing hiccup, have supposed the oesophagus to co-operate with it. Thus Mahon (Encyclopedie Methodique) explains the HICCUP. 451 affection as consisting in "a convulsive move- ment of the oesophagus, which draws the stomach and diaphragm upwards, whilst at the same time the diaphragm itself experiences a convulsion which draws it downwards."* It is, however, very questionable whether the oesophagus ever executes movements of the kind here supposed. With regard to the peculiar noise which accom- panies hiccup, there can be little doubt that it is caused by a convulsive or spasmodic action of the muscles about the glottis. There are two convulsive affections which, without being absolutely identical with ordinary hiccup, so nearly resemble it, that they are desig- nated by the same word, at least in some lan- guages, and must apparently be referred to nearly the same muscular powers. Thus, what is pro- perly called the hiccup of death, although owing its name to a similarity to the true hiccup, in some respects differs from it. According to Double, it consists of two quick and forcible inspirations pre- ceding a feeble and protracted expiration. The affection which we call sobbing is so analogous to hiccup, that, as has been before observed, the Greeks and Romans designated both by the same words. Indeed, not only do they nearly resemble one another, but sobbing in children often passes into perfect hiccup. Having considered the mechanism of the affec- tion, we may next advert to its causes, and the circumstances under which it occurs. In relation to these points, all the cases which are met with may be referred to two general heads, according as the hiccup is or is not preceded or accompanied by some other recognised morbid affection, of which it may be considered a symptom or conse- quence. It will be convenient to designate these two divisions by the terms symptomatic and idio- pathic, although the strict propriety of such words is questionable. By far the most frequent cause of idiopathic hiccup is some impression directly made upon the stomach; as, for example, by very hot or highly seasoned food, especially in a liquid form; by alcoholic and other stimulant liquors ; and by food swallowed hastily, or in two great quantity, espe- cially after long fasting. As the affection, when produced by causes of this kind, generally occurs almost immediately after the irritating matter is taken into the stomach, it may be reasonably inferred that the impression upon that organ, which calls forth the muscular efforts by which the hiccup is affected, is chiefly made upon its cardiac extremity ; and we shall hereafter see that one mode of explaining the final cause of the affection is by a deduction from this opinion. The occasional causes just enumerated evidently act upon the sensibility of the lining membrane of the stomach ; but there are others which seem to operate by a mechanical impulse communicated to the whole organ. Thus, in children more par- ticularly, any vehement or convulsive movement of the ;espiratory muscles, as violent crying and sobbing, or a fit of coughing, is apt to end in hic- cup. The same occasionally happens with vomit- "L'n motivement convulsif de I'oesophage, qui tire en ""lit I'estomacli et le diaphragme, tandis qu'en meme tenis le diaphragme lui-uieuie eprouve une convulsion lui le tire en bas." ing, as was observed by Hippocrates, who noted it as an unfavourable occurrence. A cause of a very different description from the above is fasting. It implies a prolonged absence of the proper and accustomed stimulus of the sto- mach ; and the influence of this negative impres- sion seems to afford a more probable explanation of the occurrence than the hypothesis which has referred it to the supposed irritation of the gastric juice. Idiopathic hiccup, though generally, is by no means exclusively produced by causes directly influencing the stomach, emotions of the mind, copious evacuations, as bleeding and purging; cold applied to the surface of the body, as the epi- gastrium, feet, &c.; and in fact, where there is a predisposition to it, almost any impression, exter- nal or internal, may call it forth. John Hunter observes that it often accompanies local irritation after operations of various kinds. To inquire whether such causes determine the muscular movements by which hiccup is effected, through the medium of an intervening impression upon the stomach, would be a fruitless indulgence in speculation. The tendency of occasional causes, of whatever kind, to induce this affection, is of course very much dependent upon the degree of predisposition in the individual. This may perhaps be stated in general terms to arise from the same circum- stances as those which appear to favour the occur- rence of other convulsive movements, and espe- cially from that condition of the system which is expressed by the common but indefinite terms of debility and irritability, or mobility. Thus it is familiar that childhood and old age are more liable to the affection than the middle periods of life; and that the female sex, especially in the puerpe- ral state, is more subject to it than the male. There seems, however, to be ground for a more definite view of the matter, and for referring the predispo- sition, at least, in a majority of cases, to a pre- ternatural sensibility of the stomach, or to a ten- dency in that organ to functional derangement. Such a condition or tendency is well known to exist in the earlier and later periods of life, and during gestation ; and it is probably owing to its presence in an unusual degree that, in some indi- viduals, even a moderate quantity of the mildest food will often cause a fit of hiccup. Indeed in such persons it not unfrequently occurs without the intervention of any known cause. The predisposition, in whatever it consists, may be either original or acquired. In the latter case it can sometimes be traced to debilitating circumstances, as excessive evacuations ; but it is much more commonly attributable to causes which directly impair the digestive powers, as the abuse of ardent spirits, excesses in diet, &c.; and such an impaired state of the function of diges- tion is probably one principal cause of the pecu- liar liability of old people. Idiopathic hiccup is commonly too slight and transient an affection to merit the name of disease. Sometimes, however, by its violence, but more often by its duration, it assumes a graver charac ter, and has even appeared to be fatal, as will be more particularly stated when the terminations of the affection come to be considered ?t luw 452 HICCUP. occasionally been observed to recur periodically, at regular intervals, as, for example, annually, and at the same period of the year. Thus Heberden speaks of cases, some of them unaccompanied by any other appreciable morbid affection, in which it lasted for many months, and even for years, being in some constant, in others intermitting. Dr. Good also refers to cases in which it returned at irregu- lar intervals, for periods of from four to twenty- four years ; in others in which it continued inces- sant, or nearly so, for eight and twelve days, and even three months. The second division of cases of hiccup includes those in which it co-exists with, and appears to depend on, some other disease as its cause : being then what we call a symptomatic affection. It has been noted by authors as occurring principally in the following diseases:—fevers, both continued and intermitting, especially the latter; a complica- tion which seems to have been formerly not un- common, as the epithet singultuosa was applied to fevers accompanied by hiccup throughout their course ; inflammation of the stomach, bowels, and liver ; peritonitis, perhaps more particularly when the peritoneal coat of the diaphragm is involved ; strangulated hernia; irritation of the mucous membrane of the alimentary canal, including worms, dentition, and the operation of poisons; disorders of the digestive function generally, espe- cially when attended by the acid eructations which cause heart-burn ; jaundice ; uterine irrita- tion, whether connected with gestation or not Thus severe and protracted hiccup has been some- times observed as one of the attendants of hyste- ria. It is also enumerated by some authors among the symptoms of inflammation of the spinal cord or its membranes; and Heberden states that it sometimes accompanies paralysis, and precedes epileptic fits. Of more uncommon instances, one deserves to be mentioned, because the hiccup is said to have been fatal. It is a case related by Bobe-Moreau, and cited by De Lens, (Art. Hoquet, Diet, des Sc. Med.) in which a severe hiccup accompanied an abscess in the upper part of the pharynx : and the death of the patient is ascribed to the symptomatic rather than to the primary affection. Some accidents affecting the diaphragm and neighbouring parts are also stated to be more or less commonly followed by hiccup: such are penetrating wounds of the abdomen, the passage of any of the abdominal viscera through the dia- phragm into the thorax, fracture of the ribs, and depression of the ensiform cartilage. As the most frequent cause of idiopathic hiccup is some direct irritation of the gastric mucous membrane, so by far the most common morbid affection on which the symptomatic variety de- pends, is functional or organic derangement of the stomach, and of those organs which are associated with it in the digestive process; a derangement of which habitual excess, particularly in the use ■)f ardent spirits, is undoubtedly the principal origin. With regard to the mode in which the other diseases and accidents above enumerated give rise to hiccup, we seem to have no adequate data on which to reason, and mere speculation would be worse than useless. It will, however, be seen that most of them either directly involve the digestive organs, or others which are known to have a close sympathy with them. The occur- rence of hiccup in some of these cases can scarcely be accounted for except by supposing a consider- able predisposition to exist; and the same may be said of its appearance under certain circumstances in which it is not strictly referrable either to the symptomatic or idiopathic form, but immediately follows the disappearance of some previously existing disease. The most common case of this kind is the sudden cessation of ague, of which numerous examples are found in the older writers. Among others, Fred. Hoffmann mentions instances in which the hiccup assumed both a continuous and periodical form. It has also been observed to ensue upon the disappearance of continued fever, gout, rheumatism, and cutaneous diseases, and upon the cessation of a natural or accidental evac- uation, as the menses, hemorrhoids, and diarrhoea. When originating in this way, it is sometimes very tedious and obstinate; as, for example, when connected with amenorrhcea, not ceasing till the menstrual evacuation is re-established. Among the circumstances which determine the occurrence, or rather the continuance of hiccup, we must include the force of habit. The influ- ence of this cause is seen in most if not all of the convulsive movements to which the body is liable; and in none more so than in the one now undei consideration. Of the terminations of this affection little need be said. When unconnected with any other se- vere malady, it almost invariably disappears sooner or later, though its duration is, as we have seen, sometimes very protracted. Cases are, however, reported to have occurred, in which the hiccup it- self was the cause of death. One has been al- ready adverted to, in which it was symptomatic, The same author (Bobe-Moreau) relates another, also complicated with difficult deglutition, and speedily fatal; but no cause of the hiccup was dis- covered by dissection ; nor have we any thing be- yond conjecture to explain the fatal termination. De Lens, apparently following some preceding authority, states that prolonged hiccup produces swelling and redness of the face ; thus implying the possible occurrence of cerebral congestion or of suffocation. It has been before stated that hiccup sometimes follows and takes the place of other convulsive movements, in the production of which the respi ratory muscles are chiefly concerned, In like manner it occasionally terminates in them. The most common instances appears to be that of sneezing : thus Hippocrates says, if hiccup be re- strained, sneezing comes on, and the hiccup ceases; and Lanzoni and Bartholin met with hiccup alter- nating with violent sneezing after tertian ague. Having thus mentioned most of the facts relat- ing to this affection which seem worthy of notice, it will be proper to make a few remarks on what may be called its final cause. In many of the convulsive movements of the body, such as cough- ing, sneezing, and vomiting, this is in general sufficiently obvious, being either the expulsion of offending matter, or the protection of the irritated part by exciting secretion, or the restoration of its interrupted circulation and functions. In others, as epilepsy and often asthma, the existence of such a cause, though not admitting of demonstrs HICCUP. 453 tion, seems deducible from a just analogy ; and the same may be said of hiccup, at least when ex- cited by some direct irritation of the stomach. In such cases, the final cause is evidently not the re- jection of the offending matter; for this would be effected by the act of vomiting, which hiccup has little or no tendency to induce. It is conceivable that one end to which it is directed is the propul- sion of the irritating matter towards the duode- num ; and thus the final cause has been conject- ured to be the removal of such matter from the cardiac extremity to a less sensitive part of the stomach. However this may be, it seems proba- ble that the hiccup subserves another and perhaps more important purpose,—that of determining so much of vital energy to the organs of digestion, especially the stomach, as shall counteract the morbid influence exerted upon them, and induce a vigorous performance of their functions. Such a view well accords with that pleasurable sensa- tion, referred to the epigastric region, which is stated often to follow a fit of hiccup. The same may be said of a fact already mentioned, the occurrence of hiccup as a termination (sometimes apparently a critical one) of continued and inter- mittent fevers, and also of its occasional appear- ance at the commencement of eruptive fevers. To these may be added another, mentioned in the first report made by Drs. Russell and Barry, on the cholera at St. Petersburgh. These gentlemen observe it is " singular enough to say, hiccough coming on in the intermediate moments between the threatening of death and the beginning of re- action, is a favourable sign, and generally an- nounces the return of circulation." Undoubtedly the above view of the final cause is most obviously applicable to those cases in which the hiccup appears as the effect and reme- dy of a temporary irritation ; but it is by no means incongruous with others in which the affection is symptomatic of some grave or fatal lesion. The parts of our frame are so associated by that inexplicable bond which we call sympa- thy, that irritation in one organ commonly gives rise to a morbid condition or movement in others. This association is governed by certain general laws, often very imperfectly known to us, but the great end of which is manifestly the preservation of the whole body ; and the operation of these laws continues, not only when it cannot produce any beneficial effect, but even when it becomes ab- solutely pernicious. Thus the hiccup which ushers in death is a fruitless effort of nature ; while that which results from abdominal wounds, inflamma- tion, or hemiae, may not only be inadequate to accomplish any good purpose, but may even ag- gravate the existing evil by a repeated concussion of parts which stand in need of perfect rest. In relation to diagnosis generally, the pre- sence or absence of hiccup does not appear to be a guide of much value, since it is pathognomonic of no one morbid affection, but appears under widely different circumstances, from an inconside- rable and temporary irritation to the most formi- dable and fatal lesions. In cases which present general indications of severe abdominal disease, but not such as enable us to localize it, hiccup may indeed point to some two or three organs more particularly, but it cannot justify us in allo- cating the disease in any one of them rather than in the others. As a ground of prognosis it may be more valuable; though, for the reasons just stated, scarcely so much so as has been generally repre- sented. Conjoined with other symptoms which portend death, it of course strengthens the evidence of its approach ; and when it occurs in affections which have produced great prostration of the vital powers, it no doubt generally implies an expiring and ineffectual struggle of nature. Thus Hippo- crates speaks of it as an alarming symptom alter hemorrhage, vomiting and purging ; and Sydenham appears to have verified the observation, especially with reference to the aged. It is, however, to be borne in mind that even in such circumstances it sometimes indicates (as already stated of cholera) a successful effort of nature to bring about a salu tary reaction. It is not necessary to say much about the treatment of an affection which is mostly either too inconsiderable and temporary to call for medica] aid, or else a mere symptom of some more formi- dable malady. In the slighter cases of idiopathic hiccup in which its recurrence seems chiefly the effect of habit, impressions of various kinds, made either upon the organs more immediately concerned, or upon the body generally, are adequate to remove it. Such are the emotions of surprise and fear, a forcible suspension of the act of respiration, sneez- ing, vomiting, protracted deglutition by sipping liquids, the administration of what are called anti- spasmocic medicines, including opium; of stimu- lants, as oil of anise, mint, &c; of mineral acids, alkalies, and bitter tonics, especially quinine; cold aspersion of the body, &c. The efficacy of many of these remedies is no doubt partly or principally owing to their removing those disorders of the digestive function of which hiccup is so often a symptom. In cases of a more severe or obstinate nature, cupping at the epigastric region, the application of blisters, sinapisms, and warm plasters to the same parts, and opiate friction, have been resorted to with success. Borrichius relates a case in which the affection returned annually at the same period, and each time yielded to a copious bleeding ; a fact which illustrates the remark of Hippocrates, that hiccup, like spasm, may result from repletion (r'XrjpiDo-is-), as well as evacuation (kivwoi^)- When it depends upon causes of the latter class, opium is undoubtedly, as Sydenham has told us, the best remedy; and the same may be said of those cases of visceral disease or lesion, in which, supposing recovery to be hopeless, we must still attempt to re- move, or at least to mitigate, a distressing symptom. Edward Ash. [HOMCEOPATHY. (See Disease.)] HOOPING - COUGH. — Hooping - cough has been described under a variety of names, many of which, as chin-cough, kink-cough, &c. refer to its prominent symptom. In France it is usually termed coqueluche,- in Germany, keuchhusten, stickhusten, &c; in Scotland, kinkhoust. It was called tussis convulsiva by Willis, tussis ferina by Hoffman. The nosological term at present most generally employed to express the disease is pertussis, first 454 HOOPING-COUGH. given to it by Sydenham, and afterwards adopted l>v Cullen, whoarranges it under the class Neu- rosis, order Spasmi. His definition of the disease is the following: — "Morbus contagiosus, tussis convulsiva, strangulans, cum inspiratione sonora, iterata, saepe vomitus." In the above definition may be found Cullen's opinion as to the contagious nature of the disease. Doubts have, however, been raised upon this point by Laennec, Desruelles, and others, though not supported in such a way as to invalidate the com- mon notions upon the subject. The disease appears to have two distinct stages. The first lasts generally from ten days to a fort- night, or even three weeks, and is not different from an ordinary catarrh ; there is cough and co- ryza often with very little fever. At the end of a period varying from one to two or three weeks, the second stage commences, and is distinguished by the peculiar convulsive cough. In this cough a number of expirations are made with such violence, and repeated in such a quick succession, that the patient seems to be almost in danger of suffocation. The face and neck are swollen and livid, the eyes protruded and full of tears; at length one or two inspirations are made with similar violence, and by them the peculiar whooping sound is produced : a little rest probably follows, and is succeeded by another fit of coughing and another whoop; until, after a succession of these actions, the paroxysm is terminated by vomiting, or a discharge of mucus from the lungs, or perhaps by both. [In very young children, as properly remarked by M. Con- stant (Gazette Medicale, 1836, p. 53,) the ex- pectoration is an important element of diagnosis, as it is the only affection at an early age in which it is met with. (Bell, art. Coqueluche, in Diet. des Etudes Medicates, Paris, 1839.)] Sometimes when the kink is unusually severe, blood is forced from the nose, ears, and even from the eye-lids; and occasionally it ends, without producing any discharge, in the complete exhaustion of the pa- tient. The number of paroxysms occurring during a day varies much in different cases, according to the severity of the disease; and the violence of each is diminished in proportion to the freeness of the expectoration. After the disease has continued at its height for two or three weeks, it begins naturally to decline ; the paroxysms become less frequent and violent, the expectoration increases, the cough soon loses its peculiar characteristics, and finally wears away altogether, leaving the patient in perfect health. It is to be observed, however, that occasionally, several weeks after the cough has entirely subsided, it may return; and for a long time, if the patient accidentally catch cold, the cough will often assume the spasmodic character, and be accompanied with the " whoop." We may safely assert, notwithstanding a con- trary surmise advanced by some of the French writers, that hooping-cough rarely if ever affects the same individual twice; and as its usual period of occurrence is during childhood, we shall of course seldom meet the disease among adults. It is also supposed to be very uncommon in early infancy (for the first two months)__an opinion which is generally true, although we have seen more than one instance of an attack in chil- dren three weeks old. When the disease attacks an adult, it generally wants the peculiar whooping inspiration, and the same thing is usually, but not constantly, observed in the cases of very young children. Nature and seat. — A great variety of opi- nions have been advanced by different authors respecting the nature of hooping-cough; all, how. ever, that have any bearing on practice may be reduced to the three following:— 1. It was considered to be essentially spasmodic, and to arise from irritation affecting either the brain or some parts of the nervous system, a theory advanced and variously modified by Cul- len, Leroy, Lobenstein, Jahn, and Webster. Dr. Webster's opinion is «that the actual seat of hooping-cough is in the head, and that the affection of the respiratory organs is only to be considered as the secondary effect, or as an effort of nature to relieve herself by expanding the lungs to an unusual degree, and thereby allowing a greater quantity of blood to flow into them, which may in some degree diminish the fulness and congestion in the head." (Med. and Phys. Journal, Dec. 1822.) Lobenstein and Breschet favoured the idea of the disease having its origin in the phrenic and pneumogastric nerves. 2. A great number of celebrated names may be enumerated in support of the opinion that it is always an inflammatory affection of the bronchial membrane; amongst these are Guersent, Watt, Marcus, Laennec, Dewees, &c. As the attention of Dr. Watt was particularly directed to hooping-cough attended with bronchial inflammation, in consequence of the death of two of his children from this cause, we shall here give an abstract of his general conclusions on the sub- ject. According to him, " it is in all cases an inflammatory disease of the mucous membrane of the larynx, trachea, bronchi, and air-cells;" and when mild, he says, it may run its course without materially disturbing the other functions of the body, or even the functions of that very mem- brane where it is seated; and that, whenever it proves dangerous or fatal, it does so by the degree of inflammation in the natural seat of the disease, or by that inflammation extending or being trans- lated to other parts. (Treatise of Chincough, Glasg. 1815.) Dr. Dawson differs from the othei writers who support the inflammatory origin of hooping-cough, in confining its first seat to the membrane of the larynx, or, strictly speaking, of the glottis. (Nosological Practice of Physic, Lon- don, 1824.) 3. Some consider the disease to be at first inflammatory, afterwards spasmodic. Desruelles advanced this opinion, and proposes to designate hooping-cough by the term " broncho-cephalite.' According to him the disease consists of an in- flammation of the bronchi complicated with irn- tation of the brain, the bronchitis being always primitive, the cerebral irritation always consecu- tive. So long as the bronchitis is simple, the cough has nothing peculiar ; but as soon as the cerebral irritation occurs, the diaphragm and respi- ratory muscles, and those of the glottis and larynx, are drawn into spasmodic action, and the cough changes its character and becomes convulsive. HOOPING-COUGH. 455 This theory has the great recommendation of being in accordance with the practice which is found most beneficial in the treatment of the dis- ease ; and it has been justly remarked that the effects of remedies, if accurately observed, are like chemical tests, frequently the means of detecting important differences in objects which otherwise could not have been distinguished from each other. Amongst so many different opinions respecting the nature of the disease, and the sources from which danger most frequently arises, the young practitioner is left without any steady guide to regulate either his prognosis or his practice. There can be little doubt that much of this confusion has arisen from the attention of prac- titioners having been directed so particularly to certain complications as to lead them to overlook the simple disease itself. In order to avoid this error, and to give (as it is hoped) a clearer view of the subject, we shall consider hooping-cough under the four following divisions :— 1. Simple hooping-cough. 2. Hooping-cough complicated with bronchitis or peripneumony. 3. Hooping-cough complicated with disordered bowels or infantile remittent fever. 4. Hooping-cough complicated with convul- sions or hydrocephalus. 1. Simple Hooping-cough.—The disease may be called simple, where after it is fully formed, the fits are neither frequent nor violent, the expec- toration is moderate, and the chilu during the in- tervals of the cough is quiet, retains his appetite, sleeps well and without fever or difficulty of breathing. A child will be playing apparently in good health, when suddenly he drops his play- things, rushes out of the room, and is heard to cough, whoop, and discharge the contents of his stomach; immediately after which he returns cal- ling out loudly for something to eat. In a few minutes after the paroxysm, his pulse will be quite tranquil; and if the stethoscope be applied to the chest, the respiration will be heard perfectly natu- ral, without any mixture of wheezing. In such a case the disease must be considered almost, if not altogether, free from danger, and it is scarcely rtasonable to suppose the existence of bronchial inflammation. It may be said that cases of this description are rarely to be met with, and this must be admitted ; but if children always lived in pure air, and were in perfect health when attacked by the disease, and if it occurred during the summer season, such cases would be much more frequent As this combination of favourable circumstances, however, rarely occurs, so we seldom meet the disease in this simple form; but its occurrence even in a single instance decides the question that the disease, in the second stage at least, is not necessarily inflammatory, as we can hardly pre- sume an inflammation to exist without any symp- toms of inflammation being present. 2. Hooping-cough complicated with Bronchitis or Peripneumony. — The symptoms of this com- plication, though sometimes obscure, are generally well marked. According to Cullen, hooping- cough hardly ever proves fatal without considera- ble dyspnoea having existed for some time. It would appear that in older children, when the dis- ease proves fatal, it is most commonly in conse- quence of inflammation supervening in the mu- cous membrane of the lungs. In very many instances where the state of the lungs was ascer- tained by dissection, the most remarkable pheno- menon that presented itself was an inflamed con- dition of the bronchi, which were almost entirely plugged up with frothy mucus and sero-purulent fluid. [Of thirty-eight cases of complications, reported by M. Blache, (Archiv. General, de Medecine, 1833, tome 3,) twelve were of pneumonia ; and of twenty-eight cases, observed by M. Constant, in the Hbpital des Enfans of Paris, ten were of the same affection. (Gazette Medicale, 1836, p. 528.)] A point of the greatest importance in the treat- ment of the disease is to watch the earliest symp- toms of bronchitis, as upon their speedy removal will principally depend the safety of the patient. We are warned of the occurrence of bronchitis when the pulse becomes permanently quick, small, and hard; the fits of coughing become more fre- quent and more distressing, and the breathing is hurried in the intervals of the paroxysms; when any exertion or speaking causes increased difficulty of breathing or panting ; the lips acquire a livid hue, and the extremities show a great tendency to become cold. As the disease advances, the pulse becomes more frequent, the difficulty of breathing increases, the alae nasi are alternately contracted and dilated, and there is great prostration of strength ; in many cases the cough is nearly suspended, and when it does occur, it is not accompanied by the usual whoop, and the difficulty of getting up the mucus is greatly increased. The respirations vary from 60 to 100 in a minute ; and if, after having maintained this fre- quency for twenty-four or thirty-six hours, they come down to 40 or 50, the change generally in- dicates recovery. There is considerable and permanent wheezing for the two first days, not audible unless by aid of the stethoscope or by applying the ear to the chest, after which it increases and becomes quite perceptible by laying one hand on the chest and the other on the back. The wheezing is greatest after sleep, or immediately before a paroxysm of coughing. When the bronchial inflammation cannot be checked, the breathing becomes more hurried and laboured; the wheezing increases; stupor and prostration succeed; the cough is suspended; the pulse becomes nearly imperceptible ; the extremi- ties cold; and in the course of eight or ten days from its commencement death ensues from the accumulation of mucus, which apparently pro- duces suffocation. When the attack terminates favourably, the breathing becomes less hurried, the wheezing di- minishes, the cough after a temporary suspension returns, the fever subsides, the countenance as- sumes a more healthy appearance, and quiet sleep succeeds to distressing restlessness. On examination after death, the most usual morbid appearance is inflammation of the mucous membrane. The lungs collapse imperfectly, and when cut into, an abundance of frothy and nuri 456 HOOPING-COUGH. form mucus exudes from the bronchi and air-cells. Increased solidity of the lung has often been found, and by some it is said to be constantly observable. When it does occur, it would appear that the in- flammation had extended from the mucous mem- brane to the substance of the lung, or attacked both its textures. 3. Hooping-cough complicated with disordered Bowels or Infantile Remittent Fever. — These, though present, are much less formidable combi- nations than the last, but still they render the dis- ease very intractable. If we find a child in this disease breathing heavily, with foul tongue, loss of appetite, tume- fied belly, and the discharges from the bowels un- natural in colour, consistence, or smell, we may rest assured that, unless these symptoms are re- moved by the prompt use of medicine calculated to effect that purpose, much distress will eventu- ally ensue. Infantile remittent fever will next arise, and this may itself prove fatal, or lead to hydrocephalus. A great number of the long-protracted cases of hooping-cough are complicated with remittent fever. After the symptoms just enumerated have continued for a longer or shorter time, the fever makes its appearance, sometimes commencing with a rigor ; more frequently, however, it comes on so gradually, that we do not know precisely when to date its commencement. The paroxysms of coughing become more frequent, and the breath- ing is quickened and oppressed ; but still it may be with a little care distinguished from the attack of bronchial inflammation. The stethoscope af- fords us useful though negative evidence. The usual symptoms of bronchial inflammation are absent. The frequency and force of the respira- tion are found increased, but this increase is not accompanied by any rale indicative of bronchial inflammation ; while the daily remissions, the loaded tongue, the nature of the alvine discharges, the aspect of the child constantly picking his nose and lips, all serve to determine the true character of the disease. 4. Hooping-cough complicated with Convul- sions or Hydrocephalus. — Every one who has seen much of hooping-cough is aware that when it occurs during the period of dentition, it is fre- quently accompanied by convulsions, and that they were among the principal sources of danger at that age. This complication may be accounted for in like manner as the bleeding from the nose, ears, &c.— namely, by the interruption given by the violence of the cough to the free return of blood from the head, and also by the circumstance of children being so liable to convulsions at this period of their lives. It is said that the child may be carried off by one of the convulsions: this, however, very rarely hap- pens. After their frequent return, the case may pass into hydrocephalus. In a child from seven months to two years of age who has the hooping-cough, if we observe that the paroxysms become suddenly increased in violence, that the thumbs are drawn into the palms of the hands, while there is no accession of bronchial inflammation to account for the increase of cough, we may apprehend convulsions. If, however, in addition to these symptoms, the child, after each fit of coughing, instead of whooping be- comes livid, we may calculate to a certainty on convulsions, if suitable means be not employed to ward them off. If the child has ever had the swelling of the top of the fingers and toes, noticed by Dr. Kellie of Leith, or that peculiar spasmodic affection described by Dr. Clarke and more re- cently by Dr. Marsh, under the title of Spasm of the Glottis, (see Glottis, Spasm of,) we can scarcely expect that it will pass through the hoop- ing-cough without an attack of convulsions. It is sometimes important and always desirable to be able to say if the convulsions in these cases depend upon disease in the head ; and rules have been laid down for ascertaining this point, but they are not altogether unobjectionable. It is said, that in hydrocephalus one side of the body is more af- fected than the other, but in convulsions which are independent of organic disease of the brain, that both sides are equally affected. If the con- vulsions are distinctly confined to one side of the body, there is every reason to fear the existence of hydrocephalus; but it certainly does not follow, because the convulsions are general, that the brain is unaffected. In the latter case we must wait until the convulsions- subside before we can dis- cover their cause, and then we must form our opinion from the general state of the child and the history of the case, rather than from any pe- culiarity in the convulsion itself. When hydrocephalus supervenes upon hoop- ing-cough in a child under two years of age, it is almost uniformly preceded or accompanied by convulsions; occasionally, however, it creeps on more insidiously, and we have several times been called upon to see a child in a state of stupor, with one arm sawing the air, whilst the other side was paralysed.- and yet neither the parents nor medical attendant were aware of the nature of the case, but were solely occupied in attending to the cough. Where hydrocephalus prevails in the family, we must, whenever the children are attacked by hooping-cough, be on the look-out for the earliest symptoms. If there are fits of drowsiness and languor, aversion to light or noise, occasional headach, screaming out during sleep, grinding the teeth, frequent sighing; after more or fewer of these symptoms, if the child is attacked with fever, accompanied by greater irritability of stomach than we can account for or than is natural in hooping-cough, and if, to use the words of Dr. Cheyne, " purgatives produce mucous rather than feculent stools," we may safely consider that our most strenuous exertions will be required for the averting of this formidable malady. The approach of hydrocephalus in these cases has been occasionally overlooked in consequence of mistaking the laborious respiration arising from oppressed brain, and considering it to be the ef- fect of bronchial inflammation. The assistance of the stethoscope would be here most valuable, but unfortunately the restlessness and crying of young children renders its application in many cases difficult if not altogether impossible, and we are often obliged to form our opinion from the character of the breathing. In hydrocephalus the breathing is not permanently quick ; it is irregular and sobbing; occasionally the child sighs heavily HOOPING-COUGH. 457 expanding the chest in a manner that never takes place in inflammatory affections of that cavity. [Causes. — Of the causes of hooping-cough, as of every other epidemic disease, we know but lit- tle. It occurs sporadically, and often epidemic- ally, and prevails at all seasons, and in all cli- mates, attacking every age and condition ; but chil- dren under the age of the second dentition are most liable to it. It is generally considered to be contagious; (M.Blache, art. Coqueluche,in Diet. de Med. tom. ix. Paris, 1835,) and the writer is rather disposed to be of this opinion, although he finds it difficult to come to any positive conclu- sion on the subject, (Practice of Medicine, 2d edit. i. 281, Philad. 1844,) and such appears to be the case with others, (Rilliet & Barthez, Traite des Maladies des Enfants, ii. 231, Paris, 1843.] Prognosis. — It is generally supposed that hooping-cough is more dangerous in proportion to the youth of the child, and it is certainly true that the majority of its victims are under two years of age. It is, however, equally true, that a healthy child under six months, who has a good nurse, will get through the disease better than one a few months older, who has been recently weaned, or in whom dentition has commenced. The follow. ing circumstances would lead us to give a favour- able prognosis: dentition being completed, and the head, bowels, and lungs not being subject to determinations or irritations; the season of the year being mild and dry ; the patient not suffering or not having recently suffered from any other of the diseases of childhood, and having a sound, healthy constitution ; finally, the accessions being at long intervals, the remissions complete, and the night, during which the symptoms are usually most se- vere, well spent. In adults, owing to their greater strength of constitution, and lesser liability to the diseases which usually produce a fatal result in hooping-cough, the prognosis will be more favour- able. [When hooping-cough prevails extensively, the mortality is occasionally considerable. In Glas- gow, according to Dr. Watt, (Treatise on the Na- ture Sec. of Chincough, Glasgow, 1813,) the deaths were pretty nearly 5£ per cent of the whole number; and in one year, they amounted to 11 ^ per cent] Genera* Treatment. — The treatment of hooping-cough has always been considered as diffi- cult; indeed, it is generally admitted that, even in the mildest form, it will run its course without much interruption or abbreviation from medicine. From this consideration it would appear that in the simple hooping-cough very little medical in- terference is required ; and judicious practitioners content themselves with giving every night a few grains of rhubarb and ipecacuan proportioned to the age of the patient, with an occasional emetic; confining the child to a milk and vegetable diet, and, during the existence of the catarrhal symp- toms, to an equable temperature. The latter ad- vice leads us to speak of the popular error, too of- ten countenanced by practitioners, of unguardedly exposing the child to cold and open air. We shall shortly find that change of air is often very beneficial in a later stage : but when the first or catarrhal stage exists, we should adopt the prac- tice now recommended. Mr. Pearson's plan of Vol. II. - 58 2 o treatment is applicable to the simple disease. He prescribes in the first instance an antimonial eme- tic, and afterwards, for a child of one or two years old, a draught containing a drop of tincture of opi- um, five drops of ipecacuan wine, and two grains carbonate of soda, to be repeated every fourth hour for several days. When purgatives are required, he gives rhubarb and calomel. As the cough subsides he diminishes the opiate, and substitutes gum myrrh in place of the ipecacuan wine. It is important to hold in mind that to patients labour- ing under hooping-cough, the great danger is from the complication with bronchitis; and in the treat- ment of the simple disease, our attention will be chiefly required to obviate this predisposition. The state of the lungs must be watched, and any approach to inflammatory symptoms met early by bleeding and purgatives, and (if the age of the child does not forbid) by tartar emetic. The lat- ter medicine will also be found of use by facilitat- ing the unloading of the stomach, which usually terminates a fit. Should the weather be cold, it will be well to have the child warmly clad, and to direct the use of flannel next the skin. When, under treatment of this kind, the disease gets through its course without any unpleasant events, and reaches the period of decline, we often find that although the patient be otherwise quite well, the cough will still continue. In such a case, when our interference appears to be necessary rather to break a habit than cure a disease, we shall often find change of air to be the very best remedy. [A change even from a better to a worse air, and even from one room of a house to another, is often serviceable. See Am, Change or.] At this period, also, antispasmodics and sedatives may occasionally be employed with advantage. The oxide of zinc has been recommended by Guersent in doses of a grain every hour for a child of six months old; and in a case of the disease with some threatenings of convulsions, we on one occa- sion found benefit from musk. The latter medi- cine has also been highly recommended to us by a practitioner of considerable experience. [Of late, iodide of silver has been advised in the dose of one-eigth to one one-fourth of a grain, three times a day. (Dr. C. Patterson, Dublin Med. Press, April 19, 1843, or Braithwaite's Re- trospect, viii. 110, Lond. 1843.) It is said to have afforded decided relief. Subcarbonate of iron has also been extolled by recent observers. Dr. Lombard (La Lancette Francaise, 9 Juin, 1838,) gave it in the quantity of 24 and even of 36 grains in the day to young children, either in water or syrup, or mixed with a cough mixture. It was found by Dr. Steymann to be especially advantageous after the first stage of the disease. (Gazette Med. de Paris, Juin 20, 1838.)] A cough mixture, containing a small quantity of tincture of opium or syrup of poppies, will sometimes be of use, as will also the laurel water, or, in adults, prussic acid itself, administered with due caution. In cases where considerable debility exists, or the disease, towards its close, Decomes manifestly intermittent, the tonic plan may be re- quired, and sulphate of quinine will be found to act most beneficially in conjunction with chaiipd of air and diet. 458 HOOPING-COUGH. [Hydrocyanic acid, according to some, (Dr. A. T. Thomson, Elements of Mat. Med. and Therap. i. 435, Lond. 1S32; and Dr. Roe, A Treatise on the Nature and Treatment of Hooping-cough, Lond. 1838,) is the sheet-anchor of the practi- tioner in simple hooping-cough. (New Remedies, 4th edit. p. 25, Philad. 1843.)] Various external applications are popular in the treatment of hooping-cough, as the patent medicine called " Roche's embrocation,-" and the "pom- made d'Autenrieth," composed of a part and a half of tartar emetic with eight parts of lard. [(W. Horn, Encyclop. Worterb. der Medicin. Wis- senschaft. xxvi. 606, Berlin, 1841 ; and Copland, Did. of Practical Medicine, Pt V. p. 250.)] These, however, are means very secondary indeed, in the treatment of any of the complications of the hoop- ing-cough. In the simple disease embrocations which merely redden the surface can do no harm, and are sometimes useful, but applications con- taining tartar emetic or other violently stimulating substances, in addition to being unnecessary, very often produce pustules and ulcerations, which ma- terially augment the sufferings of the patient Treatment of Complications.—The first com- plications of which we have spoken are inflamma- tion of the bronchial mucous membrane, or of the substance of the lungs itself,—bronchitis and peri- pneumonia. And in truth it is to the guarding against these affections that much of our attention and remedial measures must be directed in the treatment of the simple disease. When from the occurrence of the symptoms mentioned above, we have reason to suppose the existence of one or both of these inflammations, we must at once take decided steps to cut short the disease, if possible; or should that not be practicable, to promote the speedy expectoration or absorption of the fluids effused into the bronchi and air-cells. The means of effecting the first of these indications are ob- viously those applicable to similar inflammations under ordinary circumstances, in which we do not propose at present to enter. A few peculiarities, however, are to be attended to in their use, to which we shall briefly advert. In the first place, we must observe that in bronchitis supervening upon hooping-cough, a more free use of the lancet is warranted and required than would be advisable in other cases, and for the reasons already men- tioned that it is proved both by the symptoms and appearances after death, that the substance of the lung is almost always affected. With respect to the employment of purgatives, we would also re- mark, that although it is very necessary to attend to the state of the bowels, still continued purging will be found to produce a degree of flatulence, which by exerting pressure upon the diaphragm will considerably increase the dyspnoea, irritate the mu- cous membrane, and needlessly debilitate. We shall occasionally meet cases attended with so much irritability of the stomach and bowels as to prevent altogether the use of either ipecacuan or antimonial medicines. In these instances, of course, our reliance must be chiefly upon the lan- cet, aided by blistering, the warm bath, and small doses of nitre. In following up the second indi- cation, after effusion into the bronchi and air-cells has taken place to any extent, we must be very cautious about the further abstraction of blood; this stage being attended with considerable debility, and our object being to prevent such exhaustion as would interfere with the process of expectora- tion. It is at this period we may expect most benefit from blistering, both by arresting inflamma- tion and preventing further effusion.* To pro- mote expectoration in older children, we may em- ploy antimonials or a combination of calomel and ipecacuan in repeated doses. In very young in- fants, when the use of antimonials is not advisable, we may give an occasional emetic of ipecacuan wine and syrup of squills, and in place of calomel substitute hydrarg. cum creta in combination with pulv. ipecac. We shall now turn our attention to the next train of morbid actions which we have mentioned as being occasionally attendant upon hooping- cough—a disordered state of the bowels and in- fantile remittent fever; and as these complications are rarely met with except in children, our observa- tions principally apply to them. In speaking of the treatment of the simple form of hooping-cough, we alluded to the frequent occurrence of derange- ment of the bowels. This tendency exists in all acute diseases of children, and in practice it will be found that the most marked improvements in the symptoms of the original disease will attend the correction of the alvine discharges. It is im- portant, therefore, to meet the symptoms indicating derangement of the bowels, by keeping up their regular action. If actual constipation exists, active purgatives will be required. Nothing is better for children than a combination of scammony, rhu- barb, and calomel in divided doses, repeated until a full effect be produced. For patients more ad- vanced, one or two grains of calomel, or three or four of blue pill, followed by any mild purgative mixture, may be administered. When the secre- tions are merely altered in quality without consti- pation, mild laxatives only will be required, as rhubarb and hydrarg. cum creta* in the younger, and blue pill and rhubarb in older patients. The state of disease we are speaking of has been accu- rately described by Dr. Hamilton as the first stage of marasmus, and some very judicious observations are made by him upon its treatment. Unfortunately, however, the fatal facility of the purgative system has led to its adoption in this affection to an ex- tent that has been very injurious, and was certainly never authorized by that able physician. Where the purging has been carried to excess, tenesmus, scanty mucous stools, tenderness of the belly, and a degree of tympanitic fulness succeed, which greatly aggravate the cough. Our object must then be to allay irritation by warm fomentation to the abdomen, soothing enemata, and sometimes, when the tenesmus is very distressing, by the em- ployment of opiate glysters. When the bowels are so irritable as to be acted upon by the force of each cough»witfT fetid depraved stools, a state whicn sometimes occurs in hooping-cough, small doses of hydrarg. cum creta and Dover's powder, followed by castor-oil, usually gives relief. When the symp- toms become decidedly 'hose of remittent fever, it is to them we must direct our treatment rather than to the original disease, as we shall always find the cough to become more distressing in a ratio with *The practitioner must, of course, hold in mind I be danger of incautiously applying blisters to children. HOOPING-COUGH. 459 the increase of the fever, and on the ether hand to be proportionately relieved by its decline. For the management of this form of fever we must refer to the article upon that subject (See Ffveh, Infantile Remittent.) We may remark, however, that the observations offered above upon the administration of purgatives are even more particularly applicable here. A torpor of the in- testines often exists to so remarkable a degree, as to render doses of purgative medicine quite inert that would at other times be amply sufficient. This we have been in the habit of accounting for by the congestion that exists in the head, and ac- cordingly have found in practice that when strong purgatives have had no action by themselves, abundant effect was produced by a much milder one employed after a general bleeding, or, if the strength of the child did not permit this, after the application of leeches to the temples or epigastrium. The last formidable complications of hooping- cough we have noticed are convulsions and hydro- cephalus. When any of the symptoms already mentioned as premonitory of convulsions occur, our treatment must be guided by what we can learn of their causes and tendencies in each par- ticular case. The convulsions of children, whether they are idiopathic or complicated with hooping- cough, generally depend upon the irritation of teething, irritation of the alimentary canal, or dis- ease of the brain itself; and the tendency most to be dreaded is the hydrocephalic. The indications, therefore, are to remove these irritations by attending to the state of the gums, by regulating the action of the bowels, and obviat- ing local determinations, particularly to the head. When, in spite of our best directed efforts, convul- sions, as will be frequently the case, do supervene, they must be treated according to the general principles laid down for their management under ordinary circumstances. When the attacks recur frequently and baffle the usual means of cure, there are two plans by which we shall often be able to prevent their return : one is, a total alter- ation of the child's diet, the other a complete change of air. When the child affected is at the breast, defectiveness of quantity or quality will usually be detected in the nurse's milk. Often it will be found that she has menstruated, or, as sometimes happens, that, without the discharge actually occurring, she has experienced sensations similar to those which attend the accession of the catamenia. In such cases the milk almost uni- formly disagrees, and here it is a good rule, when- ever the convulsive attacks withstand ordinary treatment, to inquire closely into the state of the nurse, and if there be any grounds for suspicion, to have a young and healthy one procured.— Change of air often in the most remarkable man- ner puts a stop to the recurrence of convulsions, and will be found particularly beneficial in those cases of spasm of the glottis to which we have already alluded. Both these means will also act most usefully in protracted attacks of hooping-cough, even where there is no tendency to convulsions. For the treatment of hydrocephalus, when it supervenes upon hooping-cough, we must refer to the article upon that disease. With respect to its prevention, the remarks made upon deranged bowels and convulsions are equally applicable as to those complications. One thing is to be re- membered, that in conjunction with hooping-cough hydrocephalus is more than usually fatal, and re- quires our whole attention to its management. Specific remedies___An immense variety of these has been brought into notice, but if the views above offered be correct, their value will be less estimated. From what we have said of the simple disease, it will be seen that such medicines must be superfluous. Some of them from their violence are dangerous, and in the various complications it must be evident that no specifics are admissible. However, as some are strongly recommended, and may perhaps occasionally be of use in the decline of the disease, when the cough has become habit- ual, we shall give a list of the most remarkable, adding the names of those who brought them into notice. Opium, recommended by Dr. Kirkland. Cicuta, ...... Dr. Butter. Belladonna, ...... Dr. Buckham. Digitalis, ...... Various authors. rTr , •, Dr. A. T. Thomson [Hydrocyanic acid,.... and Dr. Roe.] Bark, ...... Dr. Cullen. Cup Moss, ...... Mr. Hayes. Arsenical solution,..... Mr Simmons. Nitrate of silver,...... Mr Jones. Assafcetida, ...... Dr. Millar. Castor, ...... Dr. Morris. Musk, ..... Mr. Hayes. Artificial Musk, ...... Dr. Hufeland. Camphor, ...... Popularly. Oil of amber, ...... Dr. Underwood, Meadow narcissus,..... Mr. Dufresnay. Alkalies, ...... Dr. Stutz. Antimonials, ...... Dr. Fothergill. Cantharides, ...... Dr. Burton. Acetate of lead, ...... Sauvages. Cochineal, ...... Popularly. C. Johnson. [See Dr. Cowan's abstract of the remedies pre- scribed by different observers in hooping-cough, in Provincial Med. Journ., May 13, 1843, and in Braithwaite's Retrospect, Pt viii. Lond., 1844, also, Rilliet & Barthez, op. cit. ii. 234, and Con- die, Practical Treatise on the Diseases of Chil- dren, p. 525, Philad. 1844.)] HYDATIDS.—This word (derived from iSarls, vesieula, BiJwp, aqua,) has in descriptive pathology been indiscriminately applied to pellucid cysts, containing a transparent fluid, developed either in the cavities, or in various tissues of the human body, as well as in those of the inferior animals. These cysts, on minute examination, having been found to vary considerably in structure, and in some instances to possess the characteristics of animal life, an extended signification has been at tached to the term, and it has been adopted as the name of an order of animals or animalcules, con sisting of several genera and species. It may be presumed that animal bodies have been subject to such vesicular formations from the earliest period, and the records of medicine abun dantly testify that their occurrence has been com 460 iYDATIDS. monly noticed from the time of Hippocrates to the present day, though, until a recent date, their real nature seems to have been little investigated. It must, however, be acknowledged that even up to the present time the term hydatid has a very in- definite meaning. The general appearance of these bodies has probably had an influence in limiting the opinion entertained by medical men of their morbid effects to mechanical action, and experience has hitherto afforded no reason which invalidates it: it is to this cause probably that we must attribute the common not" it of their occurrence by the early writers on medicine, without further description than that which the etymology of the word hyda- tid conveys ; and as we find little in their obser- vations which can serve to elucidate the subject, we shall endeavour to be very brief in showing how far they attracted their notice. Hippocrates has adverted to them in his general application of the word growth, ipvpa, particulariz- ing this kind by the nature of the contents; and he seems to have been well aware of their occur- rence in some of the inferior animals as well as in man. It is remarkable, however, that he has only noticed their presence in the chest, a part of the body in which they are not most frequently ob- served, and where they are in general acknow- ledged to be only simple cysts. Such were probably the nature of those to which he has alluded as the precursors of anasarca and hydrothorax, and as occurring frequently in the ox, the dog, and in swine, quadrupeds in which, he says, growths on the lung, containing water, were most frequently found, as dissection testified: " and such things (he adds) seem to be formed in man more than in cattle, inasmuch as our diet is more conducive to disease." (TJipl t&v ivrds TraOSv, sect. v. p. 544.) Aretaeus alludes to a species of dropsy in the abdomen, occasioned by several small bladders, in proof of which he says, if the abdomen be pierced, a very small quantity of water escapes, these bladders including it; but their origin and nature he confesses were unknown to him, and adds that there were some who affirmed that bub- bles of this kind passed through the intestines into the belly. (Lib. ii. cap. i. 51.) Celsus pro- bably alludes to dropsy from the same cause in the observation, " modo corpus inaequale est tu- moribus alitor aliterque per totum id orientibus;" but makes no direct mention of hydatids, or other reference to them. (Lib. iii. s. xxi.) Galen no- ticed the aptitude of the liver to generate them, and their frequent presence in this organ in ani- mals killed without disease, (Comment in Aph. 55;) they are referred to also by ^Etius, (Serin. x. cap. 20, p. 234;) and in the compilations of Bonetus, Morgagni, and Van Swieten, are in- troduced, from various sources, numerous obser- vations on hydatids in man as well as in the inferior animals. The idea of the animalcular nature of hydatids, which appears to have first excited attention to the difference of bodies re- ferred to under this name, was broached by Hart- mann (Misc. Nat cur. Dec. 2 A. 4to.) in the year 1685, and was the result of a more particu- lar examination than had been before instituted on some taken from the inferior animals; it was par- ticularly suggested by his witnessing their motions when immersed in warm water: his observations, however, seem to have been unknown to our countryman Dr. Tyson, when in the year 1691 he published in the Philosophical Transactions (No 193) a paper entitled " Lumbrieus Hydropi- cus, or an essay to prove that hydatids often met with in morbid animal bodies are a species of worms or imperfect animals." It should be par- ticularly borne in mind that Tyson's observations were made from hydatids found in the dissection of a gazella or antelope, and were consistent with a preconceived suspicion (by what circumstances suggested he does not inform us) that such hyda- tids were of the insect tribe, or at least their embryos or eggs. His reasons for this supposi- tion, he states, were, first, that he observed them to be included in an outward membrane like a matrix, so loosely that, by opening it with his fin- gers or a knife, the inward bladder containing the lymph or serum seemed no where to have any connection or hold to it, but very readily dropped out, still perfectly retaining its contents: — se- condly, from observing with the naked eye, that to the inward bladder there was attached a neck or white body more opaque than the rest of the bladder and protuberant from it, with an orifice observable at the extremity, which seemed to be occasioned by the retraction of some part of it inwards, serving, as he conjectured, the purpose of a mouth to suck the serum from the outward membrane, and so to supply its bladder or sto- mach, organs with which his imagination had also supplied it: thirdly, by finding with the tes- timony of another observer, that this neck, on being approached to the flame of a candle, did really move, at first protruding, and then retract ing itself. On further examination, two small strings or pipes were observed proceeding from the neck, and floating in the liquor, the object of which Dr. Tyson conceived was to convey from the mouth the pabulum of the animal, derived by suction from the outer involving membrane. " Perhaps some," he adds, " may be more inclined to think that the whole is but an egg or embryo of another insect formation, and that this bladder is as it were the amnion, and the outer coat that includes it the chorion ;" but having observed the same peculiarity of construction in every one of several hydatids taken from a rotten sheep, he considered such a supposition void of probability. The hydatids of the human body Tyson seems also to have minutely examined, and the circumstances in which he found them to differ he has noted in the record of a case so illustrative of the subject and fortunate in its termination, that we deem it well worth transcribing in this place :—'• 'Thus in a patient still living, and enjoying her health bet- ter than all her lifetime before, about ten years of age, I caused her right side to be opened a little below her short ribs, whence issued out abundance of limpid water; but what was most surprising, together with it a great many hydatids, that first and last we guessed there might come out about five hundred of these bladders: most were entire and filled with limpid water, of others that were too large for the orifice the films were broken, but in none of them could I observe the neck, though I was inquisitive to find it, which makes me thinl HYDATIDS. 461 them to be different from our present subject; as are also* those I have frequently met with in the ovaria of women who have died hydropical, which I take to be only the eggs contained there, which by an extravagant flux of humours into them are often swelled to that prodigious size that I have taken several gallons of liquor out of them." Dr. Tyson further adverts to hydatids without necks, which he had found in the bladder of a human subject. " I shall only add," he says, " that the lumbrici hydropici I have always found hanging to the membraneous parts rather than included in the body of any of the viscera, as to the omentum peritoneum or the outward membranes that cover the stomach, liver, colon, or other intestines." Hydatids of this kind were afterwards examined by Pallas, (Miscel. Zool. Ed. Hagae Comitum, 1766, p. 157,) and named by him taeniae hydati- genae, from the resemblance of their heads to those of the common worm of that genus. They have been further recognised as animalcules and adopted as such in the classifications of Linnaeus, Fon- tana, Mulier, Bloch, Werner, Cuvier, Lamarck, Zeder, Rudolphi, and Laennec. With regard to hydatids of the human body, Pallas has noted that those which came under his examination were void of neck and head, but that they evinced considerable contractility, as was exemplified by the retraction of their coats on division with a knife, " and with such force as to be turned almost inside outwards." The insect nature of the for- mer having been acknowledged, the property just noticed was considered a title to the credit of dis- tinct animalcular life in the latter, which had hitherto been regarded as morbid products en- dowed with the mere organic life of the parts with which they were found in contact. The new hypothesis seems to have been generally received with little further examination, and to have gained additional confirmation by the observations of Dr. John Hunter, published in the first volume of the Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge for the year 1793. In this paper are detailed the case and dissection of a subject, with the result of an ex- amination of some hydatids, taken from a col- lection found between the neck of the bladder and the rectum, compared with others which presented themselves in the abdomen of a rotten sheep. The just estimation of Dr. Hunter's evidence will induce us to draw largely on the information he has left on record; we cannot, however, but re- mark with regard to hydatids of the human body, that he has expressed himself in language pre- sumptive of data acknowledged by him to rest only on probability, assuming the endowment of the highest functions demonstrative of animal life, for bodies in which the existence of the lowest order was a question yet undetermined. It is worthy of remark that the hydatids of the ga- zella, examined as we have already stated by Tyson, were found in a situation in that animal corresponding to that of the human subject from which Dr. Hunter's specimens were taken. From the period at which animalcular life be- came a distinctive characteristic of certain hydatids in the inferior animals, and that this property, though on more slender evidence, was sssigned to some others which were found in man, the pre- 2o* vailing inclination among medical writers and in oral communication has been to appropriate the term hydatid to those apparently so endowed ; hence they have been denominated true hydatids ; and to other pellucid cysts, formerly so considered, the epithet false has been applied in contradis- tinction. From the preceding remarks it will be obvious that things most diversified in nature have been incongruously confounded under one name, and that to view them in their clear light as well as to see their pathological bearings with any profit or advantage, they must be severally considered with the definite signification proper to the classes in which nature presents them. These appear to us to be three in number, the first of which compre- hends those hydatids which evince in their struc- ture and properties the unquestionable endowment of distinct animalcular life. The second consists of such as have no evidence of animalcular life either in their construction or properties, but which has been assigned to them from certain phenomena, presently to be noticed, connected with their situa- tion and growth. The third division embraces such as are universally admitted to have no place in the animal kingdom, but which may be re- garded as excrescences or morbid formations, aris- ing out of the natural tissues and organs of animal bodies. The animalcular hydatids to which our first di- vision refers have been observed to vary conside- rably in their structure, and have been ranged by naturalists in four distinct genera placed in the order Vermes, and thus designated, H. cysticercus, H. polycephalus, H. ditrachyceros, and H. echi- nococcus : to these a fifth genus has been added, constituted by the hydatids of our second division, the real nature of which, to say the least, is ques- tionable, though they are commonly considered to belong to the insect tribe, and described as such under the name of H. acephalocystis. The occurrence in the human body of the first four genera, and their specific consequences, have been little if at all investigated by the pathologists of our own country, and we find recorded by them only a single case in which any of them are par- ticularly referred to. This case appears in the tenth volume of the London Medical Journal, but contains merely the statement that the patient had voided a number of taeniae hydatigenae, a name synonymous with the cysticercus of the above classification, and with the lumbrieus hydropicus of Dr. Tyson, which, as we have already stated, was described by him and also by Dr. Hunter from specimens taken from the inferior animals. That their occurrence in the human body is not frequent, we infer from their having been rarely noticed by writers on pathology or medicine; but as minuteness of structure may have been more frequently overlooked than we have reason to sup- pose, and as they have been particularly adverted to on high authority, the following description, for which we are indented to the labours of Cloquet, (Diet, des Sciences Med. Art. Hydatid. Paris, 1818,) will, we conceive, be an acceptable guide for future comparison and inquiry. Genus. 1. Hydatis cysticercus, Rudolphi. from k6otis, vesica, and xtp/co?, cauda. Body nearly cylindrical or slightly depressed, wrinkle-, 462 HYDATIDS. terminated by a caudal vesicle; head furnished at its base with four parts or suckers. Sp. 1. Cysticercus, tenuicollis, Rudolphi. Syn. vermis vesicularis, Hart mann,- hydra hy- dratula, Linnxus,- taenia hydatigena, Pallas; vermis vesicularis eremita, Bloch,- hydatigena orbicularis, Goeze ,- hydatigena globosa, Batsch ,- vesicaria orbicularis, Schrank,- taenia globosa, Gmelin,- hydatis globosa, Lamarck, Bosc, Bru- gnieres,- cysticercus lineatus, Laennec; cysti- cercus globosus, Zeder. Character.—Head almost tetragonal, snout cyl- indrical, a little crooked, neck short, body small, caudal bladder nearly spherical. Habitat.—The peritoneum and plura of ruminating animals, and of swine, especially in sheep, oxen, and goats, in the stag, the roebuck, and gazclla. A single in- stance is cited by Goeze of this species of hydatid having been found in the plexus choroides of an apoplectic human subject. Sp. 2. Cysticercus cellulosus, Rudolphi. Syn. finna humana, Werner ,- taenia hydatigena ovilla, Fischer; taenia cellulosa v. finna, Gmelin,- vesi- caria hygroma v. finna, Schrank; hydatis finna, Blumenbuch,- vermis vesicularis, Brera,- cysti- cercus finna, pyriformis, albo punctatus, Zeder,- taenia hydatigena anomala, Steinbach,- cysticer- cus fiunus, Laennec. Character.—Body conoid, from four to ten lines in length, caudal bladder ovoid, formed by a thin membrane, equal, transparent, without fibres ; head tetragonal, furnished with four suckers, and thirty-two hooks divided into two rows. Habitat. —The hog, in which animal it causes the disease commonly known under the name of leprosy. The word finna applied to this species of hyda- tid is of German extraction, from finnen, the name of this disgusting affection. Werner is reported to have found this species of hydatid in man. Sp. 3. — Cysticercus fischerianus, Laennec. Body round, very slender, annulated ; head larger than the neck, furnished with suckers and crooks ; caudal bladder pyriform, three or four lines in length, united to the body by its large extremity, and terminating in a point which adheres to the viscus which this worm inhabits. No cyst. Ha- bitat.—This hydatid has been found twice in the plexus choroides of the human subject, by M. Fischer of Leipsic. It is yet but little known. Sp. 4.—Cysticercus dicystus. This worm has been observed but once, and then by Laennec; he met with it in the ventricles of the brain of a man who died of apoplexy. It presents two pretty large bladders; one of these is caudal, whilst the other encloses the body anteriorly. This, which consequently is only developed in a bag which forms part of the animal itself, is coni- cal, annulated, composed of an outer membrane of a yellowish colour, rather transparent, and of an anterior substance, white and rather bluish, and almost opaque. It is crossed by a large canal, terminating in a cul-de-sac at the side of the head, but which at the other extremity com- municates with the caudal bladder. The number or" hooks of the head is undetermined. It has only four suckers. Sp. 5—Cysticercus albo punctatus. M. Treut- ter is the only person up to the present time who lias observed this hydatid; he found it in the plexus choroides of a woman who died atrtwenty- two years of age. The body of this hydatid is three times longer than the caudal bladder. M. Treutter thought that he distinguished, with the aid of a magnify. ing-glass, one sucker and six hooks. The caudal bladder is spherical and sprinkled irregularly with small white points. Genus 2.—H. polycephalus, Reder,- caenurus, Rudolphi, from ir6~\vs, mullus, and KtQaXfi, caput. The derivation of the name of this genus explains its principal character. There are two species of it, viz. the P. cerebralis, and the P. granulosus,- but as neither of them has been found in the hu- man species, we shall pass on to Genus 3. — H. ditrachyceros, from its, bis, rpaxys, scaber, and «paf, cornu. Only one spe- cies of this vesicular worm has been noticed, viz. the D. rudis. The following is its character: Body oval, a line and a half long, flattened, termi- nated in a point posteriorly, enclosed in a mem- branous bladder, furnished anteriorly with a bifur- cated horn, which appears rough to the naked eye, and, seen through a microscope, to be thick- set with straight and long scales. In which par- ticular organ is the usual nidus of this hydatid is unknown. The specimens which Sultzer had an opportunity of observing had been expelled by stool from a young woman after having taken a purgative. Genus 4.—H. echinococcus, from i^Tvoj, echi- nus, and kSkkos, signifying a body of a round form with asperities, which characterise this genus. Sp. 1.—E. hominis.— Character. Body pyri- form, retracted towards the part where it adheres to the common bladder, one row of hooks on the head. This species of hydatid was first found by M. Meckel, and afterwards by Zeder in the brain of a young woman. They were about twelve in num- ber, and occupied the third and fourth ventricles. Of the nature and effects of these hydatids in the human body little is yet known, their charac- teristic distinctions having been more an object of inquiry amongst naturalists than pathologists. Dr. Hunter has remarked, as Hartmann, Tyson, and Pallas had done before, that hydatids taken from a sheep (the cysticercus tenuicollis) even twelve and fourteen hours after the animal had been killed, moved briskly with a kind of peris- taltic motion over the whole body, on immersion in hot water ; and Sir Everard Home states thai in a similar experiment made by himself, h« witnessed a very evident contraction and relax* tion of their bodies, with a brisk undulation of the circumambient fluid, which continued for half an hour, and exactly resembled the action of muscles in more perfect animals. (Croonian Lect Lond. 1795.) The author last named submitted animal- cules of the same kind to examinations with micro- scopical glasses of a high magnifying power, but was unable to detect any appearance of musculM structure: he remarked, however, that their coats resembled paper made upon a wire frame, and, as this structure does not belong to membranes in general, considered it to be the organization upon which their motions depend. (Ibid.) Observations are wholly wanting as to the par ticular effects on the human body of those hyda- HYDA TIDS. 463 tids already described, and stated to have been oc- casionally found in it; but it is probable that their morbific agency must nearly correspond to that of any foreign body situated in the same cavity or structure. During life, unless when they are evacuated either naturally or artificially, there appear to be no means of ascertaining that their particular presence is the cause of constitutional disorder, even though, as when they occur within the cranium, it may be severe and irremediable. Under such circumstances therapeutic attention can be directed only on general principles to the relief of sympathetic disorder, and to the main- tenance, as far as possible, of the due functions of the abdominal viscera. Some of the inferior animals, particularly sheep, often become the subjects of disease in which the H. cysticerci are generated. A cachectic state of the body, followed by abdominal dropsy, com- monly described under the vague and indefinite term rot, are the conditions with which their occurrence is most usually observed. Co-existent with them are frequently found pervading the liver and in its ducts great numbers of the flat vesicular worm named fluke, fasciola hepatica : the small intestines are at the same time blackish, and easily lacerable, and the glands of the mesen- tery enlarged and indurated; purulent tubercles and cysts containing transparent fluid are also observed to pervade the lungs. Hydatids of the same kind are apt also to be generated within the crania of these animals, giving rise to that singu- lar affection commonly called gid or staggers, from the particular effect produced on their loco- motive powers: their precise situation in this cavity has been frequently discovered by the effects produced on particular nerves and the action of those parts under their influence, indications which have sometimes led to their extraction, to the per- fect relief of the suffering animals. Wet seasons, variable temperatures, and watery pasturage, are the causes to which the occurrence of rot in sheep, and consequently hydatids, are usually attributed ; and Dr. Jenner has proved, by direct , experiments made upon rabbits, that the same animalcules could be produced at will by feeding them solely on green succulent food. (See In- quiry into the Nature of tuberculated Accretions. By John Baron, M.D., 8vo. 1819, p. 96.) The production of hydatids in these instances is pro- bably consequent to the general disease induced in the constitution, and its restoration to a healthy state in sheep is often successfully attempted by removing them to a dry and sheltered pasturage, with the exhibition at the same time of muriate of soda, considered the safest and most effectual of all the remedies of this distemper. To relieve the hydropic state of the body which accompanies it, diuretics are given, and it is from their diuretic action, we presume, that fox-glove and spirits of turpentine have been much extolled. Broom, heather, elecampane, and coltsfoot are also popu- lar: and tonic medicines, such as the preparations of iron, have been highly recommended by those who have had the care of sheep thus diseased. How far medicines of the same kind may be use- ful in the human subject under circumstances apparently similar, we shall not pretend to deter- mine ; but direct experience having failed to sup- ply the requisite information, some hints of prac- tical advantage may be derived from analogy. The second division of our subject refers to one distinct kind of hydatid which very commonly occurs in the human body, and is a simple blad- der, more or less transparent, without any visible fibres or other traces in its organization of animal- cular life. It has been considered, however, from some phenomena presently to be noticed, of the same nature as the hydatids already described, and has been classed with them under a name pro- posed by Laennec, viz. hydatis acephalocystis, de- rived from the Greek words a, priv. KHpaXi), caput, and Kvang, vesica. The shape of the acephalocyst is uniformly round or oval, and in size they vary from the smallest perceptible through every gradation to that of several inches in circumference. Their coats are translucent and composed of a white semi-opaque pulpy matter, separable into two lay- ers of variable thickness, in the same as well as in different specimens. The fluid they contain is clear and transparent like water, but occasionally of a yellowish or amber hue ; but their most dis- tinguishing characteristics are, that they are al- ways found unattached to each other or to the cyst in which they are included, together with a fluid very variable in its nature, sometimes con- sisting of serum, at others of serum mixed with blood, or pus, or both; occasionally of pus only, and now and then of a fluid which has the appear- ance of dirty water with chalk diffused through it; and it is remarkable that, whatever it may be, it does not affect the contents of the acephalocysts, a fact which has been considered indicative of an assimilative function proper to their tunics, ana hence to favour the hypothesis f their animalcular nature. The acephalocyst is sometimes solitary, but in most instances a great number of them are found in the same cyst or sac : the latter is usu- ally of a firm texture, formed of condensed cellular membrane, and consisting of two laminae, the outer of which is strongest and thickest; the inner ten- der, soft, and pulpy ; but together they have a strong contractile power, and have been observed on incision forcibly to protrude their contents. These sacs are sometimes fibrous in their texture, fibro-cartilaginous, cartilaginous, and even occa- sionally osseous. When acephalocysts, imme- diately after removal from the body, have been partially divided with a knife, the cut edges have been ohserved to be immediately incurvated, — a circumstance which has been considered indicative of animal contractility. Adhering to the inner surface of a small proportion of them, several minute vesicles are to be seen, which have the appearance of so many pearls or studs ; but ex- amined with a microscope, they were noticed by Hunter to be merely sessile on the tunic, and to be covered by a thin transparent membrane, so as to be interposed as it were between the two. These he considered to be young hydatids, an opinion which Laennec amongst other patholo- gists also entertains; and that the numerous vesi- cles, observable with a microscope diffused through- out the fluid of acephalocysts, are of the same nature. They have been noticed in every variety of size, from the two-hundredth part of an inch in diameter to that of a red globule of blood, antf 464 HYDATIDS. even less: and the coats of the largest to be a little rough, with numerous filaments or villi, which, examined with a deeper magnifier, pre- sented somewhat of a mulberry appearance. " It is not improbable," says Hunter, " that the small globules attach themselves by the villi to the side of the hydatid and to each other, and thereby give the appearance of being covered by a thin mem- brane. However that may be, the globules being found of various sizes floating in the liquor, seems to prove that they are originally formed there, and not in the coats of the hydatid upon which they are afterwards deposited." To proceed with the graphic description of the same writer : « The hydatids in their growth and decay appear to pass through various stages ; they are first found floating in the fluid that fills the hydatid, and afterwards attached to its coats. The hydatid thus pregnant with young, if the expres- sion may be allowed, adheres to the neighbouring parts, increases in size, and becomes itself a sac, containing numerous small hydatids. These after » certain time decay, and the skins or empty bags are squeezed together into a substance like isin- glass. It is probable they still undergo a further change ; two small bodies of the size of a common bean, of a cheese-like consistence, and covered with a skin, were taken notice of adhering to the bladder near its neck," in a human subject, in whom the bodies now described were found be- tween the rectum and the organ just mentioned. " It may be a question whether those were not the remains of hydatids; but that must be determined by future observations. It is to be observed that the young hydatids are found in two very differ- ent stages ; in the one they are attached to the coats of an hydatid that floats loose in the parent bag or sac ; in the other extremely small globules adhere slightly to the inner surface of a bag or sac, which is firmly attached to the neighbouring parts, and covered with a strong outer coat. It is obvious that the progress of growth is very un- equal in these two, and, indeed, inverted ; for in the first the young ones are as large as the heads of pins, while the parent bag is not larger than a walnut, and floats unattached ; but, on the con- trary, in the second there is a larger sac, with a strong outer coat, and a more tender inner one, adhering strongly to the surrounding parts, while the young ones that are very slightly attached to its sides are not of a larger diameter than a two hundredth part of an inch " Besides the small transparent vesicles already described, Laennec has remarked that on the exterior as well as inte- rior surfaces of aceohalocysts, some small promi- nences (bourgeons) of i-regular form and variable size are presented to notice. These, we presume, correspond to the mulberry appearance adverted to by Hunter, and are considered by the former distinguished pathologist as nascent hydatids, which in a certain state of growth are detached, the interior increasing the number in the fluid of the acephalocyst, and those from the outside form- ing so many distinct and separate hydatids in the surrounding fluid. In some instances hydatids (probably of this kind) are stated to have been included in succession to the number of three or four, with the fluid proper to them interposed be- tween the several layers, the last being distended in the usual manner of single hydatids. An illus. trative specimen in a state of transformation, that appeared in the examination of a human body which came under his notice, has been described by Dr. Baron ; at least such is our inference from the statement that its section exhibited a series of concentric laminae, resembling very much the ap- pearance of a urinary calculus. (See Dr. Baron's Inquiry, p. 95.) Another instance of the same kind is related by Sir Astley Cooper in his valua- ble work on Diseases of the Breast, page 41. Their appearance is thus described : when opened, they were found to be composed of numerous lamellae, like the crystalline humour of the eye, or like the layers in the onion, which could be readily peeled from each other. Acephalocysts have been found in almost every structure and cavity of the human body, but par- ticularly in the liver, the uterus, the kidneys, and cellular tissue; they have been ejected in consi- derable numbers from the stomach by vomiting, and downwards from the intestines; brought up from the lungs by coughing, voided with the urine, and discharged from tumours in various parts of the body. Pallas seems to allude to their occurrence in the lungs and liver of the ox tribe and other ruminating animals, and Laennec has noticed their presence in sheep. From the period of Tyson's publication already alluded to, it has been a question which refers particularly to the hydatids we are now consider- ing, whether they are distinct members of the ani- mal kingdom. We have cited pathologists of the highest repute who have supported this hypothe- sis, and it must be acknowledged that it has ob- tained an extensive credit; it behoves us, however, to examine the ground on which it is founded, believing, as we have reason to do, that the great- est misconception exists as to the nature of these bodies. Our knowledge of the structure of the acephalocyst has afforded no inference favourable to the conclusion, nor can we recognise any evi- dence of it in the retraction which is said to take place in its cut edges when divided, such being a phenomenon of mere organic life, and their incurv- ation an effect which would be mechanically caused in any spherical membranous bag distended with fluid under similar circumstances. Proof has been further sought, but found wanting, on the immer- sion of acephalocysts in hot water, no contraction having been evinced in obedience to this stimulus, which, as already stated, has occurred most obvi- ously when the H. cysticerci have been the sub- jects of the same experiment. Baillie (Morbid Anat. vol. ii. p. 205) and Monro, (Morbid Anat. of the Gullet, p. 256,) as well as Huntur, (Medico- Chir. Trans, vol. i.,) contend that this failure in the anticipated result may depend on the hyda- tids (acephalocysts) having been allowed to re- main a longer time in the dead body before exa- mination, than would be compatible with their vi- tality, supposing them to be possessed of it. "Di. Monro has also stated that purulent matter proves fatal to hydatids, but if applied to acephalocysts, the assertion involves a petitio principii unsup- ported by facts. It must be admitted that there are phenomena in their economy difficult to be accounted for, from which arguments in favour of their animalcular nature have been advanced! HYDATIDS. 465 these we shall mention seriatim. 1. Their origi- nal production ; 2. their growth and increase, without any vascular continuation with surround- ing structures; 3. the unvarying identity of their fluid contents under the diversified media of that by which they are found surrounded; lastly, their inclusion, or, as it has been termed, the genera- tion, of others often found in considerable num- bers and different sizes within them. The earliest hypothesis which appears to us to refer to the origin of the particular kind of hyda- tids now under discussion, ascribes their forma- tion to an altered state of the lymphatics, sug- gested probably by a resemblance of the fluid pro- per to them to the usual contents of these bodies. It was supposed that on any accidental impedi- ment to the transit of the lymph, the valvular structure of these vessels would prevent its reflux, and necessarily occasion a distension of its parie- tes between the obstructed portion and the valve immediately above it; and that, from their natural approximation to each other, a successive disten- sion would ensue, giving rise to an adhesive appo- sition, or to a complete separation of them in the spherical form of the hydatids now called acepha- locysts. This view of their formation seems to have originated with the celebrated anatomist Bartholine, afterwards to have been disseminated by Wharton and Nuck, and to have been gene- rally adopted until their promotion, on the score of analogy, from the rank of inanimate to that of animated bodies. If it be admitted that acephalocysts are animal- cules, their origin must necessarily be involved in all the obscurity which envelopes the subject of generation in the lowest grade of insects, rendered still more incomprehensible by their natural loca- lities in the bodies of men as well as of the infe- rior animals, unless, indeed, it be accounted for by the following general explanation, given us by Andral, which, to say the least, deserves conside- rate attention. •< Besides the clot of extravasated blood which, by the experiments of Hunter and Home, has been proved susceptible of organiza- tion, it not unfrequently happens," says Andral, "that under the influence of causes more or less appreciable, the fibrine, either alone or accompa- nied with a considerable proportion of colouring matter, abandons the blood, and escaping from the vessels by some morbid process, finds its way into the adjacent tissues, as is proved to demonstration in the cavities lined by serous membranes. The fluid containing these is not unfrequently found to exhibit certain fibrinous concretions presenting evident marks of incipient organization ; and of the same nature, though in a more advanced stage, may the transparent cysts now under dis- cussion be considered, the formation taking place just in the same manner as the coagulum of fibrine, at first an amorphous mass, becomes vas- cular and organized." As successive links in the chain are placed " the cysticerci and other hyda- tids in their progressively complicated forms, and next to these the flattened worms, in which the characters of animal life, become much better marked, by the manifestation of unequivocal movements, and by the appearance of different organs as distinct and as well formed as those of the vertebrated animals. In this way we pass by Vol. II. —59 regular and almost insensible gradations from the simple clot of fibrine deposited in the serous cavity, to the strongylus or the ascaris lumbricoides ; just as during the formation of the embryo we observe it gradually advancing from the state in which it exists as a homogeneous mass, devoid of form or texture, until it acquires all the organs of a perfect animal; and as in the series of animated nature we can trace the development and progress of life and organization from the green matter of vegeta- bles up to man. It appears to me perfectly futile to attempt fixing the point in this series of trans- formations where what is called animal life com- mences. If we give the name of animal to the cyst which floats loose in a serous cavity, and is moreover provided with vessels, and if we consent to admit the animal existence of this clot of fibrine, where are we to stop, or where draw the line of demarcation ? If we admit to the rank of animal every aggegrate of matter which, being developed in the interior of a being endowed with life, is capable of supporting itself, and of increas- ing in size without having any connection with that being, the serous cysts already described must then be considered as animals, and accordingly they have been described as such by Laennec. But if we only recognise as animals those bodies which present some trace of sensibility or mobility, these cysts then forfeit all claims to that title : so that, in fact, this much agitated question turns out to be a mere dispute of words, which can never be finally adjusted until the contending parties shall agree in their definition of what it is which essentially constitutes an animal." (Vide Treatise on Pathol. Anat. Trans, vol. i. p. 477.) The growth of the acephalocyst, it is evident, depends on some property inherent in its mem- branous portion, whereby it is fitted to appropriaie to itself from the surrounding medium the parti- cular fluid proper to it The process appears to be analogous to that of secretion in serous mem- branes ; but in the latter it must be remembered that red blood is the immediate pabulum of the secernents, whereas in the present instance it is a fluid which has already been eliminated from it; a circumstance certainly favourable to the hypo- thesis of the parasitic nature of acephalocysts, but which nevertheless may be referred to the mecha- nical process of imbibition, a property belonging, there can be little doubt, to the serous as well as other membranes of animal bodies. The third division of our subject embraces the simple pellucid vesicles commonly called false hydatids, which are found either partially or wholly in contact with the adjacent tissues, and are supplied directly through them with the fluid by which they are sustained and their growths in- creased. As they have been usually adverted to in medical writings, they consist either of perfect bladders, capable of being detached without lesion of structure, or else are, as it were, diverticula from the subjacent membranous expansions, from which they could not be separated at their bases without laceration of a part essential to the inte- grity of one or the other. The manner in which the former are produced is a question yet unde • termined, but the following explanation seems to us to be consistent with che knowledge we pos- sess on the subject ■ tnat under particular condi 466 HYDA T1DS. tions of the system, either general or local, there takes place a deposition of serous fluid, which accumulates in proportion to the distensible nature of the part; but according as the latter is more re- sistant, an increase of pressure ensues, serving to condense the surrounding cellular membrane into a corresponding envelope, and thus to present an entire cyst. Bichat, however, contends that the formation of the cyst lakes place prior to the deposit of the fluid, which, though scanty at first, increases with its growth, and that it is first de- veloped in the filamentous tissue, according to laws analogous to those of the growth of parts in general, to be referred, in his view, to unknown aberrations or unnatural application of those laws. He argues thus against the explanation previously advanced: " 1. That cysts are analogous in all respects to serous membranes, and should there- fore have the same origin ; 2. that the mechanical hvpothesis of their origin, in which all the vessels ought to be obliterated, does not accord with the exhaling and absorbing function of cysts, nor with the mode of inflammation; 3. that if these sacs are formed by the mutual application and agglu- tination or adhesion of cells, (that is, of the fila- ments,) the contiguous tissue ought to be dimin- ished, or to disappear when they are bulky, which is not observed to take place; 4. that if cysts are formed by condensation of the filamentous tissue, and if their fluid is effused by exhalation, this fluid ought to exist in the organ which separates them from the blood." (Elements of Pathol. Anat. by David Craigie, M.D., Svo edit p. 52.) The second kind are produced by the distension of the interstices of the particular structures or of natural cavities with effused deposits of fluid, and vary, therefore, in nature, according to the texture of the parts in which they are situated, the quality of the fluid being determined anterior to its sepa- ration from its depositing vessels. It is, we pre- sume to cysts of this kind, under the denomina- tion of hydatids, that Boerhaave and Halter have ascribed an origin in the follicles of glandular structures; which Monro has treated of as an al- teration of the cellular membrane ; and in like manner Portal and Broussais as the result of a chronic inflammation of the capillaries which con- vey the blood deprived of its colouring matter to the cellular membrane interposed between the serous and other textures. Single cysts of this kind are sometimes met with, but frequently they grow in clusters, and resemble bunches of grapes; sometimes they are thickly set on a broad surface, and present a honey-comb appearance ; occasion- ally they are found adhering to each other at their sides, and when crowded on the superficies of an organ having a cavity, or when produced in the same manner from the internal surface of another cyst, they occasionally lose their organic vitality in consequence of pressure at their pedunculated extremities. When single, they sometimes have broad bases, not unlike the vesications produced ".,y a blister plaster, or boiling water, which might with as much reason be called hydatids as the cysts to which we now refer. The contents of these cysts as to quantity vary in every gradation from a single drop even to several pints of fluid, and are found also to differ in nature, being fre- quently clear, like water, often resembling serum mixed with blood, and occasionally purulent. To cysts of this kind recent pathologists have applied the term hydroma. Examples of it are often found in the female ovary, in which they vary much in size, and also in the colour and consist- ence of their contents from mere serum, with more or less of albumen, to reddish, bloody, or even tar- like fluid. Their appearance, it is probable, may depend on an altered condition of a particular part, as they have been frequently witnessed in bodies free from disease ; but they are often the result of a hydropic state, which is general, when they appear to be produced under circumstances precisely corresponding to those of dropsy. Hence from an early period after the discovery of the lymphatics, their occurrence has been attributed to a morbid condition of this system of vessels; and though the links in the chain of their causes have never been distinctly traced, experience seems to prove that a cachectic state most com- monly predisposes to their formation. Although frequently connected with disease which is irre- mediable, they are in themselves void of all ma- lignant tendency ; and their influential action on the organic function seems to be limited to the degree of pressure occasioned by their presence and the nature of the organ in which they are situated. An hypothesis has been promulgated by Dr, Baron, that the hydatid or vesicular form is the primitive state of the tuberculous and other mor- bid formations, as the strumous, scirrhus, sarcoma- tous, steatomatous, and fungous. The period at which these transformations take place he states is very uncertain ; that they may commence in a few days after the hydatid is brought into exist- ence, or that they may not occur at all, the origi- nal structure continuing for many years. The occasional co-existence of hydatids with such morbid changes is consistent with general observa- tion, and is confirmed by the undeleted testimony of several pathologists cited by Dr. Baron. Proof, however, is wanting that the one state is com- monly consequent to the other; and supposing the elementary particles of such morbid growths to be deposited in a state of fluidity, we see no reason why they should be regarded as hydatids. On the same principles, we conceive, might every globule of blood or every collection of fluid be similarly classed, and thus the real nature of the product be lost sight of in the extension of a term already too vague and indefinite. Moreover it seems very improbable that morbid products aris- ing under a diversity of constitutional circum- stances, and manifested by appearances as well as producing effects as different, should at any inter- mediate stage evince a perfect identity of charac- ter. To Dr. Baron's work, however, we refer for the full elucidation of his views, which could not be transferred to this place without obliging us un- reasonably to exceed the necessary limits of this article; and we do so with the less reluctance, be- cause, whatever may be the reader's conclusion, he cannot fail to benefit by the consideration of the facts and reasoning with which Dr. Baron has supported his positions. It has been already stated that hydatids have been found in most of the structures of the human HYDA' body :* we si all now proceed to the practical con- sideration of them according to their several lo- calities. Hydatids m the brain.—The presence of ani- malcular hydatids in the human brain has been rarely noticed, but the occurrence of cysts under this denomination has been very frequently re- ferred to by medical writers. Their real nature it is impossible to determine during life, but their effects are found to be similar to those from any other foreign bodies in the same structures, pass- ing on from those of nervous irritations to the par- tial impediment and abolition of the functions of the parts under their influence, and ultimately in most instances, it is to be feared, to death. An instructive illustration has been given to us by Dr. Abercrombie, in the following case submit- ted to him by Mr. Headington :—A boy, aged eleven, was suddenly attacked with dimness of sight, amounting to blindness. It went oft' in a few minutes ; but from that time his sight was gradually impaired, and after a year nearly lost. He then had an affection resembling chorea, and after a short time suffered an attack in which he lay speechless for three days. This was followed by hemiplegia of the right side. He complained much of his head, which appeared to his friends to enlarge, and he sometimes lost his speech for two cr three days. His intellect was not affected, but at times extremely acute. He died, after coma of five weeks' continuance, about a year after the attack of hemiplegia, and two years from the commencement of the disease. Dissection.—On the surface of the left hemi- sphere, the membranes adhered firmly to the sur- face, of the brain for some extent on the middle lobe. On raising them at this place fluid escaped in great quantity, and on further examination it was found to have been discharged from the cyst of an immense hydatid, which was seated in the left lateral ventricle, and had gradually advanced to the circumference of the brain. It contained about sixteen ounces of limpid fluid, and besides these there were several ounces in the proper cavity of the ventricle. (Researches on the Pa- thology of the Brain, by John Abercrombie, M.D. Part iv. Case 29.) * Experiments on the nature of the fluid constituent of hydatids have not been sufficiently numerous and di- versified to determine how far our knowledge of the subject may be advanced by the aid of chemistry. Dr. Marcet, in "an account of various dropsical fluids," (Med. Chir. Trans, vol. ii. p. 373,) has thus described his analysis. " A quantity of this fluid was procured from a hydatid attached to the kidney of a woman, whose horiy was opened by Mr. Cooper and myself at Guy's Hospital. It was clear and transparent, though of a yel- lowish colour. No coagulum or turhidness appeared on adding dilute sulphuric or muriatic acid, but concentrated muriatic acid produced a milkiness. Infusion of galls and oxymuriate of mercury occasioned precipitates. Heat did not produce any coagulation except after \T ry considera- ble concentration. The specific gravity of this fluid was not ascertained, but a thousand grains of it being evapo- rated to dryness, at a temperature not exceeding 180°, the residue weighed thirty-six grains, and yielded by incine- ration a saline mass weighing 8.7 grains. This saline mass contained the usual ingredients ; namely, muriate of soda crystallized chiefly in octohedrons, phosphate of iron and of lime, and a small portion of sulphuric acid. Upon thp whole, this fluid, which was examined long since, and with much less minuteness than the other, ap- pp.ars to resemble much in its chemical composition that ui" hydrocephalus and spina bifida, only containing a larzer proportion of animal matter, which appeared to be chiefly of the muco-cxtractive kind, since it did not co- ■SUlate by heat or gelatinize by cold or concentration," i TIDS. 467 In an examination of the brain of a man who died on the fifteenth day of synochus, we disco- vered not long since a pellucid cyst, full of trans- parent, yellowish, limpid fluid, lying close to the base of the brain at the side of the tuber annulare. Tts size was that of a plover's egg, but during life there were no particular symptoms to indicate the presence of such a body. It would be to little purpose to go on enumerating similar instances of morbid formation. We refer, therefore, to the several works on general pathology, especially to those of Bonetus and Morgagni, and to the very valuable work entitled Elements of Pathology, re- cently published by Dr. Craigie, in which (page 477) references are given to several remarkable instances of similar encysted bodies found within the cavity of the cranium, and imbedded in the substance or cavities of the brain. It is obvious that medical treatment under such circumstances must be limited to the relief of the organ oppressed, and to the suitable regulation of the functions of those which, primarily influenced by external agents, exert a corresponding action upon it. The means of effecting these objects could not be defined for general application, even if the cause of the existent disease were ascer- tained ; but latent as it must be, alleviation of the consequent symptoms can be rationally attempted only by a reference to the general principles of therapeutics. Hydatids in the thorax.—The lungs, though not often the nidus of hydatids, have occasionally been found to contain them ; and instances are related of acephalocysts having been ejected from this organ by coughing. Their presence usually excites considerable irritation, and gives rise to cough, pain, dyspnoea, and quickness of pulse; but we are unacquainted with any particular symptoms by which their existence here could be positively ascertained. A case in which their ex- pulsion from the lungs was followed by complete recovery has been recorded by Dr. Doubleday, in the fifth volume of the Medical Observations and Enquiries, by a Society of Physicians in London, 1779 ; and another by Dr. Monro, unattended with any pulmonary symptoms except that of pain on the right side of the chest behind the mamma, and which was not relieved by bleeding or the ap- plication of a blister. In this particular instance there was no sense of oppression nor difficulty of breathing, nor any alteration in the state of the pulse, and the patient could steep on either side or on his back. By coughing he was relieved of portions of hydatids, and also of some entire, vary- ing from the size of a hazel to that of a walnut, and in quantities amounting at times to as much as would fill a pint measure. The larger hydatids contained a fluid which was clear and viscid; in the smaller it was of a yellow hue and reported to have been bitter to the taste. A few days before their ejection the patient suffered very acute past! in the breast, which he compared to that of thti penetration of a pointed instrument. The pre- vious fits of coughing were violent and attended with paroxysms threatening suffocation which continued for two or three minutes. Thesm effects were first manifested when the patient wa>> fourteen years of age, and occurred at intervals foi seventeen years, when at length he was attended 468 HYDA TIDS. by the present Dr. Monro and his father. Hav- ing been recommended to smoke tobacco and to inhale the fumes as deep as he could into the chest, the symptoms appeared to be arrested, and for the following eight years he was known to have remained free from any return of the disor- der. (See Morbid Anatomy of the Human Gullet, by Alexander Monro, M.D. 8vo. edit. 1811, p. 279.) Instances are on record of hydatids having oc- casionally passed through morbid perforations in the diaphragm into the thorax. In the first volume of the London Medical Communications, we read an account of a post-mortem examination in which " a common cyst found to contain a quantity of them, and attached to the liver, omentum, mesen- tery, and peritoneum, passed through a perfora- tion in the diaphragm; from thence expanding again, it adh< red to the plura and mediastinum, filled almost the whole of the left cavity of the thorax, and communicated in several places with the lungs, which were ulcerated. Had the patient lived long enough, it is possible that hydatids would have been coughed up, as one of the open- ings from the cyst into the lungs was large enough to admit a goose-quill." In the substance of the liver, which weighed sixteen pounds and a half, another large cyst was found. A similar case is related in the Edinburgh Medical and Surgical Journal, vol. ii. p. 170, in which, " an immense cyst occupying the whole cavity of the abdomen" was found after death connected to the mesentery. It was distended to the utmost, and contained thirty-five pints of hydatids, many of them ex- ceeding the largest oranges in size. In both these cases the disease was supposed to be common as- cites during life, and in both a fruitless attempt was made to draw off the fluid by tapping. An instance somewhat analogous has been recorded by Dr. Collet, (Transactions of the College of Phy- sicians, Lond. vol. ii.,) in which hydatids origi- nally lodged within the liver, were discharged by coughing: the patient, a female, aged thirty-seven, "first complained of lowness of spirits and of an oppression on her breath," followed by some oede- ma of the ancles, which, however, soon disap- peared. A violent cough, attended with great dyspnoea, and the occasional expectoration of tough viscid phlegm, soon followed, and the subsequent ejection by coughing of hydatids at different peri- ods in the course of six months, amounting to the number of one hundred and thirty-five: these va- ried from the size of a pea to that of a pullet's egg, and were in their ruptured state, no water either accompanying or following them : there had been a swelling at the umbilicus evidently containing fluid, and distension of the whole abdomen, which in parts communicated to the hand of the exa- miner the sensation of lumps; these, however, had disappeared, and the case promised a favourable issue. Another instance of the same kind is re- lated in the London Medical Journal, vol. vi. p. 593, 1785. A lady, during an illness which con- tinued more or less for three years, « coughed up several hundred of hydatids, most of which were burst, and of these many must have been as large as a pullet's egg: those which were not burst were only about the size of a nutmeg." This pa- tient was considered dropsical, and to have disease «f the liver; she, however, recovered her health. It is probable that the bronchi are very rarely if ever the original seat of hydatids, but that they are passed into their ramifications from the pa- renchyma of the lungs and the pleura, or from other structures, as in the cases above related; but, under whatever circumstances, we may generally anticipate recovery if their expulsion through this channel has commenced, provided that other dis- eases be not co-existent, when of course the pro- babilities of the issue must depend on the nature and circumstances of the latter, and the remedial means be applied accordingly. " Although," says Andral, " instances are not uncommon of animalculae having been found in the vascular system of quadrupeds, I know only of a single occurrence of this nature in the human body." The subject was examined by himself at La Charite. " I found both lungs," he writes, " filled with hydatids, and thought that these en- tozoaires were lodged in the parenchyma of the lungs; but a more close examination disclosed the existence of hydatids in the pulmonary veins of both lungs. They had all the characters of ace- phalocysts. Around them the pulmonary tissue was in some cases sound and crepitating; in others obstructed and hepatized. An hydatiferous cyst, with cartilaginous parietes as large as an orange, existed in the middle of the liver, and con- tained from eight to ten hydatids. The indivi- dual who was the subject of this case was fifty-five years of age, for a year previously had been ill-fed, and often experienced considerable distress. The symptoms of an aneurism of the aorta under which he laboured were the object of therapeutic atten- tion during life; and from the post-mortem exa- mination, the latter appeared to be the effect of impeded circulation, consequent to the presence of hydatids in the pulmonary veins." (Andral's Pathol. Anat. Trans, vol. ii. p. 424; and Med. Repos. vol. xix. p. 347.) Hydatids in the Abdomen. — Hydatids have been frequently found in the several viscera of the abdomen, occasionally attached to the peritoneum, and sometimes loose, either between it and the abdominal muscles, or amongst the viscera them- selves. Except the kidneys, the liver is more frequently affected with hydatids than any other organ, and in sheep as well as in some other quadrupeds, un- der the particular circumstances of wet seasons and marshy pasturage, this appearance of disease is apt to prevail very extensively. In the human species corresponding causes have not been ob- served to influence their formation, although there is reason to believe that a cachectic state of body has been conducive to it. Symptoms of a disor- dered liver to a greater or less extent are usually present; occasionally the same effect is produced as when a calculus is passing through the gall- ducts, viz. violent spasmodic pain at the epigas- trium, frequent vomiting, with an unaccelerated pulse, and sometimes jaundice alternating with intervals of good health. When hydatids are confined within the sub- stance of the liver, there appear to be no means of ascertaining their existence ; but when formed on its outer surface near its lower edge, it is pro- bable that they may be detected by examination. When, however, the parietes of the abdomen are HYDATIDS. 469 thick, and hydatids or their cysts not distinct, but lying in contact with each other and making an irregular tumour, it will hardly be possible to form an accurate opinion of their nature. If the tu- mour be gradually formed, and the general health little affected, it is probable that hydatids may be the cause. Close attention to the sensation which the tumour yields on pressure or on striking it gen- tly with the hand, may also assist in enabling the examiner to form a probable idea as to its nature. [f it should consist of hydatids, it will generally feel to a certain degree soft; and if the hydatids should be very large, there may be an obscure sense of fluctuation on striking the tumour with one hand while the other is applied to the oppo- site side of it. If, moreover, it should occupy a great part of the cavity of the abdomen, and can be clearly traced from the liver as the source of its growth, there can be little doubt of hydatids being the cause. (See Works of Matthew Bail- lie, M.D. vol. ii. p. 212.) Some instances have already been referred to in which hydatids had passed through a peiforation in the diaphragm from the abdomen, and were ejected by coughing from the lungs : they have occasionally also been evacuated from abscesses, and sometimes from the abdomen with the fluid discharged by tapping; in the former most fre- quently to the complete relief of the patient. The circumstances under which they thus occur being variable, preclude any specific character being given of them, and therefore must be illustrated by example. A female was treated with mercury under the supposition that hepatitis and conse- quent suppuration in the liver had taken place. In about ten days the mercury began to affect her mouth, and at the same time she voided an incre- dible quantity of the txnix hydatigenx, or hyda- tids, by stool and vomiting, calculated by her at- tendants to amount to a thousand, varying in size from that of a small pea to an inch and a half in diameter. An hepatic abscess afterwards opened externally, a gall-stone was discharged from it, and she ultimately recovered. (Lond. Med. Journ. Vol. x. p. 7. 1789.) An instructive case of the same kind is related by Mr. Gaitskell, of Rotherhithe, in the fourth volume of the London Medical Repository. The patient, a married female, aged thirty-eight, had been under treatment for hepatic disorder with in- flammatory symptoms, and, a short time after pty- alism was induced, began to void biliary calculi, which in three months amounted to forty-seven in number, and with them hydatids not less than a thousand, varying from the size of a grape to that of a peach. At the date of the report the patient was convalescent. An example of fatality occasioned by a sac of hydatids situated in the porta or the liver, which hy its pressure on the vessels produced complete obstruction and jaundice, is related by Dr. Dun- can, Sen., in the Edinburgh Medical and Surgi- cal Journal, vol. iv. p. 137. Hydatids which are ejected from the stomach or discharged from the alvine canal, have in most instances been generated in the liver, but occa- sionally it is probable that they have passed from their common sac in consequence of its adhesions 2p to, and resulting communication with, some part of this tube : they may be transferred in the same manner, we conceive, from the other abdominal viscera, but having found an exit through this channel, recovery so commonly ensues, that the opportunity of proving the truth of the remark by ocular inspection can rarely occur, nor can we adduce any such positive testimony in support of it. From the co-existent disease, rather than from the presence of hydatids in the liver, the judge- ment of the practitioner must be formed as to the issue ; and the requisite treatment of the patient must necessarily be influenced by the same circum- stances. The hepatic disorder will generally be such as to render the exhibition of mercury neces- sary, and the stimulating effect of this remedy on the absorbent system renders its use, at all events externally, of considerable importance in the re- moval of hydatids, whether situated in the liver or in any other of the abdominal viscera. The presence of hydatids in the spleen is an occurrence which has not often been noticed: during life the symptoms occasioned by them in this organ are too obscure to be recognised, and can never become the specific object of medical treatment. We shall subjoin a remarkable case of this kind in preference to any discussion which we cannot found on experience. " A labourer, thirty years of age, of a phleg- matic habit, after lifting a heavy load, complained of pain in the chest, accompanied with cough and much debility. Two months afterwards his legs began to swell; he spat blood twice, a little at a time, which degenerated into a purulent expectora- tion of a bitter taste. He now applied for medi- cal assistance, under the idea of his disorder being the first stage of pulmonary consumption. His pectoral sufferings abated, but the oedema increased, and the parts became erysipelatous, but soon changed their colour again on the application of dry aromatic fomentations; and the oedema sub- siding on using twice anti-hydropic medicines, the patient thought himself cured. A short time after, however, when he had been at hard labour, the spitting of blood returned, and he complained of stitching pains in the chest; the scrotum was swelled, the pulse very slow, and digestion dis- turbed. These symptoms were also attended with headach. The pectoral sufferings were again soon removed, but the dropsical swelling remained, and a painful, hard, circumscribed tumour, beginning in the left hypochondrium, and extending upwards to the xiphoid cartilage, now made its appearance, which, with the obstinacy of the dropsical swelling, induced Dr. R. to make use of drastic medicines. An abscess now formed over the right knee, which effused a considerable deal of ichor; but the dropsy increased, and the patient at last died suddenly after a long ambiguous state of health. "Dissection.—The greatest mark of disease was found in the spleen, which was unusually distended, and weighed about nine pounds; and a tendinous place was found in its centre, about the size of a hand, from which, on being cut open, a great quantity of water escaped, with a number of globular vesicles, varying in size from that of a millet-grain to that of a duck-egg, containing 470 HYDA TIDS. partly a Ciear liquid and partly a friable substance, which by the help of a magnifying-glass exhibited other small vesicles. Many of them were burst asunder and dried away. The bag containing these bladders divided the disorganized spleen into two halves, formed by an aponeuritic membrane, from half a line to two lines in thickness, inter- woven with the substance of the viscus, and fur- nished with very swollen blood-vessels. It ran obliquely through the spleen, so that its larger half lay to the left and upwards, and the smaller to the right and downwards. All the other viscera were healthy, except that some water was contained in cavities caused by serous membranes." (Lond. Med. Repos, vol. vi. 1816, p. 332. Extracted from Horn's Journal, 1815.) The pancreas is still more rarely the seat of hydatids than the spleen, and it is probable that their occurrence in this organ can only be ascer- tained by post-mortem examination. Of the various organs of the body, the kidneys are more frequently than any other affected with hydatids: these for the most part are simple cysts produced in their peritoneal covering, and on in- spection present an appearance resembling bunches of grapes: they may exist to a very considerable extent without manifesting any distinguishing characteristics of their presence during life, and without at all affecting the quantity or sensible qualities of the urine. Sometimes, however, though rarely, acephalocysts have been found to pervade these organs, but no particular symptoms have been evinced to render their presence recog- nisable during life. Pain is commonly felt in the loins during their formation ; there has also been remarked symptomatic fever, nausea, and vomiting, but these are symptoms which belong also to other diseases: they have occasionally, however, been passed through the urethra, and in such instances have sometimes occasioned dysuria from interrup- tion to the passage of the urine, either in the ureters, the neck of the bladder, or in some part of the urethra. (Works of Matthew Baillie, M.D. vol. ii. p. 257.) One or more acephalocysts having been passed with the urine, a continuance or repetition of the precursory symptoms, or the subsequent occurrence of dysuria, will be almost certain indications that others are in their transit; and even if the same symptoms should have been caused by the passage of renal calculi in a subject prone to the latter tormation, the treatment during the paroxysm •> unsequent to the obstruction will alike be directed to the relief of an organic channel thrown into a state of spastic contraction in consequence of un- natural distention. The symptoms of acephalo- cysts in these as in other organs will be variously modified by other disease with which they are al- most always connected, particularly, and most fre- quently perhaps, abscesses following blows or other injuries. On this account, therefore, it seems to us that examples are essential to an intelligible description of the morbid states in which their presence is evinced. We subjoin the following as particularly illustrative of renal acephalocysts. " A gentleman, aged 32, was thrown from his horse in February 1780, by which he received an injury on the loins, and had considerable hematu- ria in consequence. After the first fortnight he experienced no further inconvenience until the June following, when he complained of cough attended with bloody expectoration, which he ascribed to the previous accident; but from a little attention he recovered, nor experienced any symp- tom of his late disorder until about three years afterwards. In December 1783, he was attacked with rigor, and felt a return of severe pain in the loins, extending to the region of the left kidney: in a few days he perceived an enlargement in the hypochondrium, which continued gradually in- creasing until the latter end of February 1784, a space of nine weeks : after the first month, the tumour was so little painful that the patient was enabled to travel to London, a distance of one hundred and thirty mites, to consult Dr. Lettsora, by whom the case is detailed. Upon examination the tumour, which was as large as ani' infant's head,' was found to contain fluid : it extended from the vertebrae of the back along the left hypo- chondrium to the umbilical region, and occupied the whole space from the ribs to the os innomina- tum. The pain increased with the swelling, and was aggravated by exercise or motion, but was relieved by an anodyne, " till at length some difficulty of making water came on, and for many hours a total obstruction : in this situation sur- geons of the first eminence were consulted, to determine how far it would be advisable to make any incision in the side and perforate the cyst, in order to take off the pressure on the bladder, and obviate the fatal event which the retention of urine threatened : this was on the 20th of Feb- ruary ; the result was, that, from the uncertainty of the situation of the tumour with respect to the intestines, which were suspected to take a curve over its anterior surface, as well as from the risk of exposing such parts to the external air, the operation was protracted, and the usual opiate of the patient was ordered to be increased in the evening, which was the chief remedy besides the use of cicuta and anodyne clysters. He passed a painful night, suffering frequent and violent rigors, but early in the morning experienced the most happy relief by a discharge of a large quantity of thick pus with the urine, which was followed the next day by that of pus and numerous hydatids. " In a few days the tumour subsided, and the purulent discharge ceased ; after this he continued recruiting in strength for nearly a fortnight, when his side enlarged again after exercise in a coach, probably by a large hydatid stopping up the ureter ; rigors and strangury succeeded as before, and the tumour became as large as in the first instance, till the latter end of March, when he experienced a second discharge in every respect like the former, except that the hydatids were much larger. His health and strength again re- turned, until his side filled a third time after exer- cise on horseback, and continued swelling until the 25th of April, when he was again relieved by a third discharge of hydatids, and these were con- siderably larger than those of the preceding attack. The passages now became so open that he fre- quently discharged the hydatids, after walking or riding, without enlargement or pain of side; or, if he felt uneasy, or perceived a tendency to tumescence, by pressing his hand upon the side he could squeeze them into the bladder, where HYDATIDS. 471 they would remain some time before they were discharged ; but the hydatids became at length so considerable in size that it was with great diffi- culty they passed the urethra. The last that he voidtd was on the 12th day of July, which was so very large that it stopped up the urethra, and remained in it for a considerable time, until the weight of the accumulated urine forced its way. The earliest hydatids burst in their exit; they gradually increased in magnitude in every succes- sive discharge, the first being not larger than a pea, and the last about the size of a pullet's egg. After the last mentioned discharge his health gradually recovered, and the patient enjoyed, without the least inconvenience, the chase and every other species of exercise as well as ever he did. "During the whole progress and termination of the disease very little medicine was administer- ed, except cicuta, gum arabic, clysters, and ano- dynes. He once took an emetic when the tumour became uneasy, previous to the second discharge, and which seemed to hasten the eruption of hy- datids. Bark was tried, but with manifest incon- venience, between the eruptions, and was left off. After the last discharge it seemed beneficial, as well as asses' milk." (Memoirs of the Medical Society of London, vol. ii. p. 33. 1789.) From the history of the disease there remains very little doubt but that it originated in the kidney, where the suppuration was extended to an amazing degree, till at length the pus, break- ing through the cyst in which it was contained, passed into the ureter, and was thereby conveyed into the bladder. A temperate man had been for some years sub- ject to paroxysms of pain in the region of the right kidney, which appeared to descend in the course of the ureter of the same side, and ceased after discharging by the urethra some membranous bags (acephalocysts) of different sizes, some whole, but others broken and empty ; there were con- siderable intervals between the paroxysms, during which the patient enjoyed perfect health ; but the latter, from recurring every four or five months, had now increased in frequency, and the hydatids in size. The patient had suffered thus for ten years previous to the date of the above report, but at first their discharge was attended with a sense of weight or pressure rather than of pain, preceded sometimes with slight rigors. These discharges, together with purulent matter, at length recurred as often as five times within a twelvemonth, accompanied with increasing pain preceded by a sense of fulness in the region of the right kidney; for three years there was a cessation of the above symptoms, reasonably attributed to continued at- tention for four months to the following prescrip- tion of Dr. Lettsom :— R Extr. cicutae et pilulae sapon. aa. gi. fiant pil. xxiv. cap. ii. omni nocte. R Elect, lenitiv. 5L *Ethiop. mineral, ^ss. Syrupi simpl. q. s. ut fiat elect, de quo cap. magn. nucis mosch. prout venter postula- verit. R Uvae ursi ^iiss. coque ex aq. font, ^ix ad 3vi. sub finem coctionis addendo rad. glycyrrh. §ss. et cola. R Liq. colati 51SS. Tinct. stomach, gi. fiat haustus bis per diem sumendus. Three years having elapsed, the report states that after some considerable pain in the back, he voided again several more hydatids, of a longer size than formerly, to the basis of which, or that part which appeared to have been attached to the kidney, some sabulous matter adhered ; he dis- charged several more at different periods, but had experienced such amendment from the use of the same prescription, the powder of uva ursi only having been substituted for the decoction, as to give a fair promise of perfect recovery. (Memoirs of the Medical Society of London, vol. ii. p. 43. 1789.) For another instructive case of the same kind, related by Dr. Alexander Russel, the reader is re- ferred to the third volume of the Medical Observer and Enquirer, published by a Society of Physi- cians in London, 1767. In this instance the patient retained his health, though at intervals he discharged hydatids with his urine occasionally mixed with purulent matter and streaked with blood ; these at first are stated to have been round, " of the size of a common garden pea, with a small stalk." The patient about ten years before, when at school, had experienced " some violent complaints in the urinary passages, when he voided dark coffee-coloured urine with great pain." Dr. Baillie has given us an account of the dissec- tion of a case in which the right kidney of the body of a man who had been a soldier was con- verted into a bag, capable of containing at least three pints of fluid, full of hydatids (acephalo- cysts) differing from a pin's head in size to that of an orange, and only a small part of the kid- ney retained its natural structure. (Morbid Ana- tomy.) When hydatids have been passed into the bladder, irritation to a greater or less degree is excited to propel them with the urine, and it is probable that the exceedingly thickened state of the parietes of this organ in those in whom they have existed has been occasioned by increase of action, as was suggested by Dr. Baillie in the above-mentioned instance. In another related by Tyson the same effect was observed to have been produced: in the latter the cysts or sacs (acepha- locysts) were twelve in number, varying from the size of a goose's to that of hen's eg^s, and dis- tended the bladder to the size of a child's head though little or no urine was contained in it: the ureters are stated to have been impervious at their vesical extremities, but distended to the calibre of the intestines of a child, and at their renal extre- mities to the size of a hen's egg, the kidneys themselves being of their natural size and figure, but resembling rather large bags than fleshy sub- stances : the cavity of the pelvis (whether of one or both kidneys is not stated) contained above three ounces of fluid. The liver, lungs, and heart of this individual were considerably dis- eased, and polypi were observed in the aorta and pulmonary vein. (Philosophical Transactions, JNo 188, p. 332. 1687.) Hydatids have occasionally been found between the bladder and the rectum, as in the case already referred to, which came under the observation o< 472 HYDATIDS. Dr. Hunter,* and had occasioned only the parti- cular symptoms of dysuria and distension of the abdomen : the patient, a man forty-six years of age, died suddenly, and on post-mortem examina- tion the bladder was found to be enormously dis- tended, reaching full eight inches above the pubis, its fundus having risen to within two inches of the arch of the colon ; it contained between five and six pints of urine, and the hydatidous tumour was found between the neck of the bladder and rectum, completely filling the pelvis, and thrusting the former forwards and upwards. (Medical and Chirurgical Transactions, vol. i. p. 35. 1793.) It was remarked by Dr. Hunter that the preju- dicial effects of the hydatids in this case were limited to those of mechanical pressure, and that of the numerous cases related by writers hardly any had proved fatal when an outlet for them was procured. The peritoneum and its various duplicatures are occasionally the nidus of hydatids, i. e. of acephalocysts and those of the simple encysted kind, but rarely if ever without implication of disease of one or more of the subjacent viscera: it is probable that the development of the hydatids takes place under the different states of cachexy arising from a depressed condition of the vital powers, from the combined circumstances of con- stitutional diathesis and chronic disease, and not unfrequently are the consequence of inflammation of this membrane taking place under the same circumstances as ascites, with which they are commonly co-existent: the pathognomonic symp- toms are thereby rendered extremely obscure, and there appear to be no other means of detecting this morbid process than by manual exploration of the abdomen, and thus only when there is an inequality in the surface, and a partial fluctuation can be perceived on altering the positions of the patient. The constitutional symptoms complicated with those of the local disease are generally such as to betoken a fatal issue in the human subject, should the real nature of the distension of the abdomen from this cause be ascertained during life ; but when the hydatiferous sac is situated between the peritoneum and muscular parietes, adhering to and distending the latter into a tumour, or, in fact, an abscess, as most frequently happens, an artificial opening will be the principal means of relieving the patient; and if this be the only disease, a fa- vourable issue may almost always be anticipated. A sense of unequal fluctuation communicated to the hand of the examiner will be the only method of distinguishing the general nature of this from other tumours; and if the fluid of the common cyst is purulent, it will have the common charac- teristics of an abscess, the presence of hydatids being concealed until the latter be emptied of its contents, as will generally be the case also, what- ever may be the particular nature of the contained fluid. The same observations will apply also to any part of the muscular structure with which for- mations of this kind may be connected. Cysts commonly denominated hydatids some- times constitute the bulk of tumefied ovaria, and * Dr. Hunter has suggested that thev may have escaped Horn a ruptured orifice of a sac originally formed in the spleen,and passed by simple gravitation into the pelvis. are probably formed by the progressive enlarge- ment of the small vesicles which belong to their natural structure; they often acquire an immense size in this organ as well as in the uterus, and vary frequently in their construction, some of the larger cysts enveloping smaller ones, and thus re- sembling acephalocysts, with which they have not unfrequently been confounded. The inner, how- ever, will be found to be reflected from the outer cysts, like the serous membranes when they are reflected off from the internal parietes of cavities upon the organs contained in them, and to receive from them a continuation of vascular structure; in this respect differing essentially from the isolated state of acephalocysts, and always sufficiently distinctive of the latter kind of vesicular bodies. Though there appears to be no reason why ace- phalocysts should not constitute ovarian disease, we are not aware of any instances of the kind being on record ; and as the preceding morbid condition more properly belongs to ovarian dropsy, and will be discussed under that head, it is not requisite to enlarge upon it here : we have to notice, how- ever, that the suspicion of such an instance in a female forty years of age, who had the symptoms of ovarian dropsy, but attended with more pain than is common in that disease, has been recorded by the present Dr. Monro as occurring within the observation of his father : about a fortnight after the patient had been seen by him, the tumour sub- sided in the night, and the patient told him '• that she had passed several watery stools with skins in them."-f- Hydatids of the uterus constitute a morbid con- dition of this organ, very frequently referred to in medical writings, but it is probable that they are invariably attached cysts, and never acephalocysts. They are described by Baillie (Morbid Anat.) as vesicles of a round or oval shape, with a narrow stalk to each, by which they adhere on the outside to one another. A large one has generally a number of small hydatids adhering to it by narrow processes, and in the same manner to the uterus, by small filaments ; and portions of a substance resembling blood and coagulating lymph are fre- quently mixed with them. A similar substance is attached to the internal part of the uterus, from which the footstalks of the hydatids grow. As these increase in number, they distend the uterus in proportion, and at length by their quantity stimulate it to contract upon them. " The cause of this complaint has not been ascertained ; it sometimes appears as a morbid condition of the opaque membranes of the ovum; and in such cases, interfering with its functions, it destroys the vitality of that body, and thus produces abortion. " It is probable that the existence of pregnancy is not necessary for the production of this disease; and perhaps a morbid condition of oiganized coagulating lymph may, under certain circum- stances, have the power of originating it, but what these circumstances are is not known. It may admit of a doubt whether, in consequence of the morbid condition of the ovaria, some separation of the corpora Graffiani may not induce the com- plaint." Hydatids of the uterus, when arising t Morbid Anatomy of the Gullet, Sec, by Alexander Monro, M.D., 8vo. Edin. 1811, p. 273 HYDATIDS. 473 from the destruction of an ovum, are preceded by the symptoms of pregnancy common to the period before this change takes place, and the time when it happens is marked by the breasts becoming flaccid, and the sickness and symptomatic effects of pregnancy going off; but of themselves they do not appear to produce any peculiar symptoms* with the exception of one to be mentioned here- after. The greater number of inconveniences at- tending the disease arise but of the pressure made by the enlarged uterus upon the subjacent parts, such as retention of urine from compression of the urethra, constipation of the bowels from compres- sion of the rectum, oedema, and cramp of the lower extremities. These symptoms, however, are not necessarily present, and instances have occurred in which they have been altogether wanting.— When the pelvis can no longer contain the en- larged uterus, that viscus will rise into the abdo- men, and may be felt as a circumscribed tumour through the parietes. The function of menstruation is usually inter- rupted as in pregnancy : on examination the body of the uterus will be found enlarged, and suddenly bulging out from the upper part of the cervix. All these symptoms, however, attend other enlarged states of this organ; but besides the absence of the movements of a fcetus, usually felt by a pregnant woman, the size of the belly and state of the womb rarely correspond with the supposed period of pregnancy, and from this condition as well as other diseases, it is especially characterized by the dis- charge of an almost colourless watery fluid. "This watery discharge is to be distinguished from that which attends the cauliflower excrescence, by the irregularity and suddenness of its appearance and cessation ; being produced by a rupture of one or more of the coats of these hydatids, in consequence of the occasional contraction of the uterus upon them, or of any sudden violence, as in the act of coughing or sneezing; whereas the discharge from the cauliflower excrescence being a secretion from its surface, is constantly escaping. It may be dis- tinguished also from those splashes of urine which sometimes come away from pregnant women, by being wholly inodorous." When the uterus is excited to contraction upon hydatids, the process resembles that of incipient labour, for which it has unfortunately been mis- taken even by experienced practitioners: "the os uteri is dilated ; the hydatids are expelled by pe- riodical pains ; and then for the first time danger presents itself in the form of alarming hemorrhage. This hemorrhage is more frightful than that which follows the removal of the placenta from an un- contracted uterus; and the reason is obvious—the placenta covered only a limited space of the internal surface of the uterus, whereas the hydatids spring from every portion of the cavity. (Observations on Diseases of Females, by Charles Mansfield Clarke, part ii. p. 116.) In some cases milk is secreted after the hydatids are expelled, and occa- sionally pain in the hypogastrium with febrile symptoms follow. The uterus is sometimes distended by a single hydatid or cyst to an enormous size, but this va- riety is very rare, for the very experienced author above cited, to whose invaluable work we are most largely indebted for our information on this part of Voi.. II. — 60 2 p* the subject, has stated that such an instance has never come under his observation, and concludes, from the accounts given of it, that its effects are purely mechanical. From the equality and size of the enlargement " it would be difficult to deter- mine whether it were produced by a single hydatid, or by a deposit of solid matter in the substance of the uterus. The fluidity of the contents of the tumour does not necessarily cause a sensible fluc- tuation of these contents. A full bladder felt above the pubis does not give to the hand the sen- sation of a fluid being contained within it. The discharge of a watery fluid in large quantities is in this variety of the disease the first announce- ment of its existence and the presage of its speedy removal. " The water having escaped, the cyst is expelled, and the disease terminated without the occurrence of those distressing symptoms which threaten the patient's life in the disease first described. " This last variety being very uncommon, the practitioner will hardly be prepared for its occur- rence, and the patient expecting it to be of long continuance, will be agreeably surprised by an ex- peditious and favourable termination of her com- plaints. "Examination by the finger will enable the practitioner readily to distinguish the single hyda- tid from the more formidable disease, fleshy tu- bercle ; a discrimination of importance in forming the necessary prognosis, though symptoms arising from both forms of disease demand similar modes of relief." It is probable that distention of this organ by hydatids is the particular condition to which some writers have referred under the term hydrops uteri; for it seems impossible from its natural position with respect to its aperture and fundus, that any large accumulation of fluid could take place, and continue for a length of time in it, unless enclosed in a cyst. Such is the expressed opinion of the writer above cited, and that neither he nor Dr. Denman should have witnessed such an instance appears to us evidence almost conclusive. The presence of a tumour consisting, as sus- pected, of a bag of hydatids situated between the neck of the uterus and the rectum, has occasionally been found to interfere considerably with the pro- cess of parturition, but the nature of its contents it would appear impossible precisely to determine either before or after delivery, unless an opportu- nity were afforded by a post-mortem examination. A tumour of this kind would occasion little pain in its growth other than that arising from pressure on the surrounding parts, the nature of which would materially depend on its size; but the greatest inconvenience would consist during preg- nancy, by its adding to the mechanical impediment to the passage of the urine. As the occurrence of hydatids in the female breast, in the tunica vaginalis testis, the thyroid gland, and between the muscles and integuments, constitutes the morbid structure of local diseases especially belonging to surgery, their present dis- cussion would be irrelevant to the particular ob jects of this work. Having no reason to suppose that hydatids have any inherent malignancy, the variety of morbid actions resulting from their presence are to be 474 HYDATIDS ascribed to mechanical irritation and compression : these are seen to be modified by their size and number, their locality, and the predisposing cir- cumstances of the constitution in which they may occur. As mechanical irritants, the effects they produce, whether inflammatory or spasmodic, must be treated entirely on general principles adapted to the age and habit of the patient, and other circum- stances, either morbid or natural, under which their occurrence is observed. When a tendency has been evinced to their expulsion by natural processes, through either of the outlets of the ahine canal, art may take advantage of the sug- gestion thus afforded, and by an emetic or purga- tive, according to the operation already induced, expedite the accomplishment of the object to be effected. When they have had their seat in the chest, or have passed into this cavity from the ab- domen, so as to be ejected through the lungs by coughing, nature may be allowed uninterruptedly to continue its purpose, but any morbid action that may result from the effort must be counteracted by the method of treatment its peculiarity may point out. When impacted in either of the biliary ducts, and giving rise to spasmodic pains and other symptoms resembling those which arise from biliary calculi similarly situated, an emetic, i.nless particular circumstances should contra-indi- tate its use, ought to be given, and if its action foil to procure the relief desired, the same kind of treatment will be required as for the analogous condition just referred to, viz. a full dose of the tincture or wine of opium, or Battley's sedative, or tincture of henbane with compound spirit of sulphuric ether in camphor mixture, to be repeated or not according to its effects : if the bowels should be in a constipated state, a combination of castor- oil and laudanum may be preferred, or if great irritability of stomach should prevail, opium com- bined with calomel, or with calomel and compound extract of colocynth, may be advantageously sub- stituted : a hot bath, a blister to the epigastrium, and injections per anum of hot water with lauda- num, or, if need be, purgative injections, are re- medies one or all of which may be had recourse to as the necessities of the case may indicate. When a cyst within the abdomen, containing acephalocysts, can be detected, and is adherent to its muscular parietes, distending them and pro- ducing great disorder of the system, an artificial aperture will be the readiest and perhaps the only method of cure. If contained within an abscess, the latter will be the prominent object of considera- tion, and the evacuation of its contents may prove a cure to the patient, and give the earliest mani- festation of their presence. If not acephalocysts, however, but the attached hydatids which grow as it were from the organic structures or tissues, the disease with which they are complicated will form the more prominent object of consideration : it will be obvious that any distension of the abdo- men from this cause cannot be relieved, as in ascites, from tapping, an operation to which, in the want of other means of relieving a patient, a rractitioner may be urged: should the hydatids be numerous, little relief could follow, and even if the evacuation of a large hydatid were to pro- mise greater advantage, the too common issue of uch cases should warn him, except under particu- larly advantageous circumstances, against a step by which his reputation might suffer, and the expectation of the patient be disappointed. When it has been ascertained that the liver is affected with hydatids, the removal of the hepatic disorder which must at the same time exist, should ftfe the prescriber's aim; and the process will com- prehend the only rational method of relieving the organ, and the rest of the system which sympathizes with it. It has been suggested that mercury in its various forms may possess a specific quality adapted to the destruction of the vitality of animal- cular hydatids, particularly acephalocysts ; and on this principle has its use as well as that of some other medicines been resorted to when their pre- sence has been recognised or suspected. How far the idea may be founded on fact, time and parti- cular attention to the subject must determine, but experience has sufficiently shown that its infJu- ence in such cases of disease has been most salu- tary, and is indispensable to restoring the natural secretion of the liver, and thereby communicating to the whole of the assimilative organs that degree of vigour which is the main defence of the sys- tem against noxious influences from without and morbid depositions within the body, and still fur- ther to the removal of various products of disease which a contrary state has engendered. The spe- cific stimulus also of mercury to the absorbents is an additional reason for its prescription when the more direct removal of hydatids cannot be effected, whether situated in the liver, spleen, pancreas, kidneys, peritoneum, or other structures. When productive of great inconvenience from their situation between the rectum and bladder, or, as in pregnancies, between the vagina and the rectum, and the nature of the resulting tumour can fortunately be determined, an incision into its most prominent part it is probable will speedily and effectually relieve the patient. The circum- stance, however, being rare, and the records of medicine affording no general guide for practice on this point, the writer feels it incumbent upon him to state that the above recommendation has been suggested by the perusal of a valuable paper on tumours within the pelvis occasioning difficult parturition, by Mr. Park of Liverpool, inserted in the second volume of the Medico-Chirurgical Transactions, p. 296, and particularly by a suc- cessful example of the practice therein recorded, and of another in which the tumour disappeared in consequence of the pressure occasioned by the act of parturition. If hydatids have been voided with the urine, and symptoms should arise indica- tive of the passage of more of these bodies from the kidneys to the bladder, relief should be sought by the immersion of the patient in a hot bath, and by the administration of antispasmodics, as advised for the corresponding effects produced by their impaction in the biliary ducts. If checked in their passage through the urethra, the impediment w conceive might easily be overcome by rupturing the enveloping bag with the point of a bougie. When the uterus has been the seat of hydatids, we are told by the highest authority that "all attempts to cure the disease artificially, and to arrest its progress otherwise than through the natural efforts of the organ, have been of no avail. The patient is to be informed of its nature, and HYDATIDS. 475 the result is to be patiently waited for. As symp- toms arise they are to be treated accordingly, and the practitioner will best perform his duty by watching over the complaint, and by doing no more than is absolutely required. But when the period arrives at which the uterus is excited by distension to unload itself of its contents, then all his skill and energy will be wanting, and all his efforts will be called forth to control the hemor- rhage and to sustain the powers of the constitu- tion." " Two or three fingers or the whole hand should be covered with pomatum, and carefully introduced into the uterus, and carried up between its sides and the hydatids, which are to be de- tached from the part to which they adhere by the most gentle efforts. The mass being now included in the hand of the operator is to be brought out of the uterus, it being remembered, in the perform- ance of this operation, that the degree to which the os uteri is dilatable without laceration is in proportion to the size of the whole uterus both in pregnancy as well as in this disease. So that, supposing it to be enlarged by hydatids to the size of the viscus in the sixth or seventh month of pregnancy, the whole hand may be, if neces- sary', introduced through the cervix ; whereas, in smaller dimensions of the uterus, if any attempt is made to introduce it through the cervix, however carefully it may be attempted, a laceration of it may ensue, and thus the patient be involved in a new danger. The contents of the uterus having been naturally expelled or artificially removed, and the hemorrhage restrained, the strength is to be restored by allowing the patient a nutritive diet, and by the exhibition of such medicines as tend to increase the tone of the system, amongst which the mineral acids and preparations of cin- chona may be accounted the most serviceable: these or other medicines, possessing similar pro- perties, should be from time to time exhibited until the vigour of the system shall have been en- tirely restored. " The usual cautions given to women after de- livery should be here impressed upon the patient, such as confinement to the horizontal posture until the parts shall have acquired their usual size and tone." (See Observations on Diseases of Fe- males, by [Sir] C. M. Clarke, M. R. C. S. &c. partii. p. 120. Lond. 1821.) " The acknowledged efficacy of the ergot of rye in stimulating the pregnant uterus to con- traction, suggests the idea that it may in the same manner be administered with advantage as soon as it is known that the distention of the uterus is occasioned by hydatids: the writer, however, is not aware that it has ever been used under such circumstances, but as there is some reason to be- lieve that it possesses to a considerable extent the additional property of restraining the hemorrhagic tendency of bleeding vessels, it appears probable that it may prove an eligible medicine for the pur- pose above specified."* *"In the fourth number of the Glasgow Medical Jour- nal, Dr. Macfarlane, in his observations on polypus of the uterus, gives a case where the ergot appeared to act by promoting the expulsion of the polypus. One drachm was infused in four ounces of water, and one ounce given every two bonis. The whole was given before the effect was produced. In the course of a few hours the tumour was discovered to be in the vagina. Four days after the exhibition of the ergot the polypus fell The single hydatid of the uterus by its growth effects its own cure, and thus affords a hint which may, under other circumstances of the disease, be usefully applied; when arrived at a considerable size, a rupture of it suddenly takes place, its fluid escapes, and the cyst is expelled; the patient being in a moment relieved of her sufferings and the cause of her fears, in most instances requiring nothing more than a bandage round the abdomen to give support to the organ which has so long been distended and consequently relaxed. In all cases of hydatids the condition of the body and the specific nature of the co-existent disease, be it either predisponent or consequent, must be special objects of remedial attention ; hence the treatment connected with these morbid formations involves also that of cachexia, of the various disorders of the digestive organs, of dropsy, &c, each of which having a proper place in this work, it is necessary only to refer to them here ; and it would be further a waste of time to dwell on means to be adopted for the removal of a mor- bid deposit under circumstances in which its pre- sence could only be discovered by post-mortem examination. Abstractedly considered, the removal of hydatids may be contemplated by three different methods: first, by their direct expulsion from the body, either naturally or artificially, as already ex- plained ; secondly, when their expulsion cannot reasonably be anticipated, by re-invigorating the relaxed habit of the body, and thus communi- cating to the absorbent system its lost power, an indication which will also be required to be at- tended, to for the prevention of their recurrence when already got rid of; thirdly, by exciting the absorbents to extraordinary action, when the ex- ercise of their natural function is inadequate to the end in view. To reinvigorate the relaxed habit of body it will be necessary to avoid the influence of the external causes by which it has been reduced to this state; to select a dry and healthy residence ; to use a nutritious diet adapted to the powers of the organs of digestion, improving the condition of the latter by promoting, in the first place, the due secretion of the liver, by the exhibition of such of the preparations of mercury and to such an extent as the occasion may demand. The irritative fever induced by such disorder having been allayed, the tone of the stomach must be invigorated by corresponding medicines, as, for instance, by some of the preparations of cinchona, especially the sulphate of quinine, or by quassia, rhubarb, gentian, or cascarilla, combined either with the alkalies or sulphuric acid, according to the condition of the stomach and alimentary ca- nal: the preparations of iron and sulphate of zinc are also medicines which will generally be adapted to constitutions thus affected. When these or similar means are found un- availing, and the inconvenience resulting from the presence of hydatids is so considerable as to render it expedient to attempt their removal by exciting the absorbents to extraordinary exertion. a process which requires more discrimination and off."—From Dr. Young's Observations or. the use of Se cale Cortiutum, in the Transactions of the Medico-CVo rurgical Society of Edinburgh, vol. iii. p. 578. 476 HYDATIDS —HYDROCEPHALUS. care perhaps than any other in medicine, it will be necessary either to have recourse to the free use of mercury in one or other of its forms, or by persevering in the use of evacuants of the alvine canal or kidneys, or by maintaining a con- tinued state of nausea with repeated doses of tartrate of antimony to effect the same end; but of all the excitants of the absorbent system none appear to have so direct and poweiful an influence upon it as iodine: we have, however, no expe- rience of its use in disease resulting from hyda- tids, and rest our anticipations of its efficacy in such cases on the great advantage stated to have been derived from it in scrofula as well as from the particular actions observed to have been pro- duced by it in the treatment of this disease. (Lu- gol on Todine, by Dr. O'Shaughnessy. 1832.) In the article Buonchocele will be found an excellent account of the medicine in question, which renders it unnecessary for us to enter into any further discussion upon it here ; we shall, therefore, merely state, as the result of our own experience of iodine and the hydriodate of potash, that the evidence of their effects on the system in medicinal doses becomes very gradually percepti- ble, but that these remain so long after their use has been discontinued, as to be prejudiced by their excess, and, as far as we know, the means have not been discovered for regulating them when the necessity has been indicated. [From a brief article in the Medico- Chirurgical Review for April 1844, p. 473, it appears that Professor Klencke, of Brunswick, has instituted some researches on the transmission of hydatids by contagion. The writer has not seen the original paper, but the following are stated in the Review to be Professor Klencke's general conclusions. First. That in all species of hydatidic animals, the mode of generation is twofold—fissiparous and oviparous. Secondly. That there are false or spurious hyda- tids, which are propagated by blastidia. Thirdly. That all the different sorts of hydatids are com- municable from one organism to another; and as they are found to exist in fluid food and in the flesh of different animals, they may be readily transmitted by infection. Fourthly. That the acephalocysts are not distinct from the echinococci; the former are only the ova of the latter, with or without the parent envelope. Fifthly. That the current of the circulation serves to diffuse the hy- datidic animalcules, whatever be the mode in which they have been introduced into the system. Sixthly. That there exist agents in the living or- ganism, as well as numerous substances in the Materia Medica, which are capable of acting as poisons to these parasitic productions.] William Kerr. HYDROCEPHALUS, from Map, water, and K£(j>a\i), the head. Under this term was formerly comprehended every preternatural effusion of se- rous fluid in the region of the head, whether ex- ternal to the cranium or contained within it. In process of time, however, it became limited to effusion occurring within the cavity of the skull. Systematic writers have laid it down that such effusion may take place either between the cra- nium and dura mater, into the great cavity of toe arachnoid, in the subarachnoid cellular membrane, or finally into the cavity of the ventri- cles. But hydrocephalus, in the more limited sense in which it is usually understood in this country, means a serous effusion taking place into the ventricles, or (which is a much rarer occur- rence) into the sac of the arachnoid. The disease is divisible into acute and chronic. Hufeland, Coindet, and many other late writers, have restricted the use of the name hydrocephalus to the chronic effusion, and have employed the term hydrencephalus to designate the acute varie- ty ; a species of nomenclature which is objection- able, as it proceeds on the erroneous assumption that the water in the latter case, and in it only, is always confined within the cavities of the brain. I. Acute Hydrocephalus.—This species has been defined by Cullen—a disease which affects chiefly infants and young persons under the age of puberty, arising gradually, and manifesting it- self at first by lassitude, feverishness, and pain in the head, and subsequently by slowness of the pulse, dilatation of the pupil, and somnolence. In addition to several of the above symptoms, Hufe- land (Conspectus Morborum—Hydrencephabn) has noticed in his definition the tendency to con- vulsions and paralysis, vomiting and constipation. Though the chronic species is plainly alluded to by several of the older writers, it has usually been supposed that the symptoms of the acute had, till the beginning of the last century, when it was imperfectly described by Petit, escaped the obser- vation of practitioners. This, however, is a mis- take, as Hippocrates was certainly acquainted with it, as appears from a passage in the treatise De Morbis, (lib. ii. cap. 6,) where he distinctly no- tices this species of water in the brain, and says that it gives rise to acute headach, pain in the eyes, double vision, blindness, vomiting, and fever; —thus clearly enumerating some of the most cha- racteristic features of the disease, whilst at the same time he recommends purgatives, emetics, and errhines, as the means best suited for its re- moval. The first accurate account of acute hydroce- phalus which appeared, was that by Dr. Whytt, in a posthumous work published in 1768, entitled Observations on the Dropsy of the Brain. His history of the symptoms and progress of the affec- tion is so full and accurate, that a late French writer asserts that little of any importance has been since added to it. So much cannot, how- ever, be said for his hypothesis as to the nature of the disease. He considered it a kind of passive dropsy, and all its symptoms merely the effect of the pressure made on the brain by the effused fluid. The disposition to vomit is attributed to the sympathy of the stomach with the brain ; the slow, irregular pulse of the second stage, to the cardiac nerves receiving an imperfect supply of nervous energy ; the quick pulse of the third stage, to the injury now done to the cerebral fibres, and the irritation thence arising in the whole system ; and, finally, the dilatation of the pupil and stertorous breathing, to the compression of the brain. But neither his theory of this affec- tion, nor his despondence as to the possibility of its ever being cured, have been justified by later and more extensive observation. Dr Fothergill's remarks on the hydrocephalus internus, and Dr. HYUROC Watson's observations on the same subject, ap- peared soon after, and the latter contained one of the first instances on record where the disease ter- minated in recovery. A valuable addition to the usual mode of treatment was made known in 1775 by Dr. Dobson, who, with a view to increas- ing the activity of the absorbents in the brain, was led to the employment of mercury, and had the satisfaction to find it successful. The first ap- proach to a correct theory of the disease was con- tained in the thesis of Dr. Quin, of Dublin, pub- lished in 1799, in which he pointed out its affinity to the inflammatory diseases, and supported his views by a reference to the appearances which are found on dissection in those who have fallen victims to it. This manner of considering the disorder necessarily led to a great improvement in the mode of treating it. A similar view of hydro- cephalus was taken about the same time by Dr. Rush of Philadelphia, who believed it to be closely allied to phrenitis, and pushed the antiphlogistic method of treating it still further than Quin had done. Dr. Withering held a similar opinion as to its inflammatory nature, and, like Quin and Rush, considered the effluvia here, as in many other in- stances, a mere result of inflammation, and not as constituting the essence of the disease. His in- troduction of digitalis into its treatment likewise entitles him to a place in the literary history of this affection. Dr. Percival of Manchester strongly advocated the use of calomel and opium in hydro- cephalus, and strove to give precision to the mode of employing the various remedies previously in use. Amongst the writers who have most con- tributed to throw light on the nature and treat- ment of hydrocephalus, we may place, in addition to those already mentioned, the names of Cheyne and Abercrombie in this country ; Odier and Coindet in Geneva; Guersent and Lallemand in France; Formey, Portenschlag, and above all Golis, in Germany. Besides these, we shall have occasion to allude, in the course of this article, to several others who have made important additions to our knowledge of the disease. Precursory Symptoms.—In a great major- ity of cases premonitory symptoms may be de- tected ; and of these the greater number and the most striking are connected with derangement of the digestive organs. The appetite is either ca- pricious or defective; the tongue slightly furred, and the breath heavy; the epigastrium and hypo- chondria are occasionally tumid and tender on pressure; the biliary secretion is deficient or viti- ated, as is evident from the torpor and irregularity of the bowels, and the unnatural appearance of the stools; the urine is high-coloured and dimin- ished in quantity ; the cutaneous circulation loses much of its vigour, as is evident from the faded and unhealthy complexion and harshness of the skin. To the attentive observer slight indications of the derangement of the cerebral functions may even at this early period be discovered, in the languid manner and frequent drowsiness; the disturbed and restless sleep, from which the child awakens unrefreshed; in the occasional complaints of giddiness or confusion, of noise or slight pain in the head, or of pains like those of rheumatism in various parts of the body and limbs. The pulse as yet deviates little from its natural condi- ! P H A L U S. 477 tion, but on attentive examination some of its beats are found weaker than others, and an occa- sional intermission may sometimes be detected. The child becomes silent and irritable, indifferent to such persons and things as it formerly took an interest in, frequently assumes a grave and thought- ful appearance, or falls into a reverie, from which it awakens with a sigh. Notwithstanding all this evidence of deranged function, the patient often makes little complaint, even when closely ques- tioned. When the disease is about to manifest itself in a more unquestionable shape, flushings and chills frequently alternate; the gait becomes laborious and unsteady. " In stepping forward," says Golis, « they raise the foot as if they were stepping over a threshold—they totter and stagger as if drunk." Dr. Yeats, who has made the earlier stages of the disease his peculiar study, places amongst the premonitory symptoms occasionally present, ten- derness in the scalp, stiffness of the neck, in- creased sensibility of the eyes to light, and in some rare cases severe ear-ach. He also draws attention to the remarkable change from the healthy appearance which the countenance under- goes, the transient paleness and occasional collapse of the features, the dulness and loss of expression in the eyes, and the dark line under them. A teasing cough is sometimes present; there is an unusual tendency to constipation. If aperient medicines be given, the consequent evacuations are both harder and less abundant than they were wont to be from a similar dose; in colour they are sometimes lighter than natural, and at others tinged of a dark greenish hue, and accompanied with slimy matter. It must be confessed that there is nothing essen- tially characteristic in the above symptoms, and that even when all are taken together, they rather indicate a derangement in the functions generally, than point in an unequivocal manner to incipient disease of the brain. Still they are sufficient to justify much watchfulness on the part of the friends and of the medical attendant, and particu- larly so when the child discovers an unusual pre- cocity of intellect, or is one of a family which has already suffered from hydrocephalus, or from scro- fula in any of its forms. The mere occasional exhibition of a purgative will in such cases, as Dr. Yeats very truly observes, usually prove quite inadequate to the removal of the symptoms; nothing less than the systematic employment of a combination of alteratives and aperients, con- tinued for some time, being capable of producing this effect. Dr. Cheyne has the merit of having been one of the first writers who strongly directed the at- tention of the profession to the derangement in the functions of the liver and of the alimentary canal, which so often precedes, and not unfre- quently seems to excite, this affection of the brain. The proportion of cases in which the diseased action commences in the abdominal vistera is, he thinks, very considerable. He was led to this be- lief partly by having observed how usually de- rangement of the above-named organs precedes hydrocephalus, and partly from the remarkable benefit which, in the early stages of the affection. so often ensues upon the use of active purgatives, 178 HYDROCEPHALUS. and finally, from the frequency with which un- cquivocaf marks of disease are discovered m the liver or intestines on dissection. In the incipient sta^e, or white the disease of the brain is as yet only forming, the colour of the stools indicates an inactive state of the liver, whilst at a subsequent period, when hydrocephalus has become fully established, the bile seems to be both vitiated and in excess. The intimate sympathy which exists between the brain and the liver is well known to surgeons, and that between the brain and the stomach and intestines is familiar to every one. There is, we think, a general aversion amongst French pathologists to admit the sympathetic or secondary origin of diseases, and accordingly most of them, in treating of hydrocephalus, have looked upon the morbid appearances found in the abdo- men as a mere casual complication, and by no means the cause of the cerebral affection. M. Brachet of Lyons has, however, departed from the general rule, and admitted a gastric variety of hydrocephalus, (hydrocephalite gastrique,) in which the disorder of the digestive organs evi- dently precedes that of the brain, and in which subsequently, during the progress of the cerebral affection, the violence of the gastric symptoms seems clearly to indicate that the irritability of the stomach is not the mere effect of sympathy, but the result of inflammation in the mucous mem- brane itself. Less importance has been attributed by Dr. Abercrombie than by most other late British writers, to derangement of the chylopoietic viscera as a cause of hydrocephalus. Disease of the brain in unhealthy children, he admits, may appear in connection with that of the liver or other abdomi- nal organs; but the latter, he thinks, cannot cor- rectly be said to be the cause of the former; on the contrary, he looks upon both as a common result of a tendency to chronic or scrofulous inflammation. When we consider, however, the close and unquestionable sympathy which exists between the head and the digestive organs, and take along with this the greater exposure of the latter to irritating causes and consequent func- tional derangement, we are disposed to think that the now very generally received opinion as to the frequent origin of hydrocephalus in abdominal disorder is well founded. Dr. Abercrombie, indeed, himself admits that the more acute affections of the bowels have some pretensions to be consider- ed an occasional cause of the disease, though even here the connection is, he thinks, very obscure: and the secondary affection in some of them arises, perhaps, merely out of the general febrile excite- ment. In admitting the precedence of the de- rangement of the digestive organs and its occa- sional connection with disease of the brain, all that is of any practical importance is conceded. How this connection is to be explained matters little. The comatose state in which inflammation of the mucous membrane of the bowels in infants about the period of weaning often terminates, is a striking instance of this origin of cerebral derange- ment. A remarkable diminution of the urinary secretion frequently precedes the oppression of the brain, and may possibly sometimes, as Dr. Aber- crombie has suggested, be in some degree con- nected with it. Under the title of "Eretysm or Irritation of the Brain in infants," Dr. Whitlock Nichol has described a state which, as it is accompanied oy no increased determination of blood to the head, is distinct from inflammation, though, it may, if neglected, terminate in it. It seems, consequently, to be one of the forms in which the precursory symptoms of hydrocephalus occasionally present themselves, and in which they appear to depend on a peculiarly irritable state of the nervous sys- tem. " It is a state," says Dr. Nichol, » in which inordinate effects arise from ordinary impressions upon different parts of the nervous system." The child is wakeful, irritable, and attentive to every sound and every object of sight, and is easily startled ; the eye is very sensible to light; there is frequent sneezing; and repeated winking or a firm spasmodic closing of the eyes is occasionally observed. A frequent, sudden cry, without any obvious cause: clenching of the fist, with the thumb laid across the palm ; throwing back of the head, and a degree of opisthotonos, are amongst its occasional symptoms. The temperature and pulse may be sometimes raised, but are for the most part natural. Scrofulous children are the most prone to this affection. It may be called into existence by any irritation of the extremities of the nerves, as by painful dentition, by disorder of the liver or alimentary canal, by surgical opera- tions, ulcers, burns, or suppressed discharges, Great wakefulness in infants should always excite attention,.as it is very apt to terminate in inflam- mation of the brain. Children in whom this alarming symptom appears should be carried out much in the open air, and have the head sponged daily with cold water, and the bowels kept in a free state. If it still persist, and we can detect any evidence of undue determination of blood to the head, leeches must be employed. If, on the other hand, the watchfulness and increased sensi- bility of the nervous system exist simply, small doses of Dover's powder are recommended by Dr. Nichol, and should be repeated at intervals of five or six hours, so as to procure a sufficiency of sleep. We believe, however, that when the bowels are duly attended to, and care is taken to give the child the advantage of air and exercise, the aid of narcotics need rarely be had recourse to ; and till every other method of inducing sleep has been tried and failed, we should certainly not advise their exhibition. Though hydrocephalus in its advanced stages presents considerable uniformity in its symptoms, yet so great a variety is there in its manner of commencement, as fully to justify Quin in styling it a truly proteiform affection. These varieties have been reduced by Dr. Cheyne to three pnn- cipal ones, which may be respectively entitled the gradual, the rapid, or violent, and the secondary, under one or other of which most of the cases met with in practice are reducible.* First or gradual form of Attack:.—It is in * Hopfengartner has made a division of hydrocephalus into three varieties, which coincides very nearly wiin that of Chevne, viz. into, 1st, the nervous, which at iw commencement strongly resembles a low nervous fever- ed, the inflammatory, characterized by high fever ano evident congestion of the head: 3d, that which succeed' to scarlatina several days or weeks after the disappe*' ance of the eruption. HYDROCEPHALUS. 479 this form that the precursory symptoms, into which we have entered with so much detail, are the most obvious. The disease here comes on by slow degrees, and at its commencement its true nature is involved in considerable obscurity. The child is indisposed for many days or even weeks, complaining from time to time of slight pain in the head or belly, together with which there is anorexia or capricious appetite, and evident de- rangement in the functions of the abdominal viscera. It is all this while somewhat feverish and dispirited; its colour fades, and the eye be- comes dim. A dragging of one of the legs, or a painful stiffness in the back of the neck, has sometimes been observed from the very com- mencement. The pain in the head soon becomes severe, returns at shorter intervals, and is com- plicated with vomiting, which, as well as the headach, is much aggravated by motion. By these symptoms the fears of the friends are at length awakened. The child now seems unable to support the weight of the head, sighs frequently, and looks dejected: the eyes are pained by a strong light, the pupils much contracted, and flashes of light are occasionally complained of. The derangement of the abdominal functions is indi- cated by the white tongue, by costiveness, or the unnatural appearance of the stools, which are at first of a clay colour, but gradually become gelati- nous and of a dark-green hue, and have a peculiar heavy smell. The pulse becomes rapid, and fre- quent exacerbations take place, characterized by increased heat and irritability, with flying pains in various parts of the body, in the nape of the neck or limbs, the chest or abdomen. This first stage usually lasts for ten days or a fortnight, the patient gradually becoming weaker and much altered in appearance, unsteady in his motions, and fretful. Sccouil or rapid form of the Attack* — The disease here assumes a more acute and tur- bulent form. After a brief period of indisposition, which has possibly been overlooked, the fever ap- pears suddenly and violently, with only short and irregular intermissions. There are frequent flush- ings, severe headach, occasional brilliancy of the eye, with increased sensibility of the retina, and indeed of the whole nervous system, and fre- quently pain in the abdomen, and tenderness on pressure. It is this form of hydrocephalus which bears so strong a resemblance to fever as often to have been confounded with it. With proper care they may, however, be usually distinguished. " We are led to suspect," says Cheyne, " some deeply seated evil from the frantic screams and com- plaints of the head and belly, alternating with stu- por, or rather lowness and unwillingness to be roused; and we are struck with the great irrita- , bility of the stomach, which exists in a degree be- yond what we generally find it in the fevers of this country, retching and vomiting being brought on by e change of posture, and certainly by every attempt to sit up in bed; act the disordered state of the bowels which attend? 'his irritability of the stomach is al*o remarkable. And when at any time the child has a little respite from the violence of these symptoms, we find our suspicions con- firmed by his look ; for when the features do not express pain or terror, there is not unfrequently a vacancy of look, the eyes being set with an ex- pression of dejection which is peculiar to certain diseases of the brain." Third form of Attack.—When hydroce- phalus supervenes upon other diseases, as upon scrofula or painful dentition, the exanthemata, re- mittent fever, or hooping-cough, it is called me- tastatic or secondary. When it ensues in the course of an acute disease, its approach is most insidious. The symptoms of the early stage are almost all absent, and palsy and convulsions often afford the first evidence of the brain having be- come implicated. Even pain in the head is occa- sionally never complained of; and Dr. Quin al- ludes to a case in which not one characteristic symptom of hydrocephalus had occurred, and yet a large quantity of fluid was discovered in the ventricles. Of these three modes of commencement, the first is the most frequent. The second occurs per- haps seldomer than either of the other two, but is the most regular in its progress, and presents the different stages the most distinctly marked. It answers to what Golis has called the tumultuous form of hydrocephalus; and to Guersent's hydro- cephale ataxique. It is the most acute variety, and Gcilis thinks it the most amenable to the in- fluence of medicine, both because it occurs in the healthiest childi—i. and because, being often ush- ered in by sudden *;ver and severe convulsions, it is apt to excite attention in its commencement, and thus has more frequently the benefit of early treatment. But if the critical moment for the emplovment of active measures be lost, in a few days, or sometimes even in a few hours, effusion and palsy ensue. Recoveries from the third form are very rare, which is ascribed partly to the pro gress which the affection of the brain has usually made before there is any suspicion of its existence. and partly to the debility produced by the previ- ous disease often rendering active treatment inad- missible. Stages of Hydrocephalus.—The great va- riety and complexity of the symptoms of hydro- cephalus have led most writers on the subject to attempt their simplification by distributing them into separate groups characteristic of successive periods of the disease. Dr. Why tt, struck by the re- markable differences which the pulse presents in the progress of this affection, has assumed it as the ground-work of a division into three stages, in the first of which the pulse is quick, in the second slow and irregular, whilst in the third it rises again, and becomes rapid and feeble. By Golis four stages have been described, founded on the presumed pathological condition of the brain at successive periods of the disorder. These are, first, the period of turgescence, which answers nearly to what we have called the precursory symptoms; second, the period of inflammation, third, that of effusion ; and, lastly, that of palsy. But two stages, on the other hand, have been ad- mitted by Frank and by Conradi; what Goiis calls the stage of turgescence being by them con sidered as merely indicative of the approach ol the disease, whilst the two last stages of Golis and of Whytt, not appearing to them to be really dis- tinct, have been consolidated into one. The three- 4S0 HYDROCEPHALUS. fold division of Whytt appears, however, to have practical advantages sufficient to justify us in re- taining it. It is that which has been adopted by Cheyne in his valuable essay : but in naming these stages, he has proceeded on a different prin- ciple from Whytt, characterizing them by the state of the nervous system instead of that of the circulation. Thus, the first he calls the period of increased sensibility, the second that of diminish- ed sensibility, and the third that of palsy or con- vulsions. "In the first stage," says he, "every stimulus produces an impression more than pro- portioned to its common effects. There is gene- rally a great aversion to light and to sounds; there is watching, sickness, pain, and a quick pulse. In the second stage, the child is not easily roused, his pupil is dilated, his pulse slow; he is lethar- gic, with obstinately costive bowels. In the third stage, which perhaps might be considered as a continuation of the second, there is squinting, rolling of the head, raving, stupor, convulsions, with a rapid thready pulse." Many cases do, it must be confessed, present themselves which set these and all other artificial divisions at defiance, cases in which the most care- ful observers fail in detecting any thing like a succession of regular stages. Thus convulsions, in place of first occurring near the end, occasion- ally usher in the disease; and as to the pulse, we have ourselves found it keep high during the whole course of the illness; whilst others have met with cases where it never exceeded the natu- ral standard; and others, again, instances of its being remarkably slow at the very commencement of the attack. First Stage.—The morbid phenomena of this period are so variable, that it would perhaps be impossible to give any description of it answering accurately to all cases. Amongst the symptoms most frequently present are pain in the head and eyes, occasionally alternating with pain in the abdomen, in the limbs, or in the nape of the neck. There is usually a certain degree of fever, with great restlessness and total inability to sit up for any length of time. During the sleep, which is very disturbed, there is frequent grinding of the teeth, and the child often awakens with a scream of terror. The head feels'hotter than natural, the conjunctiva is occasionally slightly injected, and the pupil usually closely contracted. There is a manifest aversion to light and noise, with other indications of increased sensibility of the nervous system. The intellect is often but little impaired, for replies, though unwillingly made, are usually correct. The symptoms of disorder in the digestive organs are numerous. The nos- trils are always dry, and the lips cracked. The tongue is for the most part slightly furred, and the breath has a faint sickly smell. There is usually complete anorexia, but often less thirst than would seem consistent with the degree of feverishness present. Vomiting very frequently occurs, and is aggravated extremely by the erect posture, er by carrying the child out of bed. The epigastrium and hypochondria are often tumid and slightly tender on pressure, but in the pro- gress of the disease the belly usually falls in, and becomes flaccid, though no proportional increase 1 the storIs has taken place. There is commonly a great tendency to constipation; and evacuations, when procured by medicines, are generally of a dark greenish spinach-like appearance. The oc- currence of such discharges does not depend, as many persons have asserted, on the employment of calomel, as they often exist before a single dose of this medicine has been given, and are frequently procured also by other purgatives. We have not, however, by any means found them invariably present. Their peculiar colour has been attributed to morbid bile, but there is reason, as we shall afterwards see, to doubt whether this be univer- sally the cause. The urine is deficient in quan- tity and turbid, with a whitish sediment; it is often retained or suppressed for a great many hours, and dysury is not unfrequently complained of. The functional derangement of the respiratory organs is manifested by the occasional cough, the irregular breathing and moaning, and by that deep sighing which is almost pathognomonic of affec- tions of the head. The pulse is considerably accelerated, and is very excitable. An occasional irregularity and slight inequality in the force of succeeding strokes may be discovered as the second stage approaches. The skin is dry and of an unhealthy colour. An eruption of almost imperceptible vesicles, which become, however, more obvious towards the latter part of the disease, now occasionally manifests itself. They occur chiefly about the mouth, cheeks, and forehead, the outside of the humerus, and the upper part of the chest. They were first pointed out by Formey of Berlin, and have been subsequently noticed by Golis, Raimann, Schmalz, and other German pa- thologists. Though these writers speak of this eruption as an almost invariable occurrence in hydrocephalus, it has attracted little attention in this country, where almost the only mention of it that we have met with is that by an anonymous writer in the second volume of the Edinburgh Medical and Surgical Journal, who says that it has been considered as a certain sign of approach- ing death. Whilst on the subject of the skin, we may mention that ecchymosed and gangrenous spots have been observed near the close of fatal cases, and we have at the same period remarked a few large-sized vesicles scattered over the body at distant intervals. The duration of the first stage varies according to the acuteness of the attack, from a few hours to a week or more. Second Stage.—The pulse, which had been gradually getting weaker, now becomes irregular, of unequal force, very variable, and unnaturally slow; yet it is still liable to be greatly accelerated on the slightest exertion, or when the patient is taken out of bed, or even placed in the sitting pos- ture. The slow pulse is accompanied with a gra- dually increasing heaviness and torpor, and thi head is now generally less complained of, though this is by no means universally the case. Squint- ing and impaired or double vision now occur along with dilatation and immobility of the pupil, M oscillatory state of the iris occasionally preceding its permanent retraction. The child lies with the eyes half closed, in a soporose state, which is in- terrupted from time to time by exclamations of suffering extorted by the momentary increase of pain. The sickness and vomiting often no* HYDROCE PHALUS. diminish; appetite occasionally seems to return, the child greedily swallowing any food which is presented to it; but the bowels still continue ob- stinately bound, except while under the influence of powerful purgatives. The stools as well as the urine are passed unconsciously. The hands, which are tremulous and unsteady, are frequently raised to the head and back of the neck; and the child is almost incessantly picking at its nostrils, lips, or hair. Spasmodic winking or a fixed stare, a stern or a desponding expression, often rapidly succeed each other. There is great emaciation, and frequent partial suspirations indicative of ex- treme debility and of irregularity in the distribu- tion of the blood. The soporose state is now often suddenly and unexpectedly dispelled, the child recovering the use of its senses, and noticing and even taking an interest in surrounding objects. But this deceitful calm is usually of short duration, and is followed within one, or at most two days, by a deeper state of coma than before. The shrill piercing scream, which is so characteristic of hydrocephalus, oc- curs chiefly in this stage ; and during its continu- ance the pulse becomes almost innumerable, and the cheeks suffused. The duration of the second stage may be variously stated at from one to two weeks. Third stage.—A feeble attempt at re-action now manifests itself, the pulse again rising and attain- ing to a height which is scarcely equalled in any other disease. We have counted it as high as two hundred in a minute, and Whytt once found it it even so high as two hundred and ten. Convul- sions in every degree, from slight spasmodic twitching of the face and vibratory motion of the eye-balls up to violent contractions of the muscles of the trunk and extremities, take place, and are usually soon followed by paralysis of one side, the opposite side continuing to be convulsed at inter- vals. The child lies raving and insensible ; moan- ing and sighing, waving the unpalsied hand through the air, and rolling its head from side to side on the pillow. The cheeks are alternately flushed or pale; the eye half closed, as if from partial para- lysis of the levator palpebrarum ; the conjunctiva bloodshot, and the cornea dim and covered over with a slimy secretion ; the pupil is dilated, the teeth grind violently together, or there is a frequent smacking of the tongue and lips. The balance of the circulation is lost, the skin being dry and burning in some parts, and drenched with partial but profuse perspiration in others. The feet grow cold, the pulse gets weaker and weaker, the respi- ration unequal and stertorous, and a violent con- vulsion often closes the scene. The length of the third stage is even more un- certain than that of the two preceding, varying from a few hours to one or even two weeks. The duration of the whole disease, where the elements of which it is made up are so variable, is necessarily very uncertain. It may be stated approximatively at from two to three weeks, but it is generally nearer to the latter than the former. There has, however, been the greatest difference of opinion as to the time the disease lasts, arising partly from the variety which actually exists in different cases, and partly from the difficulty, in those cases where hydrocephalus is grafted on a Vol. II___61 2 o. previous disease, of ascertaining precisely the pe- riod at which it originated. Fothergill, Cheyne, Golis, and the majority of writers think it usually runs its course in less than twenty-one days, whilst Whytt, on the other hand, has attributed to it a period of from four to six weeks, and Frank has mentioned a case which lasted the longest of these periods. It seems to be considerably in- fluenced in this respect by age, as in very young infants it is often over within a week ; and Coin- det has mentioned one instance which terminated fatally within three days. A still more rapid spe- cies, in which effusion and death take place within a few hours from the commencement of the attack, has been described by Golis under the name of the water-stroke, (wasserschlag,) or hyperacute hy- drocephalus, which may, according to this writer, be either an idiopathic affection, or else the con- sequence of the repulsion of some of the exanthe- mata; or of the suppression of some cutaneous dis- charge, (as that from crusta lactea, tinea, sore ears, &c.) or of the sudden and imprudent check- ing of a diarrhcea, dysentery, or perspiration. The precursory symptoms in this variety are either absent or so slight as to escape notice; and the stages of inflammation and effusion seem to be al- most coincident, the fluid being poured out at the very onset of the disease. Such a disorder rarely leaves any time for treatment, and it terminates almost invariably in death. On dissection, a fluid more turbid than that usually found in hydroce- phalus is detected in the ventricles. Of the cases of hydrocephalus appended to Golis's work, the most rapid was one which terminated fatally in twelve hours ; in the majority death seems to have occurred about the seventeenth or eighteenth day. Springel has assumed fourteen days as the average duration. When the disease makes its attack in a very violent form, infants may be cut off by con- vulsions in its very commencement. Prognosis.—Hydrocephalus has always, and with too much reason, been considered a very fatal disorder. It does not, however, as some would have us believe, universally and necessarily termi- nate in death. Since its diagnosis in the earlier stages has become more accurate, and its inflam- matory nature in the majority of cases been gene- rally recognized, patients have been saved much more frequently than formerly. Recovery has been known to take place after the occurrence of all the most decided symptoms of the disease; slow pulse and stupor, strabismus, dilatation Of the pupil and blindness, convulsions and paralysis. In Dr. Cheyne's essay numerous instances of re- covery under the influence of judicious and ener- getic treatment are detailed. At Geneva, accord- ing to Odier, about eighteen children on an average are attacked by it yearly, and of these about six, or one-third, recovered. Of the eleven cases re- corded by M. Brichteau, four recovered; of Dr. Mill's twenty-eight cases, seven ; and of the thirty- seven given in Golis's work, five had a similar termination. In the whole practice of the latter physician, which has been unusually extensive in the diseases of children, forty-one cases of re- covery from hydrocephalus have been met witii, these were, however, very early seen, and being sub- dued in the inflammatory stage, have been thrown in his tables under the head of inflammation of tha 482 HYDROCEPHALUS. brain. These results are very gratifying to those who feel an interest in the progress of medical science, and form a pleasing contrast to the de- sponding views of Whytt and Fothergill, and the other early writers on the disease. " So long," says Dr. Cheyne, " as the pulse continues steady and the breathing natural, we are not to be pre- vented by the most alarming symptoms from an employment of active remedies." A very few in- stances of what may almost be called spontaneous recovery, so inefficient was the treatment employed, are to be met with in medical writings, and must still farther encourage our exertions on the behalf of those labouring under the disease. Willan speaks of an infant which recovered in the fifth week of its illness, though its case had been aban- doned by the medical attendants as hopeless. No medical man who has a due regard for his own character or for the feelings of the friends of a hydrocephalic patient, should desert a case of this kind at any stage, however unpromising it may be. Under circumstances apparently desperate, a temporary or even permanent amendment will sometimes most unexpectedly take place; and if a new medical attendant has been called in, what is perhaps only the effect of an effort of nature will be set down to the credit of his superior penetra- tion and more judicious measures. After effusion has occurred, the disease is generally supposed to be utterly hopeless ; but such a dogma should be allowed to exert no influence on our practice, both because it seems unwarrantably to limit the powers of nature, and because we possess no unequivocal signs from which we can certainly conclude that such effusion has actually taken place ; for all the symptoms usually attributed to it may, it is now well known, be produced by inflammation alone. In forming our prognosis, much attention must be paid to the state of the pulse and of the excre- tions. If the pulse, from being very quick, falls slowly and moderately, the prognosis must be more favourable than where it comes suddenly down ; the former showing a diminution of fever, whilst the latter might imply that the second stage of hydrocephalus was about to establish itself. Inattention to this point in suspicious febrile cases has often led practitioners into disagreeable mis- takes ; the fall of the pulse inducing them to give a very favourable prognosis, and pronounce the disease at an end at the very moment it was about to assume a new and fatal aspect. Where the pulse, on the other hand, has already become un- naturally slow, a slight increase of frequency may be considered a favourable circumstance; whilst a rapid and very considerable rise would point to the commencement of the final stage. An increased facility in procuring stools, an im- provement in their appearance, a plentiful secre- tion of urine, a profuse warm perspiration, or a running from the nose, are to be considered pro- mising circumstances. It is on the latter of these evacuations that the vulgar reckon most, and em- pirics often take advantage of their credulity to exhibit powerful errhines, a practice which is said, we know not how truly, in some rare instances to have been successful. We must beware, however, of attributing too much importance to any single symptom: thus we nave known a profuse perspi- lation about the head and neck occur though the disease was rapidly hastening to a fatal conclusion- Indeed partial perspirations here, as in most other cases, are generally to be looked on with a sus- picious eye: in the stage of palsy they are the usual forerunners of death. If under the influence of powerful medicines or otherwise, an intermission of symptoms for two or three entire days takes place, we may entertain good hopes of recovery; but unfortunately this cessation is rarely so prolonged. In the great majority of cases the truce is a brief and fallacious one, the irregularity of pulse, headach, vomiting, &c, recurring in a few hours, and the disease pro- ceeding rapidly to its fatal termination. Even in cases of apparent recovery we. must not be too sanguine as long as the pupil continues dilated, 01 contracts but sluggishly on exposure of the eyi to a strong light. Where the acute disease supervenes on the chronic, the prognosis is very unfavourable ; not indeed on account of any irritating or corroding quality which the effused fluid has, as some of the German writers fancy, contracted, but on account of the almost irremediable nature of the exciting cause and the debilitated state of the constitution generally. Where it occurs during the slow and imperfect convalescence from an acute disease, or develops itself in the course of hooping-cough, infantile remittent, or painful dentition, or succeeds to some scrofulous affection or other tedious dis- ease by which the powers of the constitution have been greatly reduced, recovery very rarely takes place. This is attributable in some of these in- stances, partly to the extreme difficulty of detecting the disease of the head in its incipient stage, and partly to the debilitated state of the patient not admitting of the employment of those active mea- sures which the nature of the local disease requires. That variety which occasionally occurs as a sequela to scarlet fever is generally more within the in- fluence of medicine than the other kinds alluded to above. On the other hand, that which occurs in the early stage of this disease or of the measles usually assumes a very violent form, and is, as we have already stated, almost always rapidly fatal. Amongst the possible terminations of acute hydrocephalus is its passage in the chronic form; but this is extremely rare, and is scarcely to be desired, being very liable to be accompanied with blindness or deafness, idiocy, epilepsy or paralysis, or some other lamentable impairment of the func- tions of the nervous system, arising from the serious injury which the brain has undergone. Such consequences are, however, not universal. Guersent mentions a case which, having become chronic, got completely well on the spontaneous occurrence of a cutaneous eruption, and that too after all the ordinary means of treatment had proved ineffectual. It has appeared to Dr. Cheyne that hydroce- phalus is more frequently cured when it occurs in such constitutions as have a decided predisposi- tion to it, which may always be presumed when several individuals of the same family have been successively attacked. This apparent paradox is perhaps only explicable on the supposition that previous losses dispose and enable parents more early to detect the incipient symptoms of the dis- ease, and thus lead to the employment of an ap- HYDROCEPHALUS. 433 propriatc treatment at that period when medicine is most likely to be of any avail. Success has by some been thought most probable in those cases which come on slowly and gradually, and thus afford ample time for treatment. According to Abercrombie and Golis, on the contrary, those are the most favourable in which the symptoms indi- cate very active inflammation, and admit of ener- getic treatment; whilst the least promising cases are those where the inflammation is of the low or scrofulous kind. " In all," says the first of these writers, " the period for active practice is short, the irremediable mischief being probably done at an early period of the disease." Diagnosis.—There is perhaps nothing more characteristic of this affection of the brain than the rapid fluctuation's which the several functions of the body undergo, and that often within a very brief space of time. This mutable condition is indicated in the cerebral functions by the state of the intellect and senses, now unnaturally acute, again dull, and at times altogether obliterated. The muscular system is at one moment unaffected save by debility, and the next moment perhaps convulsed or paralysed. The pulse and capillary circulation are constantly varying under the in- fluence of slight or inappreciable causes, the face being at one moment flushed and at the next deadly pale, whilst heats and chills, perspiration and dryness of the surface, rapidly alternate. The respiration likewise undergoes endless changes in force and frequency. The functions of the diges- tive organs are equally variable, anorexia and in- cessant vomiting being succeeded by an apparent insensibility of stomach, or a ravenous and indis- criminating appetite. Of effusion having actually taken place, there is, as we have already stated, no symptom, nor even set of symptoms, which can afford us certain evidence. Somnolence, strabismus, convulsions, and partial paralysis, which were once so much confided in, have lost much of their credit since pathological anatomy has been more diligently cultivated ; and numerous cases are now on record where they all existed though no water was found on dissection. Coma, immobility and dilatation of the pupil, and blindness, and sundry other symptoms which have been supposed by later au- thorities to be more worthy of reliance, will also frequently deceive us as far as effusion is con- cerned : their true value consists in fixing atten- tion on the state of the brain itself. When we recollect that the effusion is a mere result or con- sequence of the disease, and reflect on the com- plicated state of cerebral derangement which often precedes or coexists with it, the difficulty of re- cognising it with certainty during life will cease to surprise us. In a practical point of view, moreover, it is of less importance than is gene- rally imagined. It is not the effusion, so much as the morbid state of the parts within the cranium which leads to it, which is the legitimate object of treatment: over the former, when it already exists, many doubt whether medicine can exert any in- fluence. The difficulty of distinguishing hydrocephalus in its earlier stages from many of the febrile affec- tions to which children are liable is often very considerable Wc may generally avoid confound- ing it with the infantile remittent fever by attend- ing to the extreme irritability of stomach, and its aggravation by the erect posture and by motion —the greater severity and constancy of the head- ach—the disposition to somnolency, the child often falling asleep the moment after it has been replaced in bed, or after it has been answering our questions—the knitting of the brows and aversion to light and noise, the pupil being at first con- tracted and subsequently unnaturally dilated—the caution in moving the head, and the frequent raising of the hands to it—the thrusting back of the neck—the variability and extreme excitability of the pulse—the green stools or obstinate cos- tiveness. The morning remissions moreover, if they occur at all, are much less marked in hydro- cephalus than in the infantile remittent. Amidst our efforts to establish a diagnosis in any particu- lar case, we must not forget that diseases are at times, in the language of the older writers, con- vertible into each other; or that, to use the more moderate phrase, complications may arise in their course, and the secondary affection eventually pre- dominate over the original. It is thus that in the course of infantile fevers hydrocephalus frequently comes on, and often with such insidious advances as altogether to elude observation almost up to the very moment of its fatal termination ; we confess we have even remained doubtful as to the existence of the disease within the head till the scalpel re- vealed its presence. Where infantile remittent is about to pass into hydrocephalus, the remissions become gradually less and less distinct. Pain is in some cases never complained of. Fevers of a typhoid type are comparatively rare in children, and when they do occur can scarcely, with ordinary attention to the symptoms, be confounded with hydrocephalus. Golis has, with a truly German patience, been at the pains of drawing a long parallel between the two dis- eases. The more equable pulse, the diarrhoea with dark and fetid stools, the trembling tongue, petechiae. and low muttering delirium, the vumid belly, supine posture, and sliding to the bottom of the bed, to say nothing of the absence of all the more striking symptoms of hydrocephalus, will scarcely suffer us to confound a case of typhus with even the obscurer examples of the former disease. In connection with low and protracted fever, symptoms frequently occur, as has been remarked by Abercrombie, which seem to indicate serious affection of the brain, and yet these shall all dis- appear as the fever subsides. Thus he gives a case of a child labouring under a tedious disorder of this kind, accompanied with stupor, blindness, dilated pupil? and squinting. After lying sueech- less for near a month, it gradually recovered attc; a copious discharge of matter from one of the ears. We think it probable, however, that the essential part of hydrocephalus, namely, inflam mation in the central parts or at the base of the brain, was present here, and that the fever was throughout only symptomatic, and its cessation attributable to the escape of pus from the external meatus. A want of correspondence in the symptoms has been pointed out as one of the marks of this disease of the brain. Thus, when the headach «» 484 H Y D R O C E PHALUS. greater or more permanent than accords with the degree of fever, and especially if the pain in- creases in intensity as the pulse falls, our suspi- cions should be awakened. Brichteau dwells on the slightness of the thirst and its total dispropor- tion to the fever. This, however, is by no means invariably the case. Many children labouring under hydrocephalus drink largely, so that M. Brachet, another French writer, has even consi- dered the extreme avidity with which they seize the vessel containing their drink as one of the most remarkable symptoms of the disease. The frequent and deep sighing and the peculiar scream, such as might be uttered under the agonies of a severe surgical operation, are also very char- acteristic of the disease. Severe pains appearing successively in different parts of the body, and for which we cannot in any way account, should in children as well as in adults always excite suspicion, and make us turn our attention to the nervous system, and especially to the state of the organs contained within the cranium and spine. The diagnosis is peculiarly difficult in feeble children who have been exhausted by long pre- vious illnesses, as scrofula, painful dentition, or chronic disorders of the digestive organs already attended with vomiting. Quin met with a case of acute hydrocephalus which proved fatal in seven days, in which there was no evident division into stages, no dislike of light, nothing characteristic in the pulse, no dilatation of the pupils, nor any violence of headach; and Rush alludes to similar cases. In very young infants the detection of the dis- ease in its er.riy stage requires the closest obser- vation. Long-continued wakefulness, or starting from sleep with a cry of alarm, or prolonged screaming without any obvious cause, should al- ways awaken our apprehensions ; and when the infant subsequently lies moaning and drowsy, and rolling the head from side to side on the nurse's arm, or thrusting it back against the pillow ; when there is frowning and aversion to light, a con- tracted state of the pupil, and unusually frequent vomiting, our suspicions are almost converted into certainty. The negative indications also, or the absence of well-marked disease in the chest or abdomen, will frequently throw additional light on the nature of the case. The face, as has been remarked by Cheyne, is expressive rather of un- easiness than of acute pain ; nor is there the ex- treme violence of temper, or the alternate throwing out and drawing up of the legs which accompa- nies colic and griping pains in the bowels. « In no other infantile complaint do we observe the same knitting of the eye-brows unaccompanied with crying. The head hanging over the nurse's shoulder, and the half-closed eye-lids, are also alarming symptoms." Where convulsions, to- gether with strabismus, dilated pupil, blindness, and a comatose state, have already taken place, the nature of the case is but too evident. Con- vulsions, as we have already stated, sometimes occur even at the commencement of the disease ; no one, we believe, at the present day considers them ever to be a purely idiopathic affection; whatever may be their exciting cause, they indi- cate sprio'is functional derangement of the nervous system, and what was originally perhaps only sympathetic disorder, may, if neglected, terminate in organic disease. When convulsions or spasm of the glottis, which may be considered as a modi- fication or local species of them, resist the ordinary means for correcting disordered states of the diges- tive organs and improving the general health, we should suspect a tendency to disease of the brain, and take our measures accordingly. A readiness in detecting that species of hydro- cephalus which occurs some days or weeks after an attack of scarlatina, is peculiarly desirable, both because it is an affection by no means of rare occurrence, and because, if taken early, it is the most manageable perhaps of all the forms of dropsical effusion within the head. The first symptom which warns us of its existence is se- vere headach ; and if this be neglected, convul- sion, loss of sight, and a comatose state soon follow. Like the general anasarca which usually accompanies it, it is a truly inflammatory affection, and may be often speedily arrested by the use of active antiphlogistic measures. It is most to be dreaded when it makes its advances in a slow and insidious manner. The sudden disappearance of the anasarca, when unaccompanied by any in- crease in the evacuations, occasionally gives rise to this affection of the head. A lethargic state, with irregularity of the pulse and dilatation of the pupil, occurring with or with- out fever, occasionally depends on constipated bowels, and vanishes rapidly on the exhibition of an active purgative; but it is highly probable that such cases, if neglected, would often pass into con- firmed hydrocephalus; for we cannot agree in opinion with Willan and Underwood in thinking that cases, though they possess all the character- istic symptoms of hydrocephalus, yet are not re- ally allied to that disease, provided they yield to the free use of purgative medicines. Dilatation of the pupils has sometimes seemed to depend on the presence of worms in the intestines. In all cases of doubt it is safer to lean to the supposition of the disease being hydrocephalus, and to treat it as such. From this, even though we should be in error, little inconvenience can arise ; whilst, on the other hand, if we wait until unequivocal symptoms of the disease in its con- firmed state have developed themselves, all our efforts at checking its further and fatal progress will too often be of no avail. Dr. Gooch has described a peculiar state of the brain occurring in infants which has usually, but erroneously, been attributed to congestion of this organ ; whereas it seems really to depend on the very opposite state, or a deficiency of blood in it It is in children of from two months to two or three years old that it usually makes its appear- ance, and generally in such as are small and deli- cate, and have been exposed to some previous de- bilitating cause. The leading symptoms consist in heaviness of the head, drowsiness, and languor. There is an absence of heat and of all the symp- toms of fever, the skin being occasionally even colder than natural. The tongue is slightly white, and a transient flush at times passes over the cheek. There are no signs of pain. Under the antiphlogistic treatment usually pursued in acute hydrocephalus, consisting of leeches, cold applica- HYDROCEPHALUS. tions, purgatives, and especially calomel, all the symptoms become aggravated, the child growing colder and more languid, the pulse quicker and weaker, and death by exhaustion takes place after a few days; whilst, on the contrary, several have recovered under the use of an abundant supply of light nourishment, and the cautious employment of ammonia and other stimulants. In two cases only did he observe symptoms of oppressed brain, coma, stertor, dilated and motionless pupils; and this was only for the last few hours before the fatal termination. On dissection, the brain is found pale and bloodless, with no other morbid appearance than perhaps an increased quantity of serum in the ventricles. The late Dr. Armstrong has applied to an affection in many respects very like that just described, the name of " hydrocepha- lus from venous congestion;" whilst by Dr. Darwall it has been called asthenic hydrocepha- lus. The disease, however, to which the term hy- drocephalus is, by the majority of writers of the present day, conventionally restricted, is so differ- ent from this passive effusion, as well in most of its symptoms as in the treatment which it requires, and in the morbid condition of the brain discovered after death, that no benefit, we think, can arise from comprising both under the same name. The term, in regard to its derivation, is, we admit, equally applicable to each; but this only shows the impropriety of having named them, not from any thing essential, but from an effusion which may be present or absent in both, and is conse- quently characteristic of neither. The above described morbid condition in in- fants has also been noticed by Dr. Marshall Hall, who was generally able, to trace it to the diarrhcea of weaning, or to leeching from some previous complaint, or some other cause of exhaustion. He too, like Gooch, believes that it is often mistaken for»hydrencephalus, or inflammation of the brain." There is at first, according to his observation, great restlessness with irritability of temper, pale and anxious countenance, and frequent pulse; dozing and deceptive appearances of amendment succeed ; but the pulse continues to rise, the cheeks and the extremities grow cold, the voice and cough husky, and the patient soon sinks ex- hausted ; — a termination which may, however, be often averted by a proper supply of nourish- ment and a cordial soothing plan of treatment. Dr. Abercrombie, in like manner, in the last stage of diseases of exhaustion has seen both adults and children, but especially the latter, fall into a state resembling coma for a considerable time before death : the pulse still continuing to be distinctly felt, though feeble ; the face pale, the pupils di- lated, and the eyes open, but insensible. He has known children, after lying for a day or two in this kind of stupor, recover under the use of wine and nourishment. This state, which seems to correspond very nearly to the apoplexia ab inani- tione of the older writers, is supposed by Dr. Gooch to consist in impairment of the nervous energy, or deficient cerebral circulation. Profuse hemorrhage is well known to be capable of producing dilata- tion of the pupil and blindness; and when ani- mals are bled to death, convulsions very usually occur, and more or less serous effusion takes place 2 a* 485 in the brain, as appears from the experiments of Dr. Leeds. Appearances on Dissection. — There is sometimes, in consequence of previous inflamma- tion and adhesion, considerable difficulty in sepa- rating the skull-cap from the dura matter, and the former is occasionally thinner, more transparent, and of a bluer colour than usual. When we come to examine the state of the parts within the cranium after death, we usually find the vessels on the surface of the brain in a state of considera- ble congestion. A net-work of florid vessels is occasionally observed in the pia mater, and even patches of extravasated blood, indicative of high inflammatory action, are occasionally detected. This membrane at times also adheres more strong- ly than natural to the brain. An effusion of se- rum underneath the arachnoid, and filling the space between the convolutions, is very frequently observed. When it is considerable in quantity and of a yellowish hue, it might be mistaken by a superficial observer for a gelatinous effusion. In some instances it has a sero-sanguinolent charac- ter. Opacity and thickening of the arachnoid membrane, and depositions of coagulable lymph, or more rarely of puriform matter on its surface, or between it and the pia mater, are amongst the more commonly observed morbid appearances, and prove unequivocally the inflammatory nature of the affection. These occur especially at the base of the brain, about the pons varolii and decussa- tion of the optic nerves. That these and many other characteristic morbid appearances should have escaped observation in the slovenly manner in which the brain used too often to be examined by slicing it from above downwards in situ, is not wonderful. Before commencing the dissection of the brain itself, it ought to be removed altogether from the skull and inverted into a plate, so as to enable us accurately to examine the important parts at its base. Adhesions between the opposite surfaces of the arachnoid through the medium of false membrane, are sometimes, though rarely, observed. The arachnoid is occasionally covered, especially when it lines the ventricles, with minute granulations, which give it a rough appearance. They are pro- bably one of the many forms which the effused coagulable lymph assumes, and require a good light for their detection. We must not confound with these granulations the bubbles of air which at times exist between the pia mater, and which may be distinguished by their vanishing on rais- ing this membrane. The mass of the brain itself, in some rare in- stances, has appeared evidently infiltrated with se- rosity. Golis mentions such a case, in which the fluid could be expressed from the cerebral sub- stance as if from a sponge; and Cheyne also has noticed this appearance of increased moisture on making sections of the organ. A frequent appearance is that of an unusual number of bloody points in the cut surface of th« brain, indicating a considerable increase in its vas cularity. The substance of the brain in acute hydroce- phalus is generally softer than natural; and this is especially observable towards the central parts. Yet in some cases, and especially in those whirb. 486 HV DROCEPHALUS. run a veiy lapid course, it is found to have re- tained its usual firmness. In most instances the ventricles contain a con- siderable quantity of fluid, which is usually more limpid than that found in the other serous cavities. Sometimes, however, it presents a turbid, whey- like, or puriform appearance, with shreds of coa- gulable lymph floating in it, as well as lining the walls of the ventricles; and this is particularly the case in the most acute and rapid examples of the disease. The existence of a fluid may often be predicted before we have punctured the ventricles, from the feeling of fluctuation communicated to the finger applied to the surface of the hemi- spheres, as well as from the flattening of the con- volutions. The quantity of water varies from a few tea-spoonsful to seven or eight ounces; four or five ounces may be stated as the average. Of this the greater part is contained in the lateral ventricles, the posterior horns being usually much enlarged, and the anterior portion of the fornix elevated so as to make the opening of communica- tion very free with the third ventricle, in which, as well as in the fourth, and in some very rare instances also between the layers of the septum lucidum, the effused fluid is likewise found. The choroid plexus is very generally remarkably pale. Small vesicles, not unlike hydatids, are occasion- ally found attached to the pia mater; and we have seen such adhering to the choroid plexus. They seem to owe their origin merely to a circumscribed sub-arachnoid infiltration; the serous membrane being detached by the effusion at a given point, and distended into a small cyst. The septum lucidum, the fornix, and other parts forming the walls of the ventricles, are often found in a state of softening, being of a pulpy or occasionally even of a creamy consistence, whilst the lining membrane of these cavities displays equal evidence of inflammation by its opacity, as well as by the layers of coagulable lymph with which it is at times overspread. A lacerated open- ing in the septum lucidum occasionally exists, and forms a new and unnatural communication be- tween the lateral ventricles. We have seen the iafundibulum and the cellular membrane in the structure of the pituitary gland distended with se- rous effusion into the form of a little bladder. This, by its direct pressure on the optic nerves, in ad- dition to that to which they are exposed from the lymph effused at the base of the brain, and from the dilatation of the ventricles, must tend to com- plete the derangement of the functions of vision. Laennec has spoken of minute tubercular gra- nulations dispersed through the brain, and disco- verable by a careful microscopic examination; but as their existence has not been confirmed by subsequent observers, it is probable they are at most only a casual occurrence. Other morbid appearances, of a date anterior to the hydrocephalus, and occasionally, no doubt, its cause, such as tubercles or abscesses in the brain, caries of the petrous portion of the temporal bone, &cc, not unfrequently co-exist, and should be care- fully sought for. With regard to the nature of the effused fluid, It differs somewhat from that found in the other serous cavities, being for the most part not coagu- lable bv heat or acids; this is, however, by no means universally the case, a slight coagulatim having in some instances been detected by Dr. Baillie, Dr. Blackall, and others. It has been carefully analyzed by Marcet. Of 1000 parts operated on, 990-80 were water; 1-12 muco-ex- tractive matter, with a trace of albumen; 6-64 muriate of soda; 1-24 sub-carbonate of soda, with a vestige of an alkaline sulphate; -20 phosphate of lime, with traces of phosphate of magnesia and of iron. Acids or heat, according to this chemist, did not produce any decided coagulation. It has been already stated that abdominal affec- tions often complicate hydrocephalus, that they frequently precede it, and are probably not very rarely its exciting cause. On dissection, unequi- vocal examples of disease in the viscera of the abdomen have been detected in too many cases to be considered a mere casual coincidence. Thus the liver has been found enlarged, and presenting evident traces of inflammation on its surface, and adhering through the medium of organized lymph to the neighbouring parts. Tubercles on its sur- face or in its substance, as well as in that of the spleen and mesenteric glands, are occasionally ob- served. We have found the mucous membrane of the stomach and intestines inflamed, the patches of Peyer's gland much developed, and such firm contraction of the intestinal tube as to give it in parts the appearance of a solid chord. This spas- modic state, when existing in the large intestines, enables us to account for the great difficulty which sometimes attends the administration of enemata during the latter part of the disease. We have likewise met with intus-susception of the small intestines, an appearance of which has been al- luded to by several writers on the disease. The spasmodic state of the intestines which is thus evinced is probably in some degree analogous to the convulsive actions in the voluntary muscles, and takes place like them under the influence of the morbid state of the brain; at least, they do not seem to be attributable solely to the irritation in the mucous membrane, both because such ex- trerhe contraction is not usually observed in in- stances of uncomplicated inflammation of this membrane, and because we have found it greatest in those parts of the intestines which presented least appearance of inflammation. We have no- ticed a similar constriction of this canal after death by tetanus, where there existed no inflammation of the intestines. The peculiar green colour of the stools in hy- drocephalus has been attributed to their union with the morbid bile. We were first led to enter- tain doubts of this opinion being universally cor- rect, and to ascribe the appearance in question rather to a morbid secretion from the glands of the intestines themselves, by observing that the peculiar porraceous tinge was not acquired in per- fection till the faeces had reached the lower part of the small intestines, the contents of the upper portion being of a pale drab colour, whilst he bile in the gall-bladder was of a yellow colour, and without any tinge of green. The assertions of Dr. Cheyne as to the fre- quency of disease in the liver and intestines have been corroborated by the subsequent observations of Dr. A. T. Thomson, Mr. Cooke, and others. In eleven dissections of patients dead of this di* HYDROCE PHALUS. 487 ease, Dr. Thomson found traces of inflammation of the liver in nine, inflammation of the colon in the tenth, and intus-susception of the jejunum in the remaining one ; whilst in three out of Mr. Cooke's four cases the liver was found diseased. Dr. Wilson Philip's experience leads him to the conclusion that five out of six cases of hydro- cephalus arise out of the derangement of the di- gestive organs; and Abernethy has mentioned three cases of hydrocephalus in all of which the liver and bowels were notably diseased. Though evident traces of inflammation in the brain or its membranes are detected in a very large proportion of cases, yet there are a few in which a trifling effusion of serum in the ventricles or under the arachnoid is the only morbid appear- ance discoverable; there being neither congestion of the vessels nor effusion of coagulable lymph, nor softening of the central parts of the brain, the whole organ being as firm and perhaps even paler than in its natural state. Such is, as we have al- ready stated, usually found to be the case in infants who have died with the symptoms of passive effusion previously described. M. Bricheteau, in the Archives Generales for the year J 824, has de- scribed a case where most of the usual symptoms of hydrocephalus had existed; and yet, on dissec- tion, a limpid serous fluid in the ventricles was almost the only thing detected, and was not by him thought to be the result of inflammatory ac- tion : by many, however, we believe it would have been considered as an instance of low inflam- mation in the arachnoid. Of late years, since pathological investigations have been conducted in a more careful and methodical manner, it has been much more rare to hear of cases which, having possessed the whole assemblage of symp- toms characteristic of acute hydrocephalus, yet present on dissection no indubitable marks of in- flammatory action. Guersent candidly confesses that amongst his earlier dissections he has notes of many such cases in which no allusion to in- flammatory appearances is made; but that, as he became more accurate in his mode of examining the brain, the instances in which proofs of their existence could be detected became infinitely rarer. Theories of the Disease.—The uncertainty which has prevailed as to the true nature of acute hydrocephalus has given rise to a corresponding diversity of opinion as to the appropriate place for it in systems of nosology. It was long con- founded with apoplexy, till Whytt, by a closer in- vestigation of its symptoms, became convinced that it was much more nearly allied to chronic hydrocephalus. Cullen, who at first classed it along with chronic hydrocephalus, in a later edi- tion of his nosology made it a species of apoplexy, under the name of apoplexia hydrocephalica. By Macbride it was placed along with fevers, under the name of febris nervosa hydrocephalica ; and a similar view of it was taken by Pinel in the earlier editions of his Nosographie Philosophique, in which it bears the name of cerebral fever; but ne subsequently restored it to its old place amongst the dropsies: there is, however, usually no evi- dence of any dropsical diathesis, effusion into the other cavities, or swelling of the face or limbs, scarcely ever co-existing with it. The investiga- tion of the disease by Quin and Rush, proceeding on the basis of pathological anatomy, the only solid groundwork of nosological arrangement, ted to a more correct conception of its nature, and demonstrated its affinity in a great majority of instances to the phlegmasiae. Subsequent inqui- ries, both in this country and on the continent, have tended to confirm the justice of this manner of considering the subject, and have proved that the effusion is almost always a secondary pheno- menon occurring in connection with obvious mor- bid changes in the brain or its membranes, and in a very large proportion of cases demonstrably the results of inflammation. So fully convinced is Rostan of the effusion being always consecutive to cerebral or meningic lesions, and never consti- tuting an essentially distinct disease, that he pro- poses that the term hydrocephalus should be alto- gether expunged from our tables of nosology. As the effusion and other morbid appearances are such as to indicate inflammation of the serous membrane, the disease has been treated of by several foreign writers under the head of arach- nitis of the ventricles and base of the brain; whilst others, conceiving that inflammation of the cerebral structure itself often precedes that of the membranes, have referred its symptoms to the head of cephalitis. Thus, by Conradi it is called " encephalitis exsudatoria infantilis," and by Coin- det, " cephalite interne hydrencephalique." That the effusion does not constitute the most important feature in the disease, and that it is not indispensable to the production of any of the symptoms which characterize hydrocephalus, we have a double proof; first, in the occasional ab- sence of these symptoms where effusion to a con- siderable extent is detected on dissection ; and secondly, in their being sometimes present, and that in a very marked degree, when an examina- tion of the brain after death has shown that no effusion had yet taken place. There is sometimes even reason to think that the inflammatory tension is temporarily relieved by this increased action of the exhalent vessels : this can, however, be the case in those instances only where the effusion is moderate. Where it takes place rapidly, and to a considerable excess, it cannot fail to add still fur- ther to the derangement of the cerebral functions, and to manifest its presence by symptoms indica- tive of compression under some circumstances, and of irritation under others. We cannot, therefore, concur in opinion with a late writer, who supposes that the increasing fluid, by stimulating the brain, may occasionally answer a beneficial purpose, and give rise to that momentary recovery of the senses and of the intellect which so often takes place before the fatal termination. Such fleeting and fallacious indications of improvement in the state of the cerebral functions should perhaps rather be attributed to a temporary diminution in the quan- tity of water in the ventricles under a casually in- creased action of the absorbing vessels. This par- tial re-absorption of the aqueous effusion, some time previous to death, is rendered probable by the instances of a similar diminution of effused fluid in the extremities and other parts of the body lying open to our observations, being by no means rare in dropsical subjects at this period. It is only to some change in the state of the effused fluids, or of the circulation within the brain, that we can 488 HYDROCE look for an explanation of this fact; for as to the alterations of structure and consistency which have occurred in any portion of the cerebral mass or its membranes, it is inconceivable that they should undergo any sufficiently rapid modification to ac- count for it. As to the presence of absorbing vessels in the brain, so long a subject of dispute, the changes which are now so well known to take place in the apoplectic coagulum cannot leave a doubt. The occasional diminution of the effused fluid in chronic hydrocephalus under the influence of pressure or other methods of treatment, is also conclusive on the same point. Indeed the analo- gies in favour of the existence of such vessels within the brain are so strong, that it seems won- derful that there ever should have been any scep- ticism on the subject. It is altogether incon- ceivable that the fluid, which even in a state of health always lubricates the serous cavities within the cranium, should, unlike that in the thorax or abdomen, be stagnant and incapable of removal. Cheyne suggests that the effused fluid may answer the usual purpose of supplying the place of the cerebral matter removed by absorption, thus giving support to the brain, and enabling it in some de- gree to continue its functions ; and hence he con- ceives that any sudden withdrawal of the water, so far from being desirable, might even have a fatal effect. Morgagni was one of the first pathological anatomists who pointed out the very frequent de- pendence of effusion on organic disease of the brain ; and Portal has likewise long since insisted on the very secondary importance of the latter* in determining the indications of cure. The belief in the inflammatory nature of hydrocephalus, since it was first promulgated by Quin and Rush, has been slowly but steadily making its way both in this and all other countries where medical theories are in any degree under the influence of morbid anatomy. Dr. Garnett argued in favour of this view of the disease from the buffy state of the blood, the acuteness of the pain, the character of the pulse, the benefit received from antiphlogistic measures early employed, as well as from the ag- gravation ensuing upon the use of stimulants, and finally from the appearances found on dissection. Similar views were followed up with great industry and ability by Dr. Cheyne, who showed that the opinion of Fothergill, who attributed the effusion to the rupture of a lymphatic vessel in the brain, as well as that of Whytt, who ascribed it to a watery state of the blood, or to a laxity of the ex- halents, and that of Darwin, who thought it con- sisted in a debility of the absorbent vessels, were all hypothetical and untenable; whilst he proved by numerous carefully made dissections that drop- sical effusion here, as in so many other cases, is, to use the language of Heberden, not so much a disease in itself as a symptom of one. The opinion of Cheyne seems to be, that hydrocephalus owes its origin, in the first instance, to inflammation; that this gives rise to a morbid accumulation of blood in the head, or venous congestion; and that effusion is the ultimate result. Occasionally the concatenation of morbid actions can be traced still farther back : thus there is often, first, disease of a distant part, then increased irritability, which is soon attended by increased arterial action, absorp- PHALUS. tion of the substance of the brain, venous conges tion, and finally effusion. " There is no proof whatever," says the above-named writer, "thatthe effusion into the ventricles is the cause of any of the violent symptoms." The greater or less quantity of fluid found in the ventricles in acute hydrocephalus seems to de- pend on the length of time which the patient has continued to live after the commencement of the second stage. Though the state of the disease may undergo some modification by the occurrence of effusion, yet there is much reason to believe that some degree of inflammation exists to the very end. Cheyne, although a strong advocate for the inflammatory nature of hydrocephalus, by no means goes the length of Dr. Rush, so as to believe it merely a modification of phrenitis. He points out, on the contrary, with his usual accu- racy, many striking marks of distinction between the two diseases, deduced from their causes and symptoms, from the ages respectively prone to each, as well as from the morbid appearances found after death. " Hydrocephalus," he con- cludes, " appears to consist in a diseased action of a peculiar kind, but of what kind we can as little explain as we can the nature of the scrofulous or syphilitic action." According to Abercrombie, hydrocephalus is originally an inflammatory affection ; in its most ordinary form seated chiefly in the substance of the central portions of the brain, and terminating generally in ramollissement of those parts, com- bined with serous effusion into the ventricles. It may, however, prove fatal, and have all the symp- toms commonly considered as those of hydro- cephalus, without any effusion. Thus we occa- sionally observe coma of long continuance, though on dissection no such cause of it is detected; and on the other hand, effusion has been unexpectedly found, though coma had never manifested itself. Again, even when the symptom does exist, it may sometimes be entirely removed by purgatives and other antiphlogistic measures, and yet the disease proceed uninterruptedly to its fatal termination. In the cases which have been published by the same able physician, we meet with every variety in the state of the pulse, the vision, and the intel- lectual functions ; so that we can obtain from none of these sources indubitable evidence of effu- sion having taken place. Though inflammation of the central parts of the brain constitutes the most frequent modification of hydrocephalus, he admits that it may take place in connexion with inflammation of other parts of this organ, or of the membranes which envelope it. He has noted but two instances in which he did not succeed in demonstrating other inflammatory appearances besides the effusion of serum ; and in these the disease presented itself in the most insidious and chronic form, and offered a remarkable contrast to the active symptoms of what he considers the usual species of the disease. As to the serum, he believes, that even though it were absorbed, the patient's condition would be little improved, as the softening or disorganization of the brain would remain behind. In a word, the coma and other symptoms of hydrocephalus are the effect, not of the effusion, but of that morbid condition of the brain of which it is itself the consequence HYDROCEPHALUS. 499 Lallemand conceives that the inflammation in hydrocephalus may commence either in the cere- bral substance, and subsequently extend to the membranes of the brain, and thus induce effusion ; or, on the other hand, begin in the arachnoid, and extend, after a longer or shorter period, to the brain ; but of these two origins he considers the latter by much the most frequent. In their earlier stages he believes that they may often be distinguished from each other. The possibility of their com- mencing simultaneously in some cases, in both these parts, under the influence of a common cause, must not, however, be forgotten. Inflam- mation of the membranes, according to Lallemand, is characterized by restlessness, insensibility, con- vulsive affections and delirium ; whilst that of the cerebral substance itself may be recognised by the gradually extending paralysis, the rigidity and pains in the limbs, together with the impairment of the memory and intellect. Inflammation of the brain itself has a rapid progress, and is speedi- ly mortal. Hence, when the symptoms of hy- drocephalus depend on inflammation of the cere- bral substance, they are more severe, and the dis- ease runs a shorter course. In several cases such inflammation has existed in the septum lucidum, fornix, and other central parts of the brain, with- out extending to the arachnoid where it lines the ventricles, and consequently without effusion, and yet all the symptoms of hydrocephalus have been present. Hence, he argues, it is highly probable that even in those other cases where effusion does exist, it has much less concern than the state of the neighbouring parts in producing the charac- teristic symptoms of the disease. From erroneous views on this subject too little attention has, he thinks, been paid in the treatment to the ramol- lissement, and the efforts of practitioners have been too exclusively directed to promoting the ab- sorption of the effused fluid. The investigations of MM. Martinet and Pa- rent-Duch&tetet have shown that inflammation of the arachnoid at the base of the brain hs much more common in infancy than in adults. In the latter, inflammation of this membrane occurs more frequently in that portion of it which covers the upper and lateral parts of the hemispheres, and is characterized at first by delirium, to which a so- porose state and at length coma succeed ; whereas in the arachnitis of infants there is a greater ten- dency to convulsive affections and less to delirium. [Dr. D. D. Davis, of the London University, maintains, that acute hydrocephalus is an inflam- matory disease, and that it is curable equally and by the same means with other diseases of inflam- mation. - (Acute Hydrocephalus or Water in the Head, an Inflammatory Disease. Amer. Med. Lib. edit. Philad. 1840.)] The inflammatory nature of the great majority of cases of hydrocephalus has also been recognised in its fullest extent by Golis, Conradi, and almost all of the German pathologists of the present day. Formey, however, a very respectable authority, thinks that the frequency of effusion into the ven- tricles during childhood depends not on inflamma- tion, but merely on a state of increased activity "i the vessels of the brain, which accompanies its rapid and premature development; but Raimann with much reason believes that in addition to this Vor..II. —62 state, the existence of true inflammation, either of an acute or chronic kind, is indispensable. [Of late years, by many pathologists the acute hydrocephalus of authors has been regarded as tubercular meningitis. According to MM. Bar- thez and Rilliet, (Traite Clinique el Pratique des Maladies des Enfants, i. 550. Paris, 1843,) M. Pa- pavoine is probably the first who established the tubercular nature of this form of meningitis. (Journal Hebdomadaire, vi. 113. Paris, .1830.) Afterwards, MM. Fabre and Constant presented a memoir on the same subject, which was " crowned" by the Institute. In 1835, Dr. Gerhard, of Phila- delphia, (American Journal of the Medical Sciences, Nov. 1835,) and M. Rufz, (Tfiise de Paris, 1835,) published their observations on the subject. An inaugural dissertation by M. Piet, published in 1836, is highly spoken of by MM. Barthez and Rilliet. These gentlemen regard tubercular meningitis or acute hydrocephalus to be characterized anatomically as follows :—First. By a deposition of tubercular matter in the meshes of the pia mater, presenting itself in the form of flattened or round granulations disseminated in different parts of the hemispheres or base of the brain, often not larger than a pin's head, most frequently opaline or white, sometimes grey; semi- transparent ; commonly isolated, sometimes con- gregated ;—in very rare cases, the granulations being the sole meningeal lesion. Secondly. By inflammation, characterized by a secretion of con- crete pus or of false membranes in the pia mater, which is thickened, yellowish or greenish, friable, and sometimes adherent to the cerebral surface. This phlegmasia most commonly coincides with the tubercular granulations of the meninges. In rare cases, it is entirely independent of them. It commonly occupies the base of the brain. In 27 of 33 patients, MM. Barthez and Rilliet found the tubercles or granulations and the phlegmasia of the pia mater associated; in four cases, the menin- gitis was not accompanied by any tubercular pro- duction of the encephalon; in two cases, the granulations or meningeal tubercles had not oc- casioned any phlegmasia. In all these cases, however, the symptoms were nearly identical. Thirdly. By a peculiar state of the arachnoid, which renders it slightly glutinous or fishy to the feel. Fourthly. By a white, creamy softening of the central parts of the brain, occupying, in the majority of cases, the septum lucidum and for- nix, seldom extending to the inferior parietes of the ventricles. Fifthly. By an effusion of serum into the ventricles, varying from two to four fluid ounces, and, at times, in much greater quantity. Sixthly. By a deposition in the organs of tuber- cular matter, generally at a slightly advanced stage, or when it has assumed the acute form. It may be proper to remark, that patients un- questionably present themselves with all the symp- toms that are ascribed to acute hydrocephalus, with- out any tubercles being present in the brain or its meninges; whilst, on the other hand, it is affirmed by Dr. P. Hennis Green, tubercles may exist with- out there being any cerebral or other phenomena, that could give occasion to more than a suspicion of their existence, and in some cases not even to that.] Causes.—Of the predisposing causes, the pe 490 HYDROCEPHALUS. riod of life seems to be one of the most influential; hydrocephalus being very much more frequent during infancy and childhood than at any subse- quent period. The rapid evolution which the brain is then undergoing, and the great proportion of blood sent to the head, appear to be the causes of the peculiar tendency to cerebral inflammation which characterizes this age. The more early and rapid the development of the cerebral organs, the greater is the risk of hydrocephalus. Its con- nection with precocity of intellect is indeed mat- ter of daily observation, and large-headed children are generally found to be the most subject to the disease. The latter fact, indeed, is doubted by Underwood, but both Gardien and Guersent con- firm the popular opinion. The greatest number of cases appear from the tables of Percival and of Bricheteau to occur between the second and fifth year; but at the same time it is not infre- quent in infants at the breast, or, indeed, in chil- dren of any age up to the twelfth or fourteenth year : after this period it is less common. A scrofulous habit predisposes strongly to the dis- ease. The greatest number of cases occur in constitutions evidently of this kind. When a strumous tendency exists, all the children of a family have been known to be thus swept off in succession as they approached a certain age. Hy- drocephalus and scrofulous affections seem to be mutually convertible into each other, the disap- pearance of scrofulous disease of the glands or joints being frequently followed by the develop- ment of hydrocephalus; while, on the other hand, all the symptoms of confirmed phthisis have been known to vanish on the occurrence of the latter affection. The disease has usually been thought to take place most frequently in children with a fair skin and hair, pink complexion, and blue eyes. Cheyne, however, says that he has seen it oftener in those with dark eyes and dark complexion. As scrofula occurs pretty equally in both these tem- peraments, it is probable that hydrocephalus also is nearly as frequent in one as in the other. Disorders of the digestive or respiratory organs, difficult dentition, scarlatina, measles, and other diseases which induce debility or excite febrile action in the system, may, according, to the in- tensity of their action, be placed either amongst the predisposing or the exciting causes. The fre- quent and indiscriminate use of calomel in chil- dren's complaints has been accused by Blackall of predisposing to the disease. This, however, can apply only to the abuse of this remedy; ju- diciously employed it is of the greatest utility in cutting short such indisposition as might, if ne- glected, terminate in hydrocephalus. The perni- cious habit practised by some unprincipled nurses, of giving narcotics to infants in order to quiet them and render them less troublesome—a prac- tice which cannot fail to derange the functions both of the digestive organs and of the brain, has been noticed as an occasional cause of this affec- tion. Belladonna, which is much and advan- tageously employed in Germany as a remedy in hooping-cough, and also as a preventive of scarlet fever, has sometimes, in imprudent hands, led to indammation and effusion within the cranium. We have seen hydrocephalus apparently induced !vy the abominable custom, unfortunately not very uncommon amongst the lower classes, of giving spirits to children. Great terror and anxiety in the mother during the last months of pregnancy has been placed by Gcilis in the list of predisposing causes, in sup- port of which he adduces the fact, that a great proportion of the children born soon after the bombardment of Vienna by the French in 1809, were seized with convulsions within a month after their birth, and died of inflammation within the cranium; effusion of coagulable lymph on the membranes, and of serum in the ventricles, being discovered on dissection. The same writer con- ceives that the frequent exhibition of emetics in catarrhal or other affections may occasionally lead to the disease in scrofulous children. We are not aware, however, that any facts in confirmation of these opinions have been observed in this country. To the list of exciting causes enumerated above, we may add external injuries, such as falls or blows on the head, the extension of inflammation from the external ear to the brain. The sudden suppression of accustomed discharges, or drying up of sores behind the ears or eruptions about the head, without an appropriate modification of diet, or the simultaneous employment of suitable eva- cuations, are also amongst its occasional causes, However erroneous may have been the explana- tion of the facts afforded by the humoral patho- logy, their reality and importance are indubitable, and will be least questioned by those who have attended the most closely to the powerful influence of counter-irritation in controlling morbid deter- minations of blood to internal organs, and in sub- duing their tendency to inflammation. Treatment.—The chances of success in the treatment of hydrocephalus depend in a great measure on the period at which it is detected. It is during the precursory symptoms, or the com- mencement of the inflammatory stage alone, that the influence of remedial measures can be reckon- ed on with any thing like confidence. It may be said that at so early a period we can have no cer- tainty of the disease being actually incipient hy- drocephalus: in dubious cases, however, it is infinitely more reasonable to assume the affirma- tive, and take our measures as if the presence of this formidable affection were fully ascertained, than to remain inactive spectators of its progress till the disease has assumed an unequivocal and comparatively hopeless character. When a family has already lost one or more of its number by this disorder, the recurrence of a precisely similar set of initiatory symptoms in any of the remaining children renders an active mode of proceeding doubly incumbent. Under the head of prognosis it has been already stated that cases in every stage of the disease have, under active and judicious modes of treatment, been brought to a favourable termination; and this is sufficient to show that trifling in the commencement, or despondency and the want of energy and perseverance to which it gives rise in the advanced stages of the complaint, are equally unjustifiable. There is too much reason to apprehend that many children have fallen victims, not so much to the incurable nature of their case, as to the indecision of their medical attendant. The precursory stage being very commonlj HYDROCEPHALUS. 491 marked by derangement in the action of the intes- tines, and interruption or perversion of the biliary secretion, the employment of active purgatives, of which mprcury should form a part, is almost always indicated; and we should persevere in their use with the double object of rendering the evacu- ations natural, and relieving the uneasiness in the head. Where the threatening symptoms have taken their rise soon after an injury of the head, though it may have been of a slight nature, and the effects be as yet trifling, the employment of vene- section, or the application of a few leeches to the temples as a precautionary measure, is advisable, in addition to the use of aperients and a reduction of the ordinary diet. Where the symptoms in the head undergo no favourable change, though the bowels have been freely acted on, the probability of disease having become established within the brain becomes hour- ly stronger, and more energetic measures must immediately be had recourse to. The chief indi- cations in hydrocephalus are to reduce the force of the cerebral circulation; to obviate all sources of irritation, whether originating in the abdominal organs or elsewhere, which might re-act on the brain, and thus aggravate, if they did not give origin to, the disease : to alleviate pain, vomiting, and convulsions, even where we fail in removing their cause; to support the strength in the ad- vanced period of the disease; and finally, when death seems inevitable, to render its approach as easy as possible. For fulfilling the first and most important of these indications, our chief resources are to be found in the antiphlogistic class of reme- dies. Bloodletting, active and repeated purga- tion, cold applications, mercury, and blisters, are amongst the most accredited remedial agents, and are here arranged nearly in the order of their rela- tive efficacy. The mode of employing these, as well as some additional therapeutic means, remains to be considered. Bloodletting.—The advantage of early blood- letting'in hydrocephalus is more generally agreed upon than that of any other measure whatsoever. The importance of the brain to all the functions of life, and the unyielding nature of the parietes of the cavity in which it is contained, show us, when conjointly considered, how the effusion, which in many other situations is the natural cure of inflammation, must, within the cranium, if it proceed to any extent, be attended with extreme danger. The only safe termination to inflamma- tion here is in resolution; and to effect this, free, early, and in some cases repeated abstraction of blood must be had recourse to. Opening the temporal artery, or copious venesection, either in the arm, or, perhaps, better still, in the jugular »ein, often affords immediate relief to the headach, reduces the fever, and causes purgatives and mer- curials to act with greater readiness and efficacy. Dr. Rush practised bleeding in this disease at least as largely as in phrenitis; and the activity of his practice has been equalled or surpassed by that of Dr. Maxwell of Dumfries, with the re- markable result of sixty recovering out of ninety cases, or two-thirds of the whole. The child being placed in the horizontal posture, Dr. Max- Well opens the jugular vein, and stops it from time to time with the finger, so as to prevent syn- cope taking place, till a very considerable quantity of blood has been obtained; the bleeding is allow- ed to go on till the pulse altogether disappears: a state of insensibility ensues, and occasionally con- tinues for some hours afterwards. The disease is said to be often immediately arrested by the shock which is thus given to the circulation. But the possibility of death occurring under the very hands of the operator will probably prevent many persons from imitating this bold proceeding ; be- sides, some doubts might be raised even as to the principle on which it is performed being physiolo- gically correct or universally applicable, as exces- sive losses of blood are known, as already stated, to induce convulsions and effusion even in healthy subjects. The experience of no single individual, however extensive it may be, is sufficient to estab- lish the propriety of such a practice ; and certainly the great debility which exists in so many cases of hydrocephalus, seems often strongly to counter- indicate such an extreme measure. Except when the attack is of the very violent kind, with high fever, a strong pulse, and extreme pain and rest- lessness, the majority of practitioners are satisfied with a single bleeding, and trust subsequently to the repeated application of leeches or to cupping. Cheyne is an advocate for early bloodletting in most infantile fevers of a suspicious character, attended with great irritability of stomach, tumid hypochondria, or suppression of the secretions. He has also adduced evidence of the utility of a moderate bleeding even in the advanced period of hydrocephalus, when pain of the head and vomit- ing continue to be predominant symptoms; at the same time he is convinced of the inadequacy of this measure singly to subdue the disease at any period of its progress, and believes th.it its repetition is even at times not unattended with hazard. The pulse must, however, be our guide, as, if it rises in strength, and the symptoms con- tinue or recur, blood may again be abstracted with safety and advantage. By Abercrombie also, venesection is employed in the most decided manner in the acuter forms of the disease; whilst he admits that in those which assume a more chronic character, it has much less control over the disease, and cannot be borne to the same extent. Bloodletting seems to have been prac- tised in some of his cases, and •with occasional good effect, even after the occurrence of the slow, varying, and weak pulse of the second stage. The French practitioners generally trust almost exclusively to the free abstraction of blood in the earlier stages of this complaint; and some of them prefer taking it from a vein in the lower extremities, instead of from the arm or jugular vein; but we are not aware that any decisive proofs of the superiority of this mode of bleeding, which is gone into very general disuse in oup own country, have been adduced. Bloodletting has, however, its opponents as well as its advocates, but they are comparatively few in number. Dr. Garnett was averse to the em- ployment of general bloodletting in children la bouring under hydrocephalus ; and even in adults he usually gave the preference to the local ab- straction of blood, both because it appeared to him to exert more influence over the local inflamma- 492 HYDROCEPHALUS. tion, and because he thought it less likely to add to the debility which comes on in the course of the disease. Similar views of the relative value of local and general bloodletting are entertained also by Dr Porter of Bristol. Such is not, how- ever, the general opinion of the profession ; and on a review of such cases as have fallen under our own observation, we have sometimes seen cause to regret that general bloodletting had not been earlier performed, or carried far enough, but never the reverse. That this as well as every other measure will, in a very great proportion of cases, prove ineffectual, we readily admit, as we do not participate in opinion with those who think that hydrocephalic inflammation is always as capable of being subdued by active antiphlogistic treat- ment, as that induced by injuries of the head in adults, which usually falls under the care of the surgeon. The predisposition and debility of con- stitution which often exist in the former, render the cases, in many instances at^least, widely dif- ferent. As to the quantity of blood which may be taken from infants with safety, the most specific direc- tions are those furnished us by the late Dr. John Clarke : his extensive experience led him to the important conclusion that very young children bear well the loss of blood even to fainting, once or twice repeated ; whilst on the other hand their powers are apt to sink if it be more frequently had recourse to. Children of four years old and upwards can, however, support the repeated per- formance of venesection with impunity. In in- fants of only a year old the jugular vein may often be opened without difficulty. At this period of life three ounces may be considered a full bleed- ing, and nearly the same quantity may again be taken away in twelve hours afterwards, if the symptoms seem to demand it, and the weakness is not too great. Where blood could not be ob- tained from a vein, Dr. Clarke gave cupping from the nape of the neck the preference to leeches. Local and general bloodletting should usually go hand in hand. Where the latter measure is, from the age of the child or any other cause, inapplica- ble, or has already been carried as far as is pru- dent, it is to cupping from the nape of the neck or to leeches that we must chiefly trust. For an infant of six months old, from four to six leeches, according to the strength of the child and the vio- lence of the symptoms, may be once or oftener applied either to the temples or behind the ears, to the angle of the jaw, or to the nape of the neck ; perhaps the latter situation, from its proximity to the medulla oblongata and base of the brain, may deserve the preference. Kuhn recommends their application to the inner angle of the eye, probably with a view to more directly unloading the cere- bral vessels. When there is pain, tenderness on pressure, or fulness in the region of the stomach or liver, the application of leeches to these parts should not be neglected. Purgatives.—Remedies of this class are exhib- ited in hydrocephalus with the double view of im- proving the secretions of the mucous membrane and liver, and thus removing one evident source of irritation, and also of producing derivation from the head, and diminishing the quantity of the cir- culating fluids. By means of calomel given in combination with jalap or compound powder of scammony, or, if these are found to irritate too much, with rhubarb, we shall generally succeed in procuring evacuations. At first these medi- cines may require to be aided by the occasional interposition of saline purgatives with the infusion of senna, which have the additional advantage of producing abundant watery secretions. Purging actively "seems to Abercrombie to be the remedy which is of the most importance in all the forms of the disease ; and though he sets a due value on the aid of venesection, he believes that more re- coveries from head affections take place under the use of very strong purgatives than under any other mode of treatment whatever. He has found the croton oil one of the most convenient and effect- ual cathartics in diseases of this kind, which are so often accompanied by great obstinacy of the bowels. Whytt never saw even temporary relief of the symptoms produced by any other means than those which increased the evacuations; and Rush was likewise a strenuous advocate for the employment of medicines of this kind. It is chiefly at the commencement of the disease that active purgatives are proper; but even here there are limits and exceptions to their use. Where there is a high degree of irritability of the mucous membrane of the stomach or intestines, they will be useless or even injurious till these states have been subdued by bloodletting in some of its forms. When in a high state of excitement, we shall often attempt in vain to force the secretions of the liver or mucous membrane; and to procure healthy evacuations under such circumstances is quite out of the question. When the usual purgatives seem to aggravate the vomiting without moving the bowels, or when they produce only mucous stools attended with much irritation, a perseverance in their use eannot fail to be prejudicial. When the commoner purgatives have been rejected by the stomach, or proved insufficient, Dr. Cheyne occa- sionally succeeded in quieting the stomach and procuring evacuations, by giving a drachm or two of magnesia saturated with lemon juice every second or third hour, venesection to an adequate extent having been usually premised. In other cases he postponed the use of aperients till the state of the secreting organs had been first modi- fied, and some appearance of feculent matter could be observed in the stools, under the influence of a combination of calomel, opium, and antimony. Besides, we must always bear in mind that the local irritation which the excessive or untimely employment of cathartics is capable of producing, cannot fail to re-act on the head, and aggravate instead of relieving the hydrocephalic symptoms So great, however, is the torpor of trie intestinal canal in most instances, that such cases are, per- haps, only to be looked upon as the exceptions. We cannot agree with Dr. Porter in condemning active purgation as an inefficient measure, even were his hypothesis granted, namely, that the de- rangement of the abdominal organs is always se- condary, and merely symptomatic of the cerebral disorder. Purgatives should have a fair trial in conjunc- tion with other antiphlogistic measures during the commencement of the disease; after which, if they do not appear to be making any decided im HYDROCE pression on it, the mercurial plan of treatment may be resorted to, a laxative enema or an ape- rient medicine being still occasionally exhibited. A large glyster of broth, with some of the purga- tive salts in solution, repeated frequently in the course of the day, has been found a useful pallia- tive by Cheyne, the child lying at ease for a con- siderable time after its exhibition. Its good effect is attributable partly to its soothing influence, and partly to its protecting the intestines from the irri- tating qualities of the morbid faeces. Cold Applications.—The increased activity of the circulation within the brain may be controlled in a considerable degree by the long-continued application of cold to the shaven scalp, which may be effected either by means of cloths, kept con- stantly wet with cold water, or evaporating lotions containing spirits and ether ; or more effectually still, by means of a bladder containing pounded ice mixed with water, kept in constant contact with the forehead, temples, and upper part of the head. This measure, in conjunction with an erect position of the head and trunk, persevered in for many days together, has been known to exert a surprising influence over inflammation of the brain both in adults and children. But the most efficient method of all consists in directing a stream of cold water against the crown of the head, and continuing it for some moments, till its full effect is produced. This is so very powerful a means of reducing cerebral action, as to demand much circumspection in its employment; and it is chiefly applicable to the more violent examples of the disease. To Burns it appears a measure of rather doubtful propriety, as it is often followed by alarming collapse: he thinks that it is only in the early part of the disease, when there is much heat, and when adequate evacuations have been already premised, that its employment can be safe. Abercrombie, while he admits that its use requires discretion, is a strenuous advocate for its utility in hydrocephalus, and has likewise em- ployed it with great success in sudden coma con- nected with congestion of the head, and in the convulsive affections of children, in which last it is more effectual and much more generally appli- cable than the warm bath. Dr. Darwall has known cases which seemed utterly hopeless reco- ver by letting water drop in a small stream upon the scalp, and continuing it till the head no longer recovered its high temperature on intermitting the stream; and Formey thinks it, when repeated every two hours for several days and nights con- secutively, the most effectual remedy we possess both in the inflammatory stage and in that of effusion. Mercury.—It is now nearly fifty years since the first recommendation of mercurials in hydro-v cephalus by Dr Dobson ; but though they have formed a part of the standard treatment of the dis- ease during all the intervening period, the mind of the profession is still far from being made up, either as to the principle on which they act, or even as to their utility. Upon an extensive ex- amination of the subject, the preponderance of evidence seems to be decidedly in favour of their employment. To bring the constitution of young children fully under the influence of mercury is often very difficult, and especially so in this dis- PHALUS. 493 ease ; and even when we have succeeded, and the gums and salivary glands have become affected, the case too often runs rapidly on to its fatal ter- mination. A few cases, however, seem unequi- vocally to have been saved by this remedy ; and in many the convulsions and other symptoms have been rendered milder by it, and the senses restored, though the disease has not been even- tually arrested, or the patient has been too weak to rally again. The effect of mercury in control- ling inflammation and modifying the action of the exhalents in other parts of the body is notorious; and in certain affections of the eye, as every step in the progress of improvement is exposed to view, there can be no doubt as to the reality of its in- fluence. Its first introduction into the treatment of hydrocephalus was grounded on the hope of increasing the activity of the absorbents, and cases have since been recorded where it seems incon- trovertibly to have had this effect. Thus in a young child labouring under the disease, where the sutures were not yet closed, Dr. Clarke has seen the fluctuating tumour at the fontanelles gradually disappear under the use of mercury ; and numerous instances of recovery by the same means in very advanced periods of the affection, in some of which effusion had in all probability occurred, are favourable to the same hypothesis; as is likewise the influence which it seems occa- sionally to exert in cases of chronic hydroce- phalus. Considerable embarrassment is often felt as to the precise period at which the mercurial treat- ment should be commenced. To lay down any in- variable rule as to this or any other part of the management of a disorder which appears under so many different forms, is impossible ; but to give this practice a fair trial, it must be commenced before the inflammatory stage is vtry far advanced; and as we are often not called in till the disease has already existed many days, it is frequently necessary, after merely clearing out the bowels and abstracting a due quantity of blood, to pro- ceed immediately to the use of mercury. Calomel is the preparation usually employed. It may be given in doses of one or two grains, with or without opium, according to the state of the bowels and other symptoms, and is to be re- peated every third or fourth hour till the gums become affected, unless griping and diarrhcea be induced by it, in which case the hydrarg. cum creta, or the external use of mercury, should be substituted. Golis, though he has great frith in calomel in the commencement of the inflammatory stage and previously, is averse to the large doses usually given in England, as he thinks he has seen them in some instances produce fatal ente- ritis, both in this disease and in croup. The dose to which he confines himself is half a grain re- peated every two hours, till it produces four or five green slimy stools or colic; and after these effects have ceased, he returns to it again. If the bowels are very hard to move, he combines with it three or four grains of jalap previously toasted, in which state it is less apt to sicken or gripe Children under one year he finds bear larger dosea of calomel without colic, diarrhcea, or salivation, than those several years older. His experienco here coincides with that of Dr. Clarke, who nev«. 494 HYDRO C] saw salivation induced in children under three years of age save in three instances, though he employed it largely in a variety of diseases. The corrosive sublimate in minute doses has been preferred by some practitioners, when it is necessary to produce the specific effects of mercury very rapidly. Dr. Merriman, who has succeeded in curing two cases of the disease with this pre- paration, employs it in doses of from one-thirtieth to one-sixteenth part of a grain repeated every four or six hours, with the effect of producing copious olive-green stools, and an increase in the urinary secretion. In very urgent cases both the internal and the external employment of mercury should be com- bined. From half a drachm to a drachm of mer- curial ointment may be rubbed into the thighs, or in very young infants more conveniently into the back three or four times a day ; and it may also be used as a dressing to blistered surfaces. If in the case of infants this ointment be objected to, calomel may be rubbed into the gums, three or four grains at a time, and repeated every four or five hours. In whatever form mercury is employed, it is usually requisite to continue its use for a great number of days uninterruptedly ; and when either it or any other medicine has produced a favour- able change in the disease, its employment should never be abruptly terminated, but on the contrary very gradually relinquished. The only exception, perhaps, to this rule is.in regard to digitalis. Blisters.—The greatest contrariety of opinions prevails as to the period at which blisters should be used, and the place where they ought to be applied. If employed at all in the commencement of the disease, white the inflammatory symptoms continue high, a practice the propriety of which there is much reason to doubt, it should only be to parts at a distance from the disease, as the legs or arms, or between the shoulders, with a view to producing derivation from the seat of the inflam- mation. In the acuter cases, where there already exist much restlessness and vascular excitement, they can scarcely fail to be injurious till the acti- vity of the circulation has been reduced by ade- quate evacuation. In the second stage of the disease, a remarkable alleviation of the symptoms is frequently pro- duced by the application of large blisters to the head or nape of the neck: a number of these may be applied in rapid succession to the vertex and all round the head ; or what is perhaps a still more effectual method, the blistered surface may be kept in a state of suppuration for several days consecutively, by dressing it with ointment of savin or of Spanish flies. The dread of strangury has deterred many practitioners from the use of the latter, tnough perhaps without sufficient reason, as it is possible that the occurrence of such an effect might occasionally even have a beneficial nfluence on the disease in the head. Tincture of cantharides has been exhibited with the very intention of inducing this species of irritation in the neck of the bladder by Dr. Merriman, in doses of five or ten drops every four hours, and the oc- currence of severe strangury has appeared to him to arrest the cerebral symptoms ; thus exemplify- ng the influence of a new and artificially excited 2PHALUS. disease in controlling the morbid action existing in a distant organ. When tenderness in the epigastric or hypochon- driac regions continues even after leeching the part, a blister may be applied here also with advantage. Golis thinks that from the sympathy of the head with the stomach, a blister over the latter organ exerts a peculiarly marked influence on the cere- bral symptoms ; but as blisters often rise but slowly in this situation, he generally applies them in preference to the calves of the leg. We have thus passed in review those remedies which seem most entitled to confidence in attempt- ing the cure of hydrocephalus. Of these, purga- tives, bloodletting, and cold applications belong, as we have seen, more peculiarly to the early or most inflammatory period of the disease—mercury and blisters to the more advanced stages. But the stages often run into each other by such insensible steps, or are so completely confounded together, as frequently to render any division of this kind of very little avail in practice. It remains to say a few words of some other modes of more equivocal efficacy, or which are useful only as palliatives. Digitalis.—This medicine, first used in this dis- ease by Dr. Withering, and very generally em- ployed since, is given in the earlier stages with a view to aid in reducing inflammatory action, and in the later to favour the absorption of the effused fluid. It is in that variety of the disease which succeeds to scarlatina, that it has appeared to be of most use. It is not, however, without difficulty that we can ascertain when it has been carried as far as is consistent with safety; for in consequence of the irregular state of the pulse, the tendency to vomiting, and derangement of the cerebral func- tions which already exist as a part of the disease, we are deprived of some of the chief signs by which to recognise the influence of the medicine. What we have seen of its use in this disease has not disposed us to value it highly. Dr. Cheyne, however, speaks rather favourably of it, and has given two cases in which it seemed to be of use, He begins with ten drops of the tincture, and to every succeeding dose, which is generally given after an interval of four hours, he adds two or three drops more than was contained in the pre- ceding one ; so that in a day or two some part of the system may be affected. He has thus given as many as one hundred and twenty drops a day to a child only four years old. He thinks that the slow irregular pulse from digitalis may be distin- guished by its smallness and sharpness from that of hydrocephalus, which is not only unequal, but more soft and full. " The languor from digitalis is attended with vertigo, and sometimes with mo- mentary blindness ; that from hydrocephalus has •more of coma in its character." Golis, without appearing to place much faith in its efficacy, gives digitalis both in the inflammatory stage and in that of effusion—in the latter chiefly as a palliative to moderate the violence of the convulsions. He employs it sometimes in the form of infusion, and sometimes in that of the powder, in doses of a quarter of a grain, combined with half a grain of calomel, repeated every second hour. He has not found it exert much influence on the urinary secretion in this disease. Some continental practitioners prefer extensive frictions made with the tincture of digi- HYDROCEPHALUS. 495 talis (sometimes combined with that of squills) to its internal employment. In whatever form it is used, if the pulse suddenly become very feeble, irregular, and slow, with increase of vomiting, and frequent recurrence of dimness of sight or blind- ness for a minute or two at a time, its use should be immediately intermitted, and stimulants, wine, soup, &c, substituted. Antimony. — The late M. Laennec succeeded thrice in curing acute hydrocephalus by means of the tartrate of antimony given after his peculiar method. In two of them the disease supervened in the course of a continued fever. The subject of the third was a young man, who, after having sat up nightly in attendance upon his sick master for nearly four months, was seized with occasional vertigo and other symptoms which excited suspi- cion of some incipient cerebral affection. Some time after this he suddenly dropped down insen- sible, and after continuing in this state five days was brought to the hospital, where Laennec found him pale, motionless, and with the pupils greatly dilated. Leeches were applied to the temples, and twelve grains of the tartrate of antimony were given in the course of twenty-four hours. The next day he was able to move, and uttered some incoherent words. Fifteen grains were now ordered, and on the third day he had completely recovered his consciousness and power of motion, and the pupil had nearly regained its natural di- mensions. He was still very feeble. As he had had no evacuation, eighteen grains of the tartrate were prescribed, and some nourishment. On the sixth day he was in a state of rapid convalescence; md crying out for food. Subsequent trials of this plan of treatment have not, we believe, tended to confirm the expectations which these cases (which by the way do not appear to have been very well marked examples of the disease) had raised. The late Dr. Mills was in the habit of giving rather large doses of the tartrate of antimony, with a view to lower the pulse and relieve the headach ; combining it, when the stomach was very irritable, with the tincture of opium. James's powder is, however, the preparation which has been most frequently used; small doses being given either alone, or oftener in combination with calomel, or calomel and opium, or with cathartics, with a view both to directly reducing the inflammatory action in the brain, and to assist in restoring the secre- tions of the abdominal organs and of the skin. This method of giving antimony is favourably spoken of by Dr. Cheyne. It has also been ad- ministered empirically in very large doses, so as to induce profuse perspiration, and it is said at times with success : in the hands of regular prac- titioners, however, this mode of giving it has failed entirely. Opiates.—In the second and third stage of hy- drocephalus considerable benefit has resulted from the use of opium. It has appeared not only to relieve the pain in the head and calm the general irritability, but also to reduce the morbid irritation in the intestines, and thus lead to an improvement in the stools, to render the pulse fuller and less irregular, and the convulsions less frequent; whilst fortunately it seems in no respect to impede, but rather to favour the action of other remedies. From the eighth to the fourth part of a grain of opium, or three or four grains of Dover's i jwder, may be given every fourth hour, either alone or in combi- nation with calomel and antimony; or else with hydrarg. cum creta. if there be great irritability of the mucous membrane. The contraction of the pupil which ensues after the use of opium has been pointed out by Drs. Crampton and Cheyne as affording evidence of the remedy having been car- ried as far as is safe. Dr. Brooke has recorded a case in the Transactions of the College of Physi- cians in Ireland, where Dover's powder, in large and repeated doses, proved a very useful palliative. All agree that a moderate employment of opium does not interfere with the action of the bowels. When its use is once commenced, the patient must be kept steadily under its influence; as, if sud- denly withdrawn, the symptoms recur with in- creased violence. Squills, colchicum, and other diuretics, have been recommended in the advanced periods of the disease. When, however, the stomach is very ir- ritable, we must be cautious in the use of medi- cines which might aggravate the vomiting, and thus increase the determination of blood to the head. Dr. Warren, indeed, was bold enough to use emetics in hydrocephalus, but in this he has had few imitators. The warm bath, which has in this country been occasionally found a useful auxiliary, is thought by Golis to determine the blood still more strongly to the head, and thus aggravate the violence of the symptoms. M. Itard is an advocate, in the advanced stages of the dis- ease, for the use of the vapour bath impregnated with vinegar, a powerful means of stimulating the surface and producing an abundant flow of perspi- ration. At an earlier period, when there is much reaction in the system, M. Recamier, on the other hand, has used the cold bath, and it is said with some benefit. Fomentations to the abdomen when pain is complained of there; stimulating pediluvia, or, what is more convenient and equally efficacious, sinapisms to the extremities, are also frequently had recourse to. Tartar emetic ointment is re- commended by Mills, especially in those cases which have succeeded to a repelled eruption.— When applied to the extremities, it has sometimes appeared to produce a very useful derivative action. In a disease in which the unfortunate patient often lingers on for an unexpected length of time in a state of great apparent suffering, a state at all times distressing to friends to witness, and most so when no efforts are made to relieve it, the ad- vantage of a variety of resources during the long and painful attendance is obvious. Recoveries having occasionally taken place under circum- stances which seemed utterly hopeless, the medical man who values his own reputation will not re- sign himself to absolute inactivity at any period of the disease. Palliatives.—When we fail in subduing the morbid condition of the brain which constitutes the disease, something may still be done in the way of alleviating symptoms, and, even when death seems inevitable, in rendering the steps which lead to it less painful. To enumerate all the measures conducing to these ends would bo to repeat much of what has been already detailed. Thus moderate blood-letting, either local or gen- eral, according to the degree of strength remain- 496 HYDROCEPHALUS. ing, will often, even in the advanced stage of the disease, afford considerable relief, without appear- ing in any degree to accelerate the progress of the disease. Opiates at the same period form an in- valuable resource. Vomiting may sometimes be temporarily stayed by effervescing draughts, to which a few drops of laudanum and ether are occasionally added with advantage. This symptom may also be frequently much relieved by the administration of laxative enemata, to which a nutritive quality may be at the same time imparted. Convulsions can often be cut short by the affu- sion of cold water on the head, or even by sprink- ling the face and chest plentifully with it; a measure which is at once of easier application, and more frequently successful, than the warm bath. The simultaneous employment of cold to the head and the warm bath is often very effica- cious. Musk and zinc in large doses appeared to Odier to have considerable influence in controlling this symptom. When very violent and long con- tinued, the trial of an enema, composed of a very weak solution of tobacco, might perhaps be justi- fiable. For the mode of employing it, and its utility in an analagous instance, see Glottis, Spasm of. Where coma is the predominating feature of the complaint, strong coffee or tea have been given in the advanced period of the disease with some appearance of benefit. Retention of urine is often relieved by turpentine enemata or the hip-bath. The diet in the earlier and more inflammatory part of the disease, should be strictly diluent; but when it has already run on for a number of days, with rapidly increasing debility and emaciation, it becomes a very important object to support the strength. This is peculiarly necessary where the urine, perspiration, or any of the evacuations, has, either by a spontaneous effort of nature or under the influence of medicine, become unnaturally in- creased. Under these circumstances, beef-tea, jelly, asses' milk, &c, should be freely given. Life has sometimes seemed to be considerably pro- longed in this disease under the influence of light stimulants and tonics, wine, small doses of am- monia, quinine, &c. Arnica is a favourite remedy with some German physicians: we need not say how reluctantly and with how much caution such remedies should be had recourse to. When recovery takes place, the convalescence is often very slow, and requires uninterrupted at- tention to the state of the bowels, and great care in the regulation of the diet. Asses' milk is here an invaluable article of nutriment, as it recruits the strength without exciting the pulse, oppressing the stomach, or confining the bowels. If hydrocephalus supervene in the course of an infantile fever, or in a child greatly debilitated by diarrhoea or other previous illness, the treatment presents peculiar difficulties. We are here often unable to venture on general bloodletting, and are obliged to trust to leeches, cold applications to the fiead, blisters, and calomel, to which opium is to be added if there be great irritability of the mu- cous membrane or nervous system. Such reme- dies certainly afford a fairer prospect of success man the arnica, serpentaria, and other stimulants recommended by Kuhn and some other German writers. Where the head becomes suddenly attacked in a patient labouring under one of the exanthemata, nothing but the most vigorous antiphlogistic mea- sures condensed into the shortest possible space of time can afford even a chance of safety. Ve- nesection or arteriotomy, leeches, ice to the head, or a stream of cold water poured from some height on the vertex, purgatives by the mouth, or if the patient is unable to swallow, active enemata ; and stimulating vapour-baths where the eruption has suddenly receded, or sinapisms or blisters to the extremities, should all follow each other in quick succession. The following case from Golis gives some idea of the rapidly fatal nature of the attack. A child of two years old, on the fourth day from the eruption of scarlet fever, seemed to be going on favourably at eight o'clock in the evening. At midnight it became highly feverish and convulsed; spasms of the muscles of the back and palsy of the right side soon followed, and within ten hours it was dead. We have ourselves seen it fatal on the second day of the attack. Fortunately, how- ever, this may be considered a rare form of the disease. That which occurs in the convalescence from scarlatina is much more frequent. It comes on with giddiness, headach, somnolence, and nau- sea or vomiting, to which convulsions and all the other symptoms of hydrocephalus are soon added. It demands the prompt employment of bloodlet- ting and purgatives, blisters, and digitalis. Bark has appeared to Dr. Blackall to have much effect in accelerating convalescence. Prevention___Where there is reason to suspect a predisposition to hydrocephalus, as is the case with respect to the children of a family which has already suffered by the disease, and perhaps with regard to scrofulous children generally, the earliest attention should be paid to every deviation from the natural state of the functions of the body, and especial care directed to the condition of the di- gestive organs. To support their tone and that of the whole system by good air, nutritious unir- ritating diet, and daily exercise, is a point of prime importance. Where costiveness exists, or the stools by their unnatural colour or consistence in- dicate derangement in the secretions of the liver or mucous membrane of the intestines, appropri- ate remedies should not be a moment delayed. An issue or seton in the arm or neck has some- times seemed to have a remarkable influence in warding off this disease. We know an individual of a family strongly predisposed to it, whose life appeared to have been saved by an issue long kept open in the arm. Though the eighth child of the family, he was the first who survived infancy, the seven older ones in whom this precaution had been neglected having all died of hydrocephalus. Dr. Cheyne, in the work to which we have been so frequently and so largely indebted, mentions some still more remarkable instances of the good effects of establishing an artificial irritation at some distance from the morbidly disposed organ. The parents and instructors of children of a pe- culiarly precocious intellect should be made aware of the danger of early and protracted application. In such individuals it should be our object, if pos- sible, rather to retard than to accelerate the deve- HYDROCEPHALUS. 497 lopment of the brain and of the mental faculties connected with it; and it is only by postponing the interests of their intellectual to those of their physical education, till the constitution has be- come established and the period of danger is past, that this object can be attained. II. Chhoxic Hydrocephalus. — This affec- tion may be either congenital or acquired. When congenital, some malformation or defective deve- lopment of the brain in many cases coexists. When acquired, it may either come on as the se- quel to the acute form, which however is rare, or it may originate insensibly, and attract little atten- tion till the functions of the nervous system and of the body generally become perceptibly deranged by the pressure of the effused fluid. In all its forms it is in the earlier stages of existence, white the brain is undergoing the process of evolution, that it chiefly occurs. When the cranium becomes very much en- larged, as the face retains its ordinary dimensions, or is even smaller than natural, the visage assumes a singular triangular appearance, and the patient being unable to support the immense head, it hangs on one shoulder or on the breast. The su- tures and fontanelles continue widely open, and pulsation of the arteries, as well as the fluctuation of the contained fluid, can be distinctly felt through them. Occasionally, from the unequal yielding of the brain and its membranes, a circumscribed tumour presents itself at some of these openings. That the dimensions of the head are always in- creased is the popular belief; and Frank has in- cluded enlargement of this part in his definition of the disease. Yet this is far from universally taking place, for the head is sometimes of the or- dinary size, or occasionally even smaller than na- tural. Golis, the best writer on this disease with whom we are acquainted, and Breschet, who usually copies him closely, have divided the disease into three varieties, having relation to the size of the head. The first variety, or that in which the head is enlarged, is either congenital or com- mences in early childhood. The second, or that in which it is unnaturally small, is always conge- nital. The sutures are found closed at birth, and the head is of a conical shape. Such children are usually dead-born, or die in convulsions soon after they come into the world. Should they by chance survive a few months, their intellect is totally de- fective; they are blind, with the pupils greatly di- lated, and the eyeballs in constant convulsive mo- tion. They lie in a state of almost total insensi- bility, with their legs crossed and drawn up to the belly, their toes contracted and feet distorted. Of this^variety Golis has known but a single instance attain the age of eighteen months. The third va- riety, or that where the head is of the natural size, is perhaps the commonest of all, as it may take place at any period of life. In chronic hydrocephalus the intellectual facul- ties, the senses, and the muscular power all suffer. The patients labouring under it become emaciated, and of a pallid unhealthy complexion, stupid and indifferent to external objects. The countenance is without expression. The senses become suc- :essively impaired, the sight being the first to fail. Vol. II. —C3 2 b* The gait is unsteady, as the power over the invo- luntary muscles is in a great degree lost. The following abstract of the symptoms is chiefly taken from the second volume of Golis's work, which has not, we believe, hitherto been translated into English. When the disease comes on at a period subse- quent to early infancy, its first approaches are commonly indicated by an unusual excitability of the nervous system. The individual is easily made to laugh or to cry by the slightest causes, is peculiarly irascible, and the temper and disposi- tions are totally changed. The memory is im- paired or lost. The muscular debility is exces- sive. Epileptic fits, especially at night, are of common occurrence; and on awakening a pecu- liar piercing cry is often uttered. There is a great degree of sleepiness, together with a dull pain and heaviness of the head. By shaking the head, ver- tigo or complete stupefaction is brought on. If we make pressure on the fontanelles, a soporose state often accompanied with convulsions is in- duced. The pupil of the eye becomes larger and larger as the disease advances, and amaurosis usu- ally takes place in the end. Squinting exists in some instances, whilst in others the eyeball oscil- lates from side to side. The sense of smell be- comes perverted or lost. In the former case ima- ginary odours are complained of; and the nose is at all times itchy and dry. The function- of hear- ing is also impaired. In short, the senses of taste and touch are often the only ones retained, and these occasionally in a very imperfect degree. Vi- olent grinding of the teeth, which are thus worn down to the stumps, is very common. If the pa- tient possess the power of speech, it is for the most part nasal and snuffling, and often inter- rupted for want of words in consequence of the defective state of the memory. From the mouth, which is usually half open, the saliva is constantly dribbling, either from this secretion taking place in an excessive quantity, or from a diminished power of swallowing. Of the secretions and ex- cretions the saliva and tears are the only ones which do not appear to suffer a decrease. The functions of the digestive organs are con- siderably changed from the natural state. The appetite is often voracious; there is frequently a tendency to vomit, and obstinate constipation is rarely absent. The urine is diminished in quan- tity, and both it and the faeces in the advanced stages of the disease are passed involuntarily. As the disorder advances, the pulse and re- spiration become affected, the patient sighs much, and is put completely out of breath by the slight- est causes, and paroxysms of suffocative cough oc- casionally take place. Debility and loss of power over the voluntary muscles is one of the earliesl symptoms, and is manifested in the unsteadiness of the gait. Automatic motions of the limbs are common. The posture is much influenced by the disease. When it has made some progress, the erect position of the body can often no longer be borne, as it causes pain in the head, with lightnesy and stupefaction, and inclination to vomit. There is usually a disposition to keep the head lowei than the rest of the body, and not unfrequently a preference is manifested for lying on the belly with the face buried in the pillow. When vary 498 HYDROCEPHALUS. lie on the back, the head is often rolled with great regularity from side to side. In the last stage the patient lies gathered up, with the legs crossed and drawn up against the belly, the cervical vertebrae and head being thrown back, whilst the rest of the spine is bent forward. As the disease approaches its fatal termination, the pulse becomes weak, ir- regular, and intermitting, and the extremities cold and damp. Death takes place either by the su- pervention of the symptoms of acute hydrocepha- lus, or by a slow hectic fever, the scene finally closing either with a paroxysm of suffocative cough or with an attack like apoplexy. Though the impairment of the intellect and senses usually keeps pace with the advancement of the disease, and the subjects of it at length may be said rather to vegetate than to possess an ani- mal existence; yet a few cases are on record, where, though the head had attained a very con- siderable magnitude, the individual continued per- fectly rational and observant of things around him ; whilst in other instances again, amidst the gene- ral wreck, some one faculty, as the memory for example, has alone escaped uninjured. The moral qualities usually suffer as much as the intellectual, the patient being frequently passionate and re- vengeful ; and every time that a fit of anger is ex- cited, convulsions are apt to follow. The sexual propensities commonly continue strong, and in several instances, in children of both sexes, a remarkably premature development of the organs of generation has been observed. Hydrocephalus being a disease of fcetal life, and the unnatural-sized head often presenting a great obstacle to delivery, and frequently even requiring an operation destructive of the life of the child, its early detection would be very desirable. Un- fortunately, however, till the head actually presents itself in the progress of delivery, we have no means of detecting its existence. The fact of the mother having previously borne hydrocephalic children should excite a suspicion of its existence in cases of difficult parturition. The disease may take its rise either before birth or very soon after it, or more rarely during the later periods of childhood. Yet even adult age is not altogether exempt from it. Golis has mentioned three cases where it came on in old age. Two of the individuals in question were about seventy years old. The third, who was a physician in Vienna, likewise died of it at a very advanced period of life, after having suffered from the dis- ease ten years. In such cases, however, it rarely runs on for more than three years. In cases oc- curring subsequent to early childhood, no change in the external form of the head is appreciable, for the sutures and fontanelles in most children are found already closed in their second or third year. Occasionally, however, as we learn from Ruysch and Van Swieten, they remain open much longer. We know at present of a child of upwards of six years old, in which the posterior fontanelle is still open ; it is of a scrofulous habit, but has hitherto manifested no tendency to hydrocephalus. Dr. Baillie met wi'.h a singular case in a boy of seven years of age, where the coronal and sagittal su- tures, after having been firmly closed, re-opened to the exteut of half an inch and upwards from the pressure of the accumulating fluid. The same author has detailed an instance of chronic hydro- cephalus occurring in a^man fifty-six years of age, in the ventricles of whose brain six ounces of fluid were discovered. The chief symptoms were pain of the head, and a loss of memory so great that he could recollect but five words, which were con- tinually reiterated to express all his wants. He seemed to retain somewhat of his intelligence. There was no dilatation of the pupils, and the sight was good. The pulse was occasionally rather quick, and never became either slow or irregular. The hemiplegia which existed was ac- companied with a permanent rigid flexion of the paralytic limbs, like a fakir. Heberden, on the other hand, has mentioned the case of a man in the ventricles of whose brain, though eight ounces of water were found on dissection, no symptom of hydrocephalus had existed during life. The duration of this disease is very various, When it commences in utero, death almost always occurs very soon after birth; and if it originate in early infancy, the child very rarely survives the third year. Yet the brain in some instances be- comes, as it were, reconciled to the pressure of the contained fluid, and existence has thence in a few rare cases been prolonged to adult age. Golis mentions one in which the patient lived to twenty- seven ; Aurivill another which reached forty-five years; and Gall one which attained to fifty-four years of age. In the case of Cardinal, who died in Guy's Hospital a few years ago at the age of thirty-two years, the head was of great magnitude, being thirty-three inches and a half in circumfer- ence, and twenty inches and a half from ear to ear. Notwithstanding this immense enlargement, many of the functions of the body were little impaired. The appetite and digestion were natural, and his intellect not remarkably deficient. He was, how- ever, subject to occasional epileptic attacks, espe- cially when costive; and he was unable to walk much, as vertigo was speedily induced by it. For some weeks before his death he was somewhat comatose, though still capable of answering ques- tions when roused : the insensibility gradually in- creased, and he sunk at length as if apoplectic. Prognosis.—It is only in the early stage that much can be effected by medicine in this disease. If treatment be deferred till the head has become greatly enlarged, the case is too often hopeless. When it is congenital, or occurs very soon after birth, its termination is, according to the best au- thorities, invariably fatal. In other cases, Porten- schlag, Dreysig, Richter, and Golis, think it may often be cured, especially if there be no complica- tion, if the disease be early seen, and no great ex- haustion has as yet come on. Frank looks upon the disease as very generally incurable. He knew of one case which disappeared on the invasion of a scrofulous affection in another part of the body; and both he and Golis have seen the breaking out of chronic cutaneous eruptions and sores behind the ears have a very favourable influence over the disease. On the other hand, where any of the exanthemata supervene, speedy death is the usual consequence. Cases originating where there is a scrofulous or spyhilitic taint, or after concussion or other accidents by which the texture of the brain may have been injured, have appeared to Golis particularly unfavourable. Those which HYDROCE arise as a sequel to acute hydrocephalus are like- wise very unpromising, as has been already stated. The same may be said of those cases where there is long-continued coma, furious delirium, or fre- quent convulsions from very slight causes. Of the causes of this disease little is known with certainty. A strong predisposition to it un- doubtedly exists in certain families. Thus Frank mentions the circumstance of a mother bearing seven children, all of which were born with this affection : and Golis another, in which six of the children were born prematurely in the sixth month of pregnancy, labouring under chronic hy- drocephalus ; and in the three others, which were carried to the full time, it appeared soon after birth. The father being very old or drunken, is thought by the last-named writer to predispose the offspring to the disease; and perhaps intemperance in either of the parents has a similar tendency. A scrofu- lous habit, and violence done to the head in birth, may also be numbered amongst the predisposing causes. Mechanical injuries, falls, shocks, and blows, are capable of exciting it; as is likewise the sudden repulsion of cutaneous diseases, the sup- pression of the menses, over-exertion of mind, and long-continued anxiety. Appearances on Dissection. — The bones, which are usually remarkably thin and transpa- rent, are frequently separated from each other by a very considerable interval. When the patient has lived for several years after the commence- ment of the attack, nature often appears to make an effort to close the sutures by the establishment of new points of ossification and the formation of ossa wormiana. The thinness of the bones of the skull, though an ordinary, is not an universal appearance. They have sometimes, on the con- trary, been observed of unnatural thickness, which, like the supernumerary bones above alluded to, seems to mark an attempt on the part of nature to counteract the effects of disease, and restore to the cranium a proportional thickness. It is sup- posed that such thick and large skulls on being dug up have been mistaken for those of giants, an error which attention to the comparatively diminu- tive bones of the face would have prevented. The head of hydrocephalic patients is sometimes of a very irregular form, one side being much more prominent than the other. The effused fluid is found either in the ventricles, or, though much more rarely, in the great sac of the arachnoid. In the former case the ventricles are extremely dilated, the convolutions are unfolded, and the brain converted into a thin membranous-like sac, in which the medullary and cineritious substance can no longer be distinguished. The corpus cal- Iosum is much raised, and the septum lucidem occasionally torn or destroyed, so that the brain has sometimes been found forming only one great hemisphere without any central division. The cerebral substance seems denser than usual, and its absolute quantity as compared by weight with that of a healthy individual of the same time of life, in many cases does not present any diminution. When the water is contained in the sac of the arachnoid, frequently scarcely any appearance of brain can be discovered ; or the parts constituting its base, the pons varolii, medulla oblongata, &c, alone exist. ] PHALUS. 499 With water in the head and imperfect develop- ment of the brain, malformation in other parts of the body frequently coexists. It is now a gene- rally received doctrine that many congenital de- fects of structure depend upon the continuance of certain states belonging to the earlier periods of foetal existence beyond their proper time. Thus the fluid which naturally occupies the ventricles during the first steps of the formation of the foetal brain, by remaining unabsorbed, may lay the foundation of congenital hydrocephalus. A rare species of the disease is mentioned by Schmalz, in which the fluid is encysted. In such cases the sudden bursting of the sac has led to a fatal result. Golis met with a cyst of this kind about the size of a goose's egg, situated between the hemispheres, in a child of six years old, who died suddenly, though the bag was in this instance entire. The quantity of fluid discovered in the head varies from a few ounces to several pounds. Cases in which upwards of ten quarts have been found are on record. In the case some years ago in Guy's Hospital, to which we have already alluded, the bones of the cranium were found on dissection to be of an ordinary thickness. On cutting through the dura mater water immediately gushed out. This was of a pale yellow colour, and the total quantity contained within the head was found to exceed ten pints. At the bottom of the great cavity formed by the immensely dilated skull, lay the brain much flattened. The corpus callosum was defective, so that the ventricles of the brain communicated directly with the great sac of the arachnoid. This was, by some of those present, thought to be a natural malformation, as the convolutions of the brain were not unfolded and obliterated, as in those cases where the effu- sion takes place originally into the ventricles. Dr. Baron, in the eight volume of the Medico- Chirurgical Transactions, has given the history of a very interesting case of congenital hydroce- phalus. At three months old the head had at- tained to the enormous magnitude of twenty-nine inches in circumference. About this time a swell- ing appeared at the posterior fontanelle, and soon acquired the magnitude of a goose's egg. This suddenly became much smaller and soft, and a constant dribbling from the urinary passage was observed, by which the head in three days became so reduced in size, and the integuments were so relaxed, that the skin of the forehead fell in wrinkles over the eyes. The urinary discharge by the end of two months diminishing, the swell- ing on the top of the head re-appeared. A watery discharge tinged with blood now began to ooze from the nostril and mouth, and flowed most freely when the head was held forward; by this the tumour was again reduced, and the circum- ference of the head brought down to twenty inches. The child died at eighteen months old. On dis- section, the dura mater was found ruptured, a well-defined circular opening nearly an inch in diameter existing in the situation of the tumour, and communicating directly with the interior of the brain. The brain itself, which was expanded into a great sac with very thin parietes, had like- wise given way at this part, and thus allowed the fluid from the internal cavity to escape into thy 500 HYDROCEPHALUS. outward swelling. A probe passed easily through the aethmoid bone into the nose. Treatment. — In this disease the unassisted efforts of nature seem incapable of effecting any thing. The indications consist in the removal of the fluid already contained within the cranium, and in subduing the tendency to its further effu- sion ; but unfortunately the resources which we possess will too often prove utterly unavailing towards the fulfilment of either of these objects. Diuretics, purgatives, and diaphoretics, together with mercury, tonics and a strengthening diet, are the internal measures which, singly or conjointly, have been most confided in ; whilst, externally, it has been recommended to keep the head warm, to apply aromatic and slightly stimulating embro- cations, or to employ severer but more promising remedies, such as blisters, issues, tartar emetic ointment, and even the actual cautery. Local and general bloodletting have also frequently been had recourse to. Golis asserts that he has cured the majority of cases when early seen, provided they were not congenital or occurring very soon after birth, by the long-continued use of calomel internally, by the application of a mercurial ointment to the head, which is kept constantly covered with a woollen cap, and by the daily use of stimulating baths. In more obstinate cases, he has been obliged, in addition to these measures, to employ issues, blis- ters, or tartar emetic ointment to the head, and under particular circumstances leeches or cupping. In scrofulous habits a tonic plan of treatment must be carried on simultaneously with the above reme- dies. He has occasionally, also, called in the aid of mild diuretics or diaphoretics, and such mea- sures as appeared to him best calculated to quiet nervous irritation, and to support the strength. The remedy which has most frequently appeared useful is, unquestionably, calomel. This he gives in doses of half a grain twice a day; and if it purge too much, he reduces it to a quarter of a grain, or even intermits its use for a short time. Whilst employing calomel, one or two scruples of mercurial ointment, combined with an ointment of juniper berries, are rubbed into the head every night. The woollen cap, in which he has great confidence on account of its keeping up a constant though slight counter-irritation "on the closely shaven scalp, and at the same time supporting the insensible perspiration, and preventing the sudden cooling of the head, is worn constantly for many months, and even then only very gradually laid aside. Becoming impregnated with mercurial ointment, it must help to bring the constitution more speedily under the influence of this remedy. Mildly stimulating baths he conceives likewise to have a very beneficial influence, as they tend to excite an extensively diffused though moderate stimulus over the whole cutaneous surface. Alka- line baths may be employed for this purpose. Baths holding tartar emetic in solution, in the proportion of one ounce of this substance to a pail- ful of water, and gradually made three or four times stronger, have been found by M. Recamier a very useful remedy in this disease, appearing, whilst it reduced the size of the head, to act as a diuretic, and render the patient thinner. If in five or six weeks some improvement is observed, or if salivation takes place, the calomel and the ointment are to be used only every second or third day. During the whole continuance of the mercurial course an acescent vegetable diet is to be avoided, as being liable, according to Golis's experience, to cause colic and gastro-enteritis. Infants require no other nutriment besides good breast-milk, whilst for older patients a moderate quantity of flesh-meat is proper. In mild weather they should both be much in the open air. Under this plan of treatment Golis has known the cir- cumference of the head decrease by from half an inch to an inch in a period of from six weeks to three months, and has frequently seen a perseve- rance in it effect a perfect recovery both of the mental and bodily powers. When the automatic motions of the limbs cease, and the patient be- comes able to hold up the head, to sit up, and even to walk a little, we have evidence that a bene- ficial change is going forward. If within two months, on the contrary, no im- provement is visible, mild diuretics, such as the acetate of potass or squills, may be associated with the preceding remedies, together with an issue in the nape of the neck, or in both arms, kept open for many months ; or tartar emetic ointment or blisters to the same parts, so as to keep up a steady discharge. The use of these measures is particu- larly indicated when the disease has supervened on the sudden disappearance of a cutaneous erup- tion. We have known large blisters, applied al- ternately to each side of the head for many weeks in succession, productive of much benefit. Con- valescence, according to Golis, may be much ac- celerated by minute doses of the sulphate of qui- nine, as a quarter of a grain thrice a day. If acute inflammation of the brain or its mem- branes supervenes, the antiphlogistic plan of treat- ment must be put in practice ; leeches, calomel in larger doses, blisters to the calves of the legs, &c. Even in the latter period of the disease, when hectic fever has come on, the symptoms have been mo- derated, and life prolonged by leeches and calomel. The palliative treatment recommended by Golis in the advanced and hopeless stages, consists in such medicines as tend to promote the secretions, and to moderate convulsions, viz. aperients, diure- tics, and antispasmodics. As to the propriety of evacuating the water by means of an operation, where all other means has failed, practitioners have long been divided in opinion. Golis has given the names of twenty- seven writers who have expressed themselves in favour of it, especially if the fluid be slowly eva- cuated, and at several repetitions of the operation. Yet he himself, along with seven or eight others, including Boerhaave, Heister, Hecker, and Porten- schlag, proscribe it altogether as cruel and useless. Richter thinks, that even where the water is gra- dually drawn off, death by the disease always sooner or later ensues; and Golis asserts that the fatal termination is even accelerated by it. It ap- pears to us, however, that he has spoken too decided- ly on this point, as there are a few cases on record where it has appeared to effect a cure, and seve- ral where it has palliated the symptoms. In cau- tious hands, and where only a moderate quantity of water is drawn off at a time, it has rarely been HYDROCEPHALUS. 501 attended with any immediate danger. In cases where all other kinds of treatment have been tried without benefit, this is, perhaps, not altoge- ther to be rejected. In a case related by Dr. Vose of Liverpool, in the Medico-Chirurgical Transactions, this opera- tion was performed with complete success on an infant seven months old, when the head was more than double the natural size. The instrument used the first time was a couching needle, and the quantity of fluid drawn off upwards of three ounces; about as much more was supposed to have dribbled away afterwards, upon which the child became very weak, but revived by means of the moderate administration of slight cordials. About six weeks after, the water having re-accu- mulated, an opening was made with a bistoury, and eight ounces were again taken away ; and by a third operation nine days after the second, twelve ounces were drawn off without any injuri- ous effect on the general health. A copious serous diarrhoea now set in, by which considerable debi- lity was induced, but this was only temporary. The head gradually diminished in size, and the patient completely recovered. Mr. Lizars has detailed a case in the Edinburgh Medical and Surgical Journal, in which he ope- rated about twenty times in the course of three months. The instrument which he usually em- ployed was a delicate trocar, which was introduced at the most lateral part of the anterior fontanelle, so as to avoid the longitudinal sinus, and thrust in to the depth of about one inch below the sur- face of the integuments. On the reduction of the water the strabismus and dilatation of the pupil ceased immediately. In some of the later opera- tions, the sutures having become in part closed from the progress of ossification, the head was no longer capable of being adequately compressed, and air rushed in to supply the place of the extra- vasated fluid, but without any ill effects ensuing. The case proves, if not the utility of the operation, at least its safety, when carefully conducted. About the same time with the above case, another was published in the same journal by Dr. Freckle- ton, of Liverpool, in which the lateral ventricles were four times punctured with safety ; but in the fifth operation, fourteen ounces of fluid being taken away at once, the child became very uneasy and convulsed, and died on the ninth day. More recently the operation has been repeatedly performed, and with very favourable results, by Dr. Conquest, of London, to whose kindness we are indebted for the following particulars. The total number of children on whom he has operated is nine, and in four of these the operation has been completely successful, the individuals being now quite healthy and free from every sy mptom of their former complaint. The largest quantity of fluid withdrawn at any one time has been twenty ounces and a half; and the greatest num- ber of operations on one child has been five, per- formed at intervals varying from two to six weeks. The largest total quantity of water removed was fifty-seven ounces by five successive operations. The trocar was introduced through the coronal suture, below the anterior fontanelle ; and pres- sure on the head was subsequently made by strips of adhesive plaster, with which likewise the wound in the integuments was carefully closed after each operation. The first successful case was operated on before a large number of medical men at St. Bartholo- mew's Hospital in the session of 1829. Of this, and a subsequent one, a short account appeared in the Lancet in April and November, 1830, to which we refer the reader for further information. [See the results of tapping the head in nineteen cases of Hydrocephalus by Dr. Conquest, in Lond. Med. Gaz., Mar. 17, p. 967, or Amer. Med. Intel- ligencer, May 1, 1838, p. 40.] Punction has likewise been lately had recourse to with complete success by the celebrated Graefe (Graefe and Walther's Journal fur Chirurgie, &c. 1831, b. xv. p. 3) of Berlin, in the case of an infant whose head, of preternatural dimensions from birth, had attained to a great magnitude at the age of four months, when the first operation was performed ; no derangement in the functions of the body had, however, as yet manifested itself. The operation was repeated eleven times within the course of six months. The fluid was each time allowed to escape only slowly and inter- ruptedly ; and the canula was altogether withdrawn and the wound closed as soon as the pulse was observed to become weak, the pupil contracted, and the expression of the face altered, symptoms which, under the influence of stimulants, always disappeared within a few hours after the operation. Each operation was followed by a considerable diminution in the size of the head, and after the eleventh and last the sutures closed. The child could walk and speak before it was a year old. At the age of two and a half (upwards of a year and a half after the completion of the cure) it was exhi- bited at the Medical Society of Berlin. A still more recent instance of the value of this operation has been put on record by Mr. Russell of Edinburgh. (Edinburgh Med. and Surg. Journ., July, 1832.) At three months old the head of his patient had attained to an enormous size, (twenty-three inches in circumference, and fifteen inches and a half from ear to ear.) There was strabismus and constant rolling of the eyes, irre- gularity of the bowels, and frequent starting in sleep; but the pupils were neither dilated nor in- sensible. Compression, blisters, mercury, diure- tics, &c, having already been tried without the slightest benefit, recourse was had to punction as the last resource. By four operations performed at intervals of about ten days, the dimensions of the head were considerably reduced. After the fourth operation, the water again threatening to accumulate, calomel was administered in small doses, so as to affect the mouth, by which all the remaining hydrocephalic symptoms were removed, and the cure confirmed. The size of the head at eight months old was found to be less by four inches in circumference and two and a half across the vertex, than it had been previous to the first operation ; and the ossification of the sutures was complete. [Dr. Charles West (Lond. Med. Gaz. April 15, 1842) has inquired into the results of puncture of the head in 56 cases of chronic hydrocephalus, from which he infers that the instances in which life was prolonged by the operation appear to be very few, and the cases in which any reasonable pros* 502 HYDROCEPHALUS-HYDRO PERICARDIUM. pect of the patient's recovery existed after a week had elapsed from the first performance of the punc- ture, still fewer. Sometimes the puncture was followed by an almost immediate aggravation of the encephalic symptoms, and by death. Usu- ally, however, a degree of apparent improvement followed the puncture ; but the fluid soon col- lected again, and the second operation was suc- ceeded by less marked relief. The quantity of fluid increased ; and whilst the size of the head continued undiminished, or even grew larger, the body became emaciated; and death took place either from exhaustion, or cerebral symptoms came on, and life was terminated by coma or convul- sions.] Storch has mentioned an instance of hydro- cephalus where the spontaneous escape of about a pint of serous fluid by the nose was followed by temporary relief; and a singular case has been related by Mr. Greatwood, where a child of fifteen months old was accidentally cured of the disease by falling upon the back of the head upon a nail, above three pints of fluid gradually escaping from the puncture thus made. When the operation of puncturing the head is followed by extreme faintness and collapse, as is occasionally the case when too much fluid is re- moved at once, small doses of ammonia, or a few tea-spoonsful of brandy and water, may be given to revive the patient. Inflammatory reaction sometimes sets in within the course of a day or two. Here leeches, cold applications, aperients, and other antiphlogistic measures must be em- ployed. Sir Gilbert Blane, conceiving that chronic hy- drocephalus might sometimes depend on a want of firmness and due resistance in the bony corn- pages of the skull, tried the effect of compression by means of a roller, with apparent benefit, in a case related in the Medical and Physical Jour- nal, for October, 1821. But as leeches and purgatives were simultaneously employed, it is very difficult to say what share the compression had in the amendment which took place. Mr. Barnard has related two cases in the Medical Re- pository, in which pressure on the head made by means of straps and adhesive plaster, along with leeches and the application of cloths wet with cold water constantly to the head, appeared beneficial. [For further cases by the same gentleman see London Lancet, Oct. 12, 1839, p. 82.] In other hands, however, compression has failed altogether. [See a similar case cited from Caspar's Wochen- schrift, in Provincial Med. Journ. April 29,1843.] W. B. Joy. HYDROPERICARDIUM.—From Mwp, aqua, and tH TtepiKapSiov, (th. irtpl et KapSia,) pericardium. Hydrops pericardii, dropsy of the pericardium. —This affection can very rarely require the ex- clusive attention of the physician, since, although the pericardium is frequently the seat of effusion, it is seldom, probably never, so affected indepen- dently of organic disease either of the heart or some other structure. The symptoms conse- quently are always more or less obscured by the concomitant affections; and even when we are enabled to attain a tolerable certainty of the pre- sence ot fluid within the pericardium, its removal alone would have but little effect in restoring the patient to health. These and some other consid- erations of a similar nature might almost induce us to exclude hydropericardium from a sepa- rate consideration, but as it has usually obtained from nosologists and writers on the diseases of the heart a distirct place, it could scarcely be omitted in a cyclopaedia of medicine. The treat- ment of the subject is, however, a matter of very considerable difficulty, and the information we have to offer must be rather of a negative than a positive kind. As the pericardium is a serous membrane, and hence always in some degree bedewed with mois- ture, a preliminary inquiry becomes necessary as to what must be considered its natural state, and what quantity of fluid ought to be regarded as constituting disease. This question has been much discussed by older authors, while the more modem have been usually content to refer to the opinion of Corvisart, without inquiring into the data upon which that opinion was founded. Among the ancient authors, Vesalius and Lower maintained that the pericardium generally con- tained some fluid, and the former had observed it in the pericaidium of criminals, who had been quartered while yet alive. He was not, however, certain of its existence in every case. Lower says decisively that some fluid is always present, but without any detail of the researches which led him to entertain so positive an opinion. Hoff- mann, after referring to these and other authori- ties, merely observes that he had never been able to detect any fluid in the pericardia of animals which he had opened alive. Halter, after review- ing these and many other writers, intimates that in his opinion some fluid, but in very small quan- tity, is always to be found, and that it does not usually exceed a few drachms. Littre had decapi- tated puppies, and had always found some water in the pericardium. Scnac, reviewing these con- tradictions, and remarking that in a number of bodies in which the heart and its envelopes were perfectly natural, the membrane was dry, inclines to the opinion that in the healthy state the peri- cardium contains no fluid, but at the same time admits that some fluid is occasionally observed which could not properly be referred to disease. Corvisart does not enter at any gre;it length into the dispute, but contents himself with pronounc- ing, that whenever the fluid exceeds six or eight ounces in quantity, it must be regarded as the effect of disease, and consequently as forming hy- dropericardium. To this last author Kreysig, Bertin, Testa, and other contemporary writers are satisfied to refer, and in this state the subject still rests. Under these circumstances we have endea- voured in some degree to promote our knowledge of this subject by the result of dissections, and the following tables will show what proportion of one hundred and fifty examinations exhibited fluid in the pericardium. Fifty of these cases are drawn from our case-book ; fifty, respectively, are furnish- ed by Mr. Wickenden and Mr. Parsons of Birming- ham, who are well qualified for such investigation. Any appreciable quantity of fluid was always noted, that is, whenever it exceeded a couple of drachms; in some cases even less than this was noted. To this we shall add an additional table HYDROPERICARDIUM. 503 of sixty-four cases, for which we are indebted to Mr. Baynham, whose pathological researches have been very extensive, and are most valuable from the accuracy with which they have been con- ducted. I. Table of one hundred dissections, with the number of cases in which water was found in the pericardium. Nature of the disease. Laryngitis.................. Bronchitis.................. Typhus and synochus........, Phthisis pulmonalis........... Scarlatina................... Convulsions................. Pneumonia.................. Hydrocephalus............... Peritonitis.................. Enteritis.................... Ascites..................... Marasmus................... Diarrhoea................... Epilepsy.................... Hooping-cough.............. Disease of stomach............ Internal abscess.............. Arachnitis.................. Disease of kidney............ Cholera.................... Concussion of the brain........ Disease of spleen............. Disease of heart.............. Fracture of skull............. Phlebitis................... Rheumatism................. Apoplexy................... Hydrothorax................ Tumour in the brain.......... Diabetes.................... Sudden death without obvious ~i cause.................. 5 Disease of spine.............. Ovarian dropsy.............. Rupture of uterus............. Cancer..................... Puerperal convulsions......... Puerperal mania.............. Menorrhagia................. Pericarditis.................. Ulceration of bowels.......... Measles..................... Pleurisy.................... Disease of pharynx........... Swallowing boiling water...... Pulmonary apoplexy.......... Total.................. 2 12 7 31 1 2 5 5 4 2 4 4 1 3 2 5 1 4 3 1 1 I 12 1 1 2 4 2 1 1 * « = ■" w C3 .a -" a) E £ °- 3 G> O) 150 30 The largest quantity of fluid was in the case of phlebitis, in which it amounted to sixteen ounces. In the cases of phthisis it never exceeded eight ounces, and generally not more than four: in some one ounc% was the whole quantity. In the other cases it varied from eight ounces to two drachms. U. Table of sixty cases in which water was found in the pericardium after death. Disease. No. of Cases, Phthisis pulmonalis................14 Diseased heart.....................8 Pleurisy..........................4 Pericarditis.......................4 Anasarca...................... . .4 Overlaid......;...................3 Hydrothorax......................2 Bronchitis........................2 Pneumonia.......................2 Diarrhoea.........................l Diseased kidney...................1 Apoplexia serosa...................1 Scrofula..........................1 Fungus haematodes.................1 Typhus..........................l Atrophia..........................1 Senilitas..........................l Hydrocephalus....................1 Rheumatism......................1 Asthma..........................1 Spinal disease.....................1 Peritonitis........................1 Ascites...........................2 Apoplexy.........................] Disease of stomach.................1 Blue disease........................ Hernia............................ Sudden death.....................1 In both these tables it will be seen that tuber cular consumption affords the largest proportion of cases in which water is found in the pericar- dium. Diseases of the heart stand in the next place, and, generally, affections of the chest are much more frequently accompanied with hydro- pericardium than those of any other cavity. The largest quantity was three pints, and was the con- sequence of inflammation of the membrane. The colour of the effused fluid much varied ; in most instances being nearly a clear serum, in others being of a chocolate colour. This is in unison with the experience of Kreysig. Notwithstanding the number of these dissec- tions, they have afforded very little information as to the diagnosis of hydropericardium; nor, if we look at the tables, can we be much surprised at this result. In no single instance, did the pre- sence of fluid constitute the only disease when it exceeded a few ounces, and in those cases in which a few drachms only were found, no symp- toms existed during life by which attention was attracted to the condition of the pericardium. Having made these preliminary remarks, we may proceed to state thai no very well authenti- cated case of idiopathic hydropericardium has yel been related. The only instance with which we are acquainted, that is on record, is one mentioned by Morgagni upon the authority of Valsalva and even of this some doubt may be entertainec The symptoms were dyspnoea increasing to ortho pncea, cough, mucous expectoration, and fever 504 HYDROPERICARDIUM. and the case proved fatal. The pericardium was distended with water. But as fhe affections of the mucous membranes were scarcely distinguished in the time of Valsalva, and as many of the symp- toms above enumerated were, if not peculiar to, at least such as are usually attendant upon bron- chitis, we may be pardoned if we refer the pres- ence of water in the pericardium to the existence of bronchitis. Nor is another case, related by Morgagni, and referred to by Kreysig, Testa, and others, much more illustrative of idiopathic hy- dropericardium independent of other disease. This case occurred in a nun in whom the over- activity of her physician had produced hyperca- tharsis, and a series of anomalous symptoms for full a year, soon after which she died. The case, nevertheless, is worthy of notice in connection with this subject, although we can scarcely refer to it as a means of diagnosis. The patient the day after the purging above alluded to became suddenly very faint upon at- tempting to rise from her bed, and this fointness recurred whenever she attempted to speak or move much. These symptoms continued with little variation for a considerable time ; her countenance still remained healthy, and her sleep undisturbed. The bowels acted regularly, and the catamenia were as usual. Respiration in every position was uneasy. Her pulse was regular. There was no palpitation, and no pain in the chest, nor cough. The only complaint was a sense of weight in the region of the heart, and excessive nervousness. Towards the termination of her life she had sharp pains in the region of the heart; her strength gradually diminished, and at length she died. On dissection the only morbid appearances were the effusion of about nine ounces of water in the pericardium, and ulceration of this membrane. The ulceration Morgagni refers to the acrid nature of the water: modern pathologists would, probably, rather refer the whole appearances to inflammation originally, which had produced equally ulceration and effusion, both common terminations of in- flammatory action. These are the only cases with which we are acquainted, where even a pretence can exist for considering hydropericardium as idiopathic: nor does any author of late years ever regard it in this light. Nevertheless, white the science of medi- cine remains in its present imperfect state, every effort to forward our knowledge of the diagnosis of disease is worthy of encouragement; for if disease is to be treated successfully, excepting by accident, it must be by an accurate acquaintance with all its phenomena. Like every other form of dropsy, hydropericar- dium may be the consequence of some affection of the membrane in which it is seated, or of some organic disease of other parts. In the former case it seems always to result from inflammation of the pericardium; in the latter it may be con- nected with inflammation, or the simple sequence of the pericardium participating in the atonic state of the general system. Kreysig has attempted to lay down the signs by which we may distinguish effusion in the pericardium succeeding inflamma- tion of the membrane. According to this author, when the more pro- minent symotoms of Deric?rditis subside, a feverish state with slight exacerbations still remains, and for some time a more marked symptom is present. These exacerbations gradually increase both in severity and frequency, and are soon accompanied by anxiety and great sense of oppression. The patient is unable to lie down, and usually sits with the head and chest leaning forward. The pulse becomes habitually irregular, the appetite uncer- tain, and the sleep bad. During the exacerbations all these symptoms are worse; the anxiety and restlessness become excessive, and delirium or most painful irritability, one or both, ensue. This state continues for some hours, and then nearly disap- pears, again, however, to return after a short in- terval of rest. The disease lasts from seven to fourteen, or even twenty-one days. During the last few days of life the patient is less complain- ing, and endures positions which had previously been intolerable. A species of drunken sleep is manifested; the patient lies as it were in a dream; the action of the heart becomes weak and more irregular; the extremities are cold ; the surface of the body is covered with a clammy perspiration; and death at length ensues as the consequence of a weakened and obstructed circulation. Such is the account given by Kreysig of this affection ; but in it we see nothing to distinguish hydropericardium from hydrothorax. Many of the symptoms are common to this with other dis- eases of the heart and thoracic organs; none of them are so peculiar as to mark without error the occurrence of effusion in the pericardium. Still the whole relation is excellent; and could we see the symptoms as well developed in every case, it would certainly much facilitate our diagnosis in this difficult disease. Unfortunately, however, this is seldom the case; sometimes one, sometimes another symptom is absent, and sometimes the dropsy of the pericardium is complicated with other diseases, which leave us doubtful to which affection particular symptoms are to be referred. It is at present scarcely possible to afford any cer- tain signs by which an accurate diagnosis may be obtained. We might here also notice the affection which Testa has named hydropericarditis of child-bed; it is, however, as in truth is the disease above de- scribed by Kreysig, a true pericarditis terminating in effusion. Hydropericardium from Organic Dis- ease.— The signs by which hydropericardium may be distinguished when complicated with or- ganic disease, especially if this disease be seated in the heart, are even, if possible, more obscure than when simply the result of pericarditis. Cor- visart, who must still be regarded as the best author on this subject, has enumerated many signs by which the presence of effusion in the pericardium is indicated; yet a very cursory perusal will show us that they are deserving of little confidence. Patients, he observes, who suffer from hydroperi- cardium have usually livid countenance, and black and livid lips; they experience great anxiety and oppression in the region of the heart; dyspnoea is so great as to threaten suffocation, especially when the patient assumes the horizontal position. In applying the hand to the heart, its action is found to be obscure and tumultuous, and the organ appears to beat through a soft body, ol HYDROPERICARDIUM. 505 rather through a liquid placed between it and the walls of the thorax. Percussion produces a dull Bound over a space commensurate with the extent of the effusion; and in some instances the left side over the region of the heart is more vaulted and elevated than the right When the disease is of long duration, the strength fails, oedema of the extremities ensues, and, more rarely, a slight puffing over the anterior and left side of the chest. Vieussens has mentioned oedema of the face and a dark leaden colour round the eye-lids, as more peculiarly indicating hydropericardium, but Testa justly regards these appearances as by no means peculiar to this affection. We have, ourselves, in a former article, remarked that all dropsies which depend upon diseases of the chest for their origin, are usually indicated by oedema of the face; and hence it must be insufficient to mark this form of dropsy alone. On the other hand, Testa remarks, and the remark is worthy of notice, that hydro- pericardium very rarely exists without oedema of some part of the face; and that this oedema does not disappear before death, as does the oedema of the extremities. Morgagni, Kreysig, and Testa have discussed at considerable length the value of individual symp- toms ; and they have all come to the same con- clusion, viz. that they are all useless to distinguish hydropericardium from hydrothorax, and often from diseases in which no effusion is present. It would take up more space than ought to be allowed to this article, were we to go over the ground which they have trodden with so much ability; nor, considering.that they at last arrive only at a negative conclusion, would any advantage be de- rived from such a discussion. Modern ingenuity has, however, introduced a new means of diagnosis, as well as revived and improved an old one. These are percussion and stethoscopic auscultation. With regard to the value of the first, no dependence can be placed upon it in this disease. It will indeed inform us, and that with tolerable accuracy, of the extent which the heart and pericardium occupy together when there has been no condensation of the lungs nor any material alteration in the change of parts; but should either of these occur, it would be useless even so far as we have indicated. But again, should no impediment arise from the source now referred to, percussion would do no more than intimate differences of sound without informing us of the causes of such differences; whether, for instance, depending upon enlargement of the heart or effusion into the pericardium. Of this difficulty Corvisart himself was well aware. The stethoscope may perhaps, in very practised hands, afford some information; and Dr. Hope thinks even eight ounces of fluid in the pericar- dium might be detected; " the sensation commu- nicated to the hand and the stethoscope being that of an impulse transmitted through a fluid, and not of an organ striking the ribs immediately." We confess that we are not so sanguine in this respect as Dr. Hope ; and we are much inclined to think, with Laennec, that less than a pint will scarcely afford any signs cognizable by auscultation. The mistake made by Desault in tapping the pericardium may seem to corroborate our doubts. This distinguished surgeon ma'de an opening into Vol. TI — 64 2 s the chest between the sixth and seventh ribs of the left side near to the apex of the heart. He intro duced his fingers into the chest, and perceived a cavity full of water, which he took for the peri- cardium. Dubois, Sue, and Dumangin, who were with him, examined the parts, and were of the same opinion; and Desault then enlarging the opening, let nearly a pint of fluid escape. The fluid being discharged, he again introduced his finger into the aperture, and perceived a pointed conical body to strike the finger. The man, how- ever, died in a few days; and the conical body was discovered to be the heart enveloped in the peri- cardium, which closely adhered to it; and the opening had been made into a cavity formed by a membrane which united the edge of the left lung to the pericardium. Here, then, the union of the pericardium to the heart, and the proximity of the fluid, would probably have obscured even this sen- sation of the heart beating through a fluid. There is only one other sign which we feel called upon to consider, and this was proposed by Corvisart; but the suggestion has not been con- firmed by any other author. Even this, however, is only applicable to very large collections of water. Corvisart had observed the phenomena now re- ferred to in two instances. To employ his own words, " the beating of the heart is perceived some- times to the right, sometimes to the left, or, to speak more clearly, in different parts of an extensive circle. Now this could not occur if the heart should be retained, as is natural, by the pericardium, whose cavity, proportioned to the volume of the organ, fixes the extent and direction of its motions. The pericardium must, therefore, be dilated, and this may happen in two ways; by augmentation in the volume of the heart itself, in which case, though the impulse of the heart might be stronger, and occupy a larger space, still it would strike against the same place; or by an accumulation of fluid in the pericardium, and then the heart, not being likewise dilated, would swim, as it were, freely into the fluid, and strike against different parts of the chest." There can be no doubt that this is a very im- portant observation; but Corvisart himself had only seen two cases in which it occurred : in one there were four pints of fluid, and in the other one pint. We have ourselves in vain endeavour- ed to detect the phenomenon, but have never yet been able ; nor can this excite surprise, when it is remembered how large a quantity of fluid is probably necessary for its exhibition. Jlorbid Appearances. — These are seldom peculiar to hydropericardium ; the essential circum- stance of the disease being merely the presence of fluid in the pericardium. This fluid, we have already stated, varies much in colour; and the membrane itself sometimes exhibits traces of in- flammation, increased vascularity, depositions of coagulable lymph, suppuration, and ulceration. A more detailed account of the morbid appearances will properly fall under those diseases of which effusion is the consequence. Treatment.—Of this we have very little to say in addition to what has been stated under the general head of Dropsy. Hydropericardium i* so rarely, perhaps never, a solitary affection, thai it cannot be treated upon any exclusive principles 006 HYDROPHOBIA. Only one remedy may be proposed which it seems to us necessary to mention, and this is tapping the pericardium. This operation has been very rarely performed on the living subject; nor can we suppose it probable that it will again be pro- posed till experiments upon animals, and observa- tions of injuries in the human subject, tending to ->rov>' that the membrane in question may be wounded with impunity, shall have afforded more justification for such an operation than at present 3xists. Certainly, however, we have no reason to believe that perfect adhesion of the pericardium is inconsistent with considerable enjoyment of life, although probably not with perfect health. John Darwall. HYDROPHOBIA. —When it becomes our duty to illustrate the nature and history of a dis- ease, our thoughts instinctively turn themselves to the mass of obscurity which hangs over so great a majority of morbid affections ; an obscurity which, under every advancement of science, di- minishes but slowly, and which keeps almost all those maladies which were unintelligible two thousand years ago unintelligible still. Some- times it may be doubted whether the disease is truly an original mischief, or merely the symptom of some other primitive disorder; whether it is not frequently confounded with affections happen- ing to coincide with it only in a few occasional symptoms, or is it not daily viewed in the most erroneous light with regard to its pathology and causes; or, in fine, whether proper evidence be not still wanting in these various respects, to enable physicians to establish any conclusion upon a firm and rational foundation. But what- ever may have formerly been the case, it is no very common occurrence, at the present day, to have the doubts and hesitation of the writer upon what may be called a disease of extreme notoriety extended to its very existence; such, however, literally happens with hydrophobia, of which many intelligent persons of different ages and countries have utterly denied the existence, ex- cept as a phrenitic or maniacal affection, deriving its sole origin from the imagination of the patient, (C. Aurel, Lib. iii. c. xiii. p. 223.—-White on Hydrophobia,) or the injudicious treatment of his attendants. It seems necessary, therefore, on the threshold, to lay before the reader the grounds of our belief in the real existence of hydrophobia, reserving for future detail any other confirmatory circumstances which may present themselves as we proceed. Having briefly stated the general arguments, we shall be at liberty to carry him along with us to the history and treatment of the malady. Our first argument is, simply, that numerous persons become affected with the disease, which is essentially characterized by spasmodic contrac- tions of the pharynx, and a difficulty of drink- ing, (the latter generally believed to be a conse- uuence of that spasm,) very soon after having Deen bitten by an animal labouring under a simi- lar affection ; and that these persons invariably gn on from bad to worse, and finally die before the sixth da^ , their bodies upon dissection pre- senting appearances as uniform as can be expected from the great mechanical irritation produced on the adjacent secreting and circulating organs by the violent convulsions. On the other hand, we rarely observe the same train of symptoms pre- ceded by any other cause. Now, of these victims some are mere infants, and cannot therefore be suffering under any mental impression; others are idiotical, others delirious; in neither of which states are the sources of mental terror long kept steadily in view. But in point of fact, a very large majority of hydrophobic patients, whose cases have been distinctly described in our medical records, are positively stated to have retained an adequate clearness of intellect till long after the terrible spasm and dread of fluids had established themselves, and in very many till the last momcnl of existence. Not a few of them have happened to be sensible, well-educated persons, of particu- larly strong minds. And seeing that we have for these facts the moral evidence of the entire faculty, of all ages and countries,—to assert in defiance of it that every hydrophobic patient is the victim of his own insane fears, does really seem to us to be begging the very question or proposition which those who make this assertion are bound to prove, although in direct contradiction to all medical testimony. Besides, if the cause consisted solely in a deep impression of fear, why should the dis- ease, its presumed effect, intermit so frequently and in so many instances, as it is known to do ' It cannot be said, therefore, that the proximate succession of the disease to the bite is the effect of mental emotion ; and it will be easy to show that in most cases of this special class, not one of the other presumed causes of hydrophobia spon- tanea, or rather nonrabida, were present. Conse- quently there is at least one form of hydrophobia of which the only constant known antecedent is the bite of a rabid animal; and this, therefore, in the present state of our knowledge, we are com- pelled to consider the cause till another is shown. Secondly, the wound inflicted is not unfrequently found to hold a manifest relation to the charac- teristic symptoms. At first, these do not show themselves, and the wound heals up kindly ; but just before the time when the characteristic symp- toms are about to appear, the cicatrix occupying the place of the wound often undergoes the remarkable alteration which we shall here for convenience technically name recrudescence. It swells, becomes red, livid, and painful, and the pain sometimes seems to shoot along the soft parts to a considerable distance from its origin. In other cases the wound opens of itself; and dis- charges a peculiar matter. Something similar is known to take place in traumatic tetanus; and although in this affection, as well as in hydropho- bia, we cannot explain why the phenomenon of recrudescence docs not occur in many fatal exam- ples, yet we ought not therefore to deny that in those cases in which it does appear, the con- nection between the recrudescence and the disease is most remarkable. Neither is it difficult to understand that, although the bite may, yet the recrudescence may not be essentially necessary to the appearance of hydrophobia ; and hence we have full warrant to infer that the wound is the antecedent principally and determinately connect- ed with the disease as an effect. Again, it u abundantly established by observation and exp«i- HYDROPHOBIA 507 ment, that the bite of a dog produces, in animals of different species, a disease to all appearance hydrophobic; and on the other hand some ex- periments of M. Magendie, M. Breschet, and Mr. Earle, have led to the inference that the bite, or at least the saliva of man, may produce similar effects on the lower animals. These analogies are so forcible, that notwithstanding all the origi- nal differences between the economy of the human body and that of the lower orders of creation, we cannot refuse here to admit its application as an evidence, that upon man also the bite of a rabid dog will probably produce similar effects. Lastly, the universal persuasion and testimony of the people of every country in the world for more than two thousand years, affirming the connection between the bite of mad dogs, and precisely the same characteristic phenomena of spasm in the throat and fear of drinking, is not to be passed over as a trivial or superstitious evidence of the reality of hydrophobia in man. It is not trivial, for the impression is deep ; and a dread of pesti- lence is not more strongly implanted in the minds of men than the fear of hydrophobia ; it is not superstitious, for it will be shown in what follows, that mankind came to a knowledge of this direful malady in the enlightened period between the days of Aristotle and the foundation of the great medical school of Alexandria ; after Democritus and Hippocrates had long freed the science from all connection with superstition; and when the cities of Greece, Asia, Sicily, and Egypt, abound- ed with medical schools, and with professors alike distinguished by their cultivation of the healing art and their improvement of general philosophy. A coincidence of belief so universal cannot fairly be ascribed to accident, and is no more to be neu- tralized by the possible circumstance that other causes also may produce these symptoms, than the operation of marshy miasm in producing ague, from a well-known fact that other causes may also induce that disease, or reproduce it in the system after it has been to all appearance subdued for many years. It is still more illogical to infer, with some authors, that because the bite of a mad dog is not always followed by hydrophobia, it is therefore never succeded by it. No known cause of disease whatever, not even the exhalations of the pest-house, the inoculation of variola, or the contact of scabies, produces its effect upon every person to whom it is daily applied ; many escape, and probably, as in the case of small-pox, after vaccination, from previous changes in the system, which have rendered the body no longer suscepti- ble of its influence. At all events, if we were to admit the conclusion drawn by late authors, we should be obliged to deny the influence of every exciting cause of disease, of which every succes- sive effect, from the point to which it was first applied, to the parts ultimately involved in the affection, could not be fully traced. Having premised these considerations, we hope we may now crave the attention of the most scep- tical of our readers, while we examine in detail the principal circumstances which have come to the knowledge of the profession respecting this leirible affection. The term hydrophobia, from vSwp, water, and $t8os, fear, has been obviouslv comnounded to ex- press the principal symptom of the present dis- ease, namely " a dread of swallowing water;" the latter fluid being taken by synecdoche as the most common liquid known then, in order to signify all other drinks as well as water. On a similar prin- ciple, the most characteristic symptom, namely, the dread of swallowing liquids, or hydrophobia, seems to have been insensibly assumed as a name for the whole diversified series of phenomena which constitute the disease resulting from the bite of rabid animals. While ignorant of the proxi- mate cause, physicians are content with naming diseases after one or more of their principal symp- toms ; and these denominations suffice for all the purposes of nomenclature, if they are so far prominent and uniform as readily to recal to the mind the thing signified. No medical man, we believe, ever heard the term hydrophobia, since its first reception as a word, without thinking of the disease produced by the bite of animals in the rabid state ; and hence, though it may be our duty to put on record some of the more remarkable synonimes, we must say that we think very lightly of all the attempts which have been made since the days of Polybus to exchange it for one that may seem more expressive. Few rational physi- cians expect to find the history of a disease con- densed into a sort of essence in its name; and it ought not to be forgotten that the most compre- hensive appellation is not always that which pro- duces the most rapid suggestion — the principal end, we presume, of all individual nomenclature. Nevertheless, several distinguished French au- thors, of late years, have seemed obstinately bent upon some innovation; and we find, for example, in the excellent Dictionnaire des Sciences Medi- cates, and the still more recent Dictionnaire de Medecine, two standard works, the term hydro- phobia appropriated to all cases exhibiting a dread of swallowing fluids, but not connected with the bite of a rabid animal; to designate, in short, every form of what is in Britain named simple hydrophobia. On the other hand, to the disease resulting from the contact of rabid animals, rabies canina, rabies, or rage, is in these works exclu- sively applied. Both terms are employed in a sense entirely conventional; for the dread of swal- lowing fluids, or hydrophobia, in the literal sense, is present almost alike in the simple and rabid forms of the disease; and it seems ridiculous to apply the epithet rabies canina to a disease which has been produced by the bite of a wolf or a cat: and the term rabies, whether separate or joined with canina, involves the incurable fault of signi- fying furious delirium, a state of mind which is scarcely ever present in the disease. The ancients did not by any means fall short of the moderns in this curious research after an expressive appel- lation. Ccelius Aurelianus allows the investigation a due share of his excellent chapter on hydropho- bia ; and so many authors have since adorned the pursuit with separate dissertations, that a fancifu person might almost imagine that in the name, as in the virus of hydrophobia there lurks something contagious. The ancient Greeks seem to have bid a specific term for the madness of dogs, namely, \vco-a or Atirra, and we see it s employed by Ho- mer, Iliad ix. 239. From this they formed a vero Wo-du) or Xvrrrfio, and the adjectives \vo-cnrri? "Svn 508 HYDROPHOBIA tniiric, rabidus, rabiosus; terms which Homer j makes his chiefs apply to Hector, while bearing all before him in the field of battle, and conse- quently presenting no bad image of that indis- criminate rage and effort at destruction generally displayed by the dog in a state of madness. The participle Xvttwv is likewise made use of by Plato in his Republic, to characterise a prince of un- governable fury. Hence the term KwiXvaaa, canis rabies, or dog-madness, has been repeatedly em- ployed to designate this affection of the canine race; and it has been extended to the hydrophobia of man by Andreas and others. This, however, is still more extreme; for the translation of kw6- \vcaa is dog-dog-madness.' an absurd pleonasm, there being no lyssa except that of dogs. The very argument urged against the term hydropho- bia, that dogs drink during their whole disease, ought to have taught writers that the disease of the dog is not the same as the disease he excites in man; and consequently that neither lyssa nor synolyssa, nor any other term which properly marks the disease of the dog, can rightly be ap- plied to that of the human species. From the patient being unable to swallow any kind of moisture, some of the Greeks named it hygropho- bia in preference to hydrophobia. Others gave it the appellation phobodipsia, to express the pre- sence of thirst generally accompanying the dread of swallowing, or the dread of liquids themselves. By Poly bus it is named pheugydros, because those affected are observed to shun or fly from water: Aurelianus translated this by the term aquifuga, in which, for obvious reasons, he has been little imitated. From two ambiguous pas- sages in Hippocrates, hydrophobics have been called brachypotse, i. e. parvibibuli, and the dis- ease brachyposia : but the word Ppa^i;, short, may also be applied to the intervals, and thus express in brachyposia two very opposite things, either the act of drinking little, or of frequent drinking at short intervals. It is simply named canis ra- bidi morsus by Africanus and Avicenna. Mead proposed to name it Svo-KaTanoota, or difficulty of swallowing drink; and Rush, full of its relations to fever, will have it called the " hydrophobic state of malignant fever." Quite recently, Dr. Good has attempted to restore the primitive Hellenic term lyssa, by inscribing the disease entasia lyssa. Notwithstanding this profuse luxuriance of no- menclature, the term hydrophobia has always been a id still is that by which this affection is distin- guished by the rest of mankind, as well as by the best medical authors. It is the name employed by Celsus, Aurelianus, Galen, Boerhaave, Sauvages, Dessault, Linnaeus, Vogel, Sagar, Cullen, and Pinel; and is still the only denomination by which the disease is known in the common language of the inhabitants of France and England, and under forms more or less translated amongst all the na- tions which inhabit Europe. Nor does there ap- pear to us the least reason why it should be changed, since, as we have shown above, it accu- rately answers in all the circumstances necessary to a simple name, and involves no theory with regard to the exciting cause or the intimate nature of the disease, but on the contrary seems a sort of etymological reduction of its essential charac- ter to the simplest terms; hence we venture to pronounce, that in defiance of all the efforts of ingenious men to the contrary, it never will be changed. Had it contained any intrinsic misre- presentation, any inherent source of fallacy, we should not have deemed the highest antiquity a sufficient reason for discussing its merits, far less for retaining it in a work of this description. But as it cannot be accused of either, and the reader was not to be left without some knowledge of its multiplied synonimes, we have endeavoured to bring them before him in as brief a manner as perspicuity would allow. The nosological relations of hydrophobia ap- pear scarcely less to have perplexed medical writers than those of its nomenclature. Concerning two radical facts all seem to be agreed ; namely, that there is one form of hydrophobia shortly succeed- ing to the bite of a rabid animal, and which is to be distinguished nosologically from all others; and secondly, that there are several slight evanes- cent forms of the hydrophobic spasm, which ap- pear distinctly as mere incidental symptoms of hysteria and other common diseases; and are ac- companied with little danger, and which, therefore, ought not to be classed as constituting any species or variety of the genus hydrophobia. But be- tween these two extremes there occur an immense number of intermediate instances, resting upon testimony respecting which no rational doubt can be entertained ; whose origin can be traced neither to injury from a rabid animal, nor to any previous disease existing in the system. For the moment, these may be divided into four different sections; first, those cases which arise almost immediately after the application of some obvious exciting cause, such as the bite of an animal not rabid, of the patient himself, a wound, or the influence of fear ; secondly, those which are preceded by an obvious exciting cause, but between which and the appearance of the disease a considerable time intervenes; thirdly, those cases which appear to originate without any probable exciting cause having preceded ; and fourthly, the numerous ex- amples of hydrophobia which occur indeed after the bite of a rabid animal, but at an interval much beyond the period at which this peculiar injury is believed by the generality of physicians to be no longer capable of manifesting its powers. It is in thefdue allotment of these various candidates for nosological distribution that the difficulty of effect- ing a systematic arrangement of hydrophobia is mainly placed. It is not easy to invent a specific name which shall comprehend the whole or even the majority of them ; for if, with M. Sauvages, we comprise them under the term hydrophobia spontanea, it is unanswerably replied, do you call the diseases of the first and second section spon- taneous when their causes are obvious and ac- knowledged ? nay, it is for you to prove that hydrophobia is ever generated spontaneously, since it is denied by the ablest authors. Again, if with Cullen, we employ the term simplex to signify this series of complaints, we are instantly told there is no reason to believe that these are of a more simple nature, or involve fewer symptoms than the cases proceeding directly from the bite of a hydrophobic animal; and that if we make use of the word simplex merely in contradistinc- tion to the term rabiosa, such an application of it HYDROPHOBIA. 509 is entirely conventional. Nevertheless, ds the terms hydrophobia rabiosa and hydrophobia sim- plex are very easily understood and contrasted with each other, especially since the latter term implies that the hydrophobia rabiosa is compli- cated (according to general belief) with the action of a poisonous virus, they are in common use in this country, and may occasionally be employed in the present article. As, however, all that seems wanted for the second species of hydrophobic affections is such an epithet as decides that the cases arranged under it do not originate from the bite of a rabid animal, (the multiplicity of causes, and our total inability to trace these causes to their obvious effects, rendering every other appel- lation more or less exceptionable,) we humbly conceive that some such specific terms as the following would obviate every objection. Genus Hydrophobia. — Great restlessness and hurry of mind; horror of and difficulty of drinking fluids, accompanied by clonic spasm of the pharynx, and spasmodic constriction of the muscles of the chest. Species 1.—Hydrophobia Lyssodes, succeeding, within the period of two years, to the bite of an animal supposed to be rabid. Species 2.—Hydrophobia Paralyssodes, not pre- ceded, within the period of two years, by the bite of a rabid animal, or by any other than anomalous causes. We shall thus reconcile popular nomenclature with the admirers of Dr. Good and of the language of Homer, avoid all verbal criticism, and enable future reasoners to arrange the different modifica- tions which the disease assumes as varieties under their respective species ; while the symptomatic imitations of the disease may be disposed as sy- nonymes under an anomalous species of hydro- phobia symptomatica, as has already been done by several eminent authors. In this manner we have— Hydrophobia Lyssodes.—Varieties, canina, fe- lina, avicularis ? insectorum ? fomitum ? sa- livas ? Hydrophobia Paralyssodes.—Varieties, trau- matica, inflammatoria, phrenitica, meticulosa, nervosa, pathelica, febrilis. The symptomatic species are, hysterica, febrilis, hypochondriaca, maniaca, melancholica, cynan- chka, venenata. Let not our readers imagine that the reflection we have bestowed upon this arrangement is barren of all useful application. On the contrary, nothing is so common, on the narration of a new case, as to hear it asked,—but is it certain that the case is one of genuine hydrophobia? Were the patho- gnomonic symptoms present ? Was it not rather one of those fatal spasmodic affections of the throat in the production of which animal virus has no share 1 And a person unacquainted with noso- logical arrangement often finds it difficult to an- swer such queries, as he must necessarily waver both with regard to the date at which the poison may still work its effects, and the circumstances which connect the approach of the animal with the ultimate symptoms, if he do not even hesitate much about the symptoms themselves. From the usual neglect of such an arrangement may be fairly traced that scepticism regarding hydrophobia 2s* which we so often meet with among members of the profession sufficiently sensible and unpreju- diced, but whose attention has been otherwise di- rected. It appears unnecessary to dilate upon the criticisms which have been made by authors upon the group of symptoms which have been assumed by various nosologists, as constituting the charac- ter of the disease. Nothing was more natural than that the fears of mankind regarding the com- munication of this formidable affection, — fears which may be traced to the time of Aristotle,— should clothe it in all the terrors suggested by an apprehension so justly vindicated by what they observed to take place in other animals. Posterity has added very little in this respect to the horrible train of suffering already so graphically described in the pages of Aurelianus ; and if some of them, since exploded by the critical science of our own day, were believed in and quoted as characteristic by the nosologists who have preceded us, these writers seem hardly to be chargeable, in fairness, with more blame than the misfortune of having lived before these errors were discovered. They are not answerable for their age ; and excluding these faults, enough still remains in their defini- tions to enable us to recognize the disease they describe ; and if there did not, it would still be very poor logic to infer that, because their defini- tions had failed, the disease was indefinable or did not exist. The hydrophobia of Cullen was the same as that of which we treat, although he erro- neously believed it to be characterized by a desire to bite and a loathing of liquids. In the last place it were equally illogical to consider the occasional absence of some one of the characteristic symp- toms a sufficient reason for withholding the gene- ral name of hydrophobia from the disease, and yet this has been a great stumbling-block with some of our most ingenious writers. Such reasoning is correct only in abstract mathematics and ab- stract logical discussion, where the things defined, being pure entities of imagination, can suffer no gradation without demanding a corresponding change of terms. But in nature, and more espe- cially in organic beings, every thing is gradation and change; and no genus of plants or animals, and still less of diseases, could be subdivided into its species and varieties which do actually exist in nature, were this rule to be rigidly observed. No disease, for example, can be better defined by no- sologists than pneumonia; yet how often do the physicians of the present day, by the aid of the stethoscope, proximate auscultation, and other well-known forms of minute observation, discover latent modification of it in every degree of ad- vancement, which but a few years ago would only have come to their knowledge long after by the appearance of adhesions which they might acci- dentally observe on dissection. Instances might be multiplied to almost any number; but it will be more practically useful to observe that a new case of disease is to be classed by the physician rather according to its general coincidence with the symptoms of some well-known type or form, than according to the presence or absence of some individual symptom ; a circumstance which, in the varied irritability of the whole system or of single organs, is often quite fortuitous . and the writer who should deny that the fatal disease sr>?- 510 HYDROPHOBIA. ceeding to the bite of a mad cat, for example, is not hydrophobia, because it is accompanied with scarcely any dread of water, although it agrees in all other indications, may seem to reason with the metaphysical accuracy and the scrupulous defini- tion which distinguish a geometer, but we should distrust his knowledge of the principles of physic, a science which requires great allowance to be made for incidental variations. From (he earliest antiquity of which we have any record, the dog has been the companion of man. In the book of Exodus cattle torn by wild beasts are ordered not to be eaten, but to be given to the " dogs,"—an expression which proves that these animals were already the constant attendants of man, and assisted in his pastoral labours. It was no doubt the impurity of their food that has rendered their name synonymous with every thing that is impure or vile throughout the whole of the scriptures. Still there is no allusion made to hy- drophobic disease any where in the sacred volume, a circumstance which is perhaps best explained by the fact that, even down to the present day, canine madness is unknown in Syria and Egypt. We have already said that the disease was well known to Homer, and applied by him, with his usual critical exactness of similitude, to the indiscrimi- nate havoc with which Hector sweeps through the battle-field of his enemies. Thus,— rary with Hippocrates, not only makes mention of this affection, but even describes its cause when speaking of opisthotonos."* And in another place, speaking of the cause of hydrophobia, " In- deed Democritus, whilst treating of emprosthoto- nos, ascribes the seat of the disease to the nerves;"+ by which in his time were chiefly meant the ten- dons, ligaments, and other white tissues. Now, we learn from several passages in Gellius, the contemporary7 of this well-informed author, that the works of Democritus were still extant in his time, and of frequent reference and high estima- tion ; and it seems most improbable that Aureli- anus would have referred to the chapters in which the passages were sure to be sought for, if he had wished to misquote, or to mislead the disputants in a controversy which, he informs us, was then become hackneyed, and the merits of which he appears to consider with perfect coolness. Demo- critus, be it remembered, was a great traveller, and may have become acquainted with the communi- cation of hydrophobia to man in countries situated beyond that sphere of information to which the industry of the great father of medicine has ever extended. At all events his opinion made little impression on the Greeks ; for we find Aristotle, nearly a century afterward, asserting that the hy- drophobia may be communicated from one animal to another, but not to man. " Dogs," he affirms, " are subject to madness, cynanche, and a sort of gout or lameness. The first of these diseases renders them rabid or furious, and all the animals which they bite become equally affected with madness, with the exception of man. The malady occasions the death of the dogs affected, and of every animal that is bitten by another animal, still excepting man." (Hist. Anim. lib. viii. c.22.) This repeated negation of the actual existence of human hydrophobia would scarcely have been made by so grave a writer as the Stagyrite, unless he had heard the contrary asserted under some degree of authority; nor could he have safely committed it to writing, unless he had previously contemplated the different circumstances. Indeed, Professor Sprengel seems to think that Euripides, who was prior even to Democritus, alludes to it in the Bacchae, v. 337. "Acteon..... mourut de 1'hydrophobie. (Euripid. Bacch. v, 335.—Apollodor. lib. iii. c. iv. p. 189.) C'est la plus ancienne trace que nous trouvions de cette cruelle maladie." (Histoire de la Medecine, tom. i. p. 117.) Upon referring to the Bacchae, how- ever, we confess we cannot discover the most re- mote trace of an allusion to hydrophobia. In that part of the drama to which Sprengel refers, Cadmus is counselling Pentheus to join in the worship of Bacchus and Semele, to dread the danger of contemning the gods, and, as an exam- ple, to take warning by the fate of Actaeon. The words are— opqs tov 'Axraliavo; aQ\iov pdpov '6v £>p6criT0i aicvXaKCs, as iQpiiparo, Suc-dcarro, Kptiooov iv Kvvrjylais 'ApreiiiSos eivat Kop-irdcavr, iv dpydctv. * " Etenim Democritus, qui Hippocrati convixit, non solum liaricmemoravitpassionrmi.sedetiamcujuscausairi tradidit, cum de opisthotonicis scriberct." Lib. iii. 15. f " Equidem Democritus, cum de Emproslhotonieis fH- ceret, nervos inquit." Ibid. ---------"KicTbip Si ptya. oBivel pXepcatvwv MaiWrai exirdyXus, xicrvvos Alt', oiSi ti rict Avipas, ovSe dtovg- Kpareprj ie i \vaoa ScSvkcv. Iliad ix. 237. Tovrov 5' ov livapai Pa\tuv Ktiva \vacrirrjpa. Iliad viii. 299. -------h Xvca&tiris, (fhoyi cikcXos, fiytpovtiei "Exrup. Iliad xiii. 53. The poet with much propriety puts these words into the mouth of Ajax his enemy, for dog was already a term of reproach among the Greeks, (Iliad i. 225,) as well as the Jews. He no where mentions the disease as actually existing in man. In the writings of Hippocrates, there occur at least two passages, the singular language of which makes it not improbable that the physician of Cos had seen hydrophobia, and was then speaking of its symptoms, but that he did not recognise it as a separate disease, and merely considered it as a variety of phrenitis or mania, affections with which it has always been but too easily con- founded :—Ol (ppeviriKoX fipa^v-rrdrai, ip6aa\ tov Bebv irapa- ypijpa avrov rrjv pop(prjv els e\ags, £«cse, >\r 526 HYDROPHOBIA. other timid unoffending animals are collected, he tears and pursues every individual of the flock he can approach. The cat is an early object of his rage, and even the horse and elephant have not unfrequently sunk under its baneful effects. Vo- miting frequently precedes or accompanies the disease, the respiration appears laborious, tremours are frequent, and the animal is at length destroyed apparently by convulsions. Inspection of the dead body exhibits, with the same irregularity, phenomena entirely similar to those detected in the bodies of the victims of human hydrophobia. It is generally believed that the latent period is shorter in dogs, and indeed in most animals, than what it appears to be in man, but this point is not very well ascertained, and there is abundance of evidence of the poison having remained in the dog for several months before the disease was produced. Nay, it seems pretty certain that he has frequently communicated hydrophobia to man and other animals during this apparently latent period ; a circumstance which shows that the viru- lent assimilation is even then going on in the animal's fluids ; and suggests great caution in our intercourse with these creatures. Many have asserted, from Aurelianus down- wards, that dogs occasionally communicate hy- drophobia to man, to their own species, and to other animals, by their exhalation and saliva alone, without inflicting a bite. To inspire the visible vapour they exhale, to receive their saliva upon the skin or into the mouth, even to be scratched by their nails, or by the nails of a cat, has been supposed to be sufficient to induce the disease. There are certainly a few cases related of hydrophobic patients which seem to come under this description ; but as has been well observed by Dr. Bardsley, it is much more probable that, in such cases, some small portion of the cuticle had been deficient at the part with which the sali- va came in contact, and thus afforded all the fa- cility of a wound to the conveyance of its poison into the system. The ancients were well aware of the possibility of this, for Celsus observes that the integrity of the lining membrane of the mouth is necessary to the operations of the Psylli ; and Dioscorides expressly orders those who were to suck out the poison of a rabid dog, first to wash their mouth with astringent wine, and afterwards to lubricate the cavity with oil. With regard to dogs, Mr. Meynell observes, that such of them as have been thought to become affected merely by the contagion of the same kennel, will generally be found, upon minute examination, to exhibit the marks of bites, although concealed by the hair from ordinary observation. With regard to the effects of a scratch, these resolve themselves into the great probability of part of the saliva of the rabid animal having been introduced by the claw which produced it, or having afterwards fallen upon the jpen wound. In fact, both dogs and cats do very frequently present their foot to the head or mouth, when affected by any uneasiness in that quarter ; and they frequently rest themselves with their Head reclining upon the fore paws. All such cases, however, are comparatively rare, and there is reason to suspect that many of these histories were examples of non-rabid hydrophobia. From what we know of the great absorbing powers of the lining membrane of the stomach and lungs, it seems not improbable that the poison, if intro- duced into the saliva, as by kissing a rabid ani- mal, by admitting pieces of cloth, leather, sticks, and the like, impregnated with the same saliva by its bite, into the mouth, the venom might find its way to the stomach and even to the trachea and lungs, and thence, by absorption, be received into the system ; and there are some very positive tes- timonies on this head extant among the older authors; but nothing satisfactory of the kind has been observed during the last two centuries : and we feel ourselves Compelled to pause before we admit the inference. The same caution must be observed with regard to the many animals, in ad- dition to those above mentioned, which have been named by medical writers as the propagators or victims of hydrophobia. The camel is alluded to by Aristotle ; the leopard, the bear, the horse, the ass, and the game-cock are mentioned by Aure- lian, as animals propagating the disease; Penada (Saggio, &c. 1793,) has recorded a case of hy- drophobia resulting from the bite of an insect; and the lion and tiger are vulgarly believed to be capable of producing the same effects. Later in- vestigations seem to show that the herbivorous animals do not easily communicate the disease but the whole evidence adduced is jejune and meagre, and the paucity of cases of communica- tion may entirely result from the pacific disposi- tion of such animals. It is the nature of the car- nivorous to be easily roused to rage, combat, and violence. The Author of nature has made them so, because by combat and violence he hath des- tined them to support their existence; but the pacific races that crop the flowery mead, and par- ticipate, without resistance, in the bounteous re- past with which they are everywhere presented, have neither habits nor motives which febrile or nervous irritation might prompt into violent ac- tion : and into them the same great Author has instilled fear only as a motive of flight, seldom as a motive of aggression or resistance. Hence, pro- bably, the extreme paucity of their bites alto- gether, and the assertion that they never repro- duce the disease; an assertion which we look upon as calculated to diminish circumspection, and to inspire more confidence than is warranted by the evidence upon which it is founded: we wish that in hydrophobia no other conclusions had been originally drawn from such slender premises, and afterwards expanded into general laws. It would be of much importance to ascertain, out of a given number of persons bitten, the ac- tual proportion that become affected with hydro- phobia. It is difficult, however, to come at any thing like distinct truth upon this point, appa- rently so obvious : for the dog is either immedi- ately kilted or tied up, and, consequently bites only a small number, or he runs wild in the country, so that the number of his victims cannot be ascer- tained. Mr. J. Hunter, however, asserts that he knew an instance in which, of twenty-one persons bitten, only one became affected with hydropho- bia ; Dr. Hamilton seems to think that one out of twenty-five becomes affected. In 1780, a mad dog in the neighbourhood of Senlis took his course within a narrow circle, when he was killed, after having bitten fifteen persons, of whom three HYDROPHOBIA. 527 afterwards died of hydrophobia. The French go- vernment ordered the most eminent physicians to resort to the spot, examine the cases judicially, place the patients in hospitals, &c.; so, though the original number is too small to warrant a strong inference, yet it presents the proportion of the number bitten to the number ultimately in- fected in one instance with exactness. At Brive, a wolf bit seventeen persons, and of these ten died hydrophobic. The causes which are said to produce the non- rabid form of hydrophobia, having no great con- nection with each other, and being incapable of inducing a successive propagation of the disease either to animals of the same or of a different spe- cies, they cannot be supposed, as yet, to have all come to our knowledge :— 1. Superficial wounds, particularly of naked and prominent parts. 2. Nervous irritation of various kinds. 3. Violent intermittent fever. 4. Injuries of the brain and spinal chord. 5. Morbid conditions of the stomach. The symptoms of the disease induced by these causes do not differ materially from those which result from rabid hydrophobia, and we therefore supersede the unprofitable labour of repeating a detail of these indications. Whoever wishes to consider them minutely will find the particulars of many cases, at great length, in the article Hy- drophobic of the Dictionnaire des Sciences Medi- cates, and the same condensed, we may be allowed to say, not with great skill, in the Dictionnaire de Vitdicine. Perhaps the best case of the kind on record is that of Lindsay, which occurred from hunger, excessive labour, and mental anxiety, and has been described with great care by Dr. S. Bards- ley in his valuable Inquiry into the Origin of Ca- nine Madness. It may be remarked that Lindsay must have long laboured under hypochondriasis; for a man that could remain, as he relates, from 1782 to 1794, in the constant dread of his family dying of hunger, without having once suffered it in all the twelve years that intervened, either want- ed the usual powers of generalization common to other men, or was no stranger to the disease cha- racterized by a metus mortis a causis non xquis. Lastly, the symptomatic forms of hydrophobia must, in a great measure, be referred to their noso- logical arrangement given above. We do not hold ourselves answerable for a disease, more or less than appears there, having exhibited symp- toms of hydrophobia. Observation cannot yet be complete in this respect; and it is certain that our means of judging of the veracity and discrimina- tion of writers describing such cases are very far from being in that state. They are quite unim- portant as regards idiopathic hydrophobia; because hitherto no connection has been established be- tween them ; and it is seldom that the disease in which symptomatic hydrophobia originates is bet- ter understood than hydrophobia itself. It follows that the only proper place for the consideration of such anomalous symptoms is under the disease in which they arise. The proximate cause or theory of hydrophobia demands particular attention. Empirical trials, of which the practitioner often thinks but too highly, conr"-rding what succeeds with the ordi- nary progress of nature, powerfully modified by external circumstances, have held out no flattering unction to human vanity here. Every thing has been tried, and every thing has failed. And un- less reason shall discover so much of the theory of hydrophobia as enables us to resist the evil or counteract its commencement, the malady must be given up as incurable ; as one certainly for which there is no longer any hope from experiment. It will not be much to the profit of the reader, how- ever, to record every extravagance which may have escaped the profession during two thousand years of ceaseless speculation upon this topic. We shall, therefore, content ourselves with chronicling a few of the most remarkable opinions that have come down to our own times, several of which have been adopted by different sects in the medi- cal world. b. c. Democritus........................... 400 Gaius, brain and motor nerves, 8th pair. . .. 200 Asclepiades, stomach................... 105 Astorius, stomach...................... 30 Themison, thirst and strictum............ 30 Artemidorus, in the stomach............. 30 Dioscorides........................... 30 Celsus.............................. 18 a. c. Aurelianus, deficient moisture........... 230 Galen............................... 230 Mead, fermentation of nervous fluid produc- ing fever...........................1720 Dessault, worms.......................1738 Push, malignant fever..................1798 Bosquillon, imagination.................1809 Dr. Read, spinal marrow................1819 Having already shown beyond all rational con- tradiction, that hydrophobia is certainly the result of a morbid poison introduced into the system of the animal which it affects, the modus operandi of the exciting cause, according to these various hypotheses, becomes much circumscribed. For example, if, with Mead and Rush, we consider hydrophobia as a fever, then must the inoculated virus be allowed to produce it after the manner in which the exanthematous viruses produce their respective febrile eruptions, or the different miasms, when inhaled, engender fevers. Of course we can make no allowance for Dr. Mead's perversion of the nervous fluid, as it is no longer believed to exist. But there is no more difficulty in compre- hending how the rabious poison may produce its peculiar fever and spasms, than why the poison of small-pox produces a severe fever, often with convulsions and vomiting, and a severe inflamma- tion of the muco-cutaneous membrane ; or why the infection of pertussis produces a fever with peculiar spasmodic coughing, and a copious dis- charge from the mouth and fauces. Nor is there any more difficulty in comprehending these latter effects, than in conceiving why croton oil, intro- duced into the circulation by abrasion or puncture, excites violent action in the bowels ; tartar-emetic in the stomach; and squill in the kidneys. They are the simple result of that original quantity ol irritability wherewith these parts have been fur nished, and by which alone they become suscep 528 HYDROPHOBIA. tible of the influence of the given irritant applied in a certain dose. Diversity of property, whether of organic or in- organic structures, is the great beauty of creation, and constitutes the essence of individual natures, or that character by which they are distinguished from every other thing, and are thus solely the things they are. It is the principal medium through which its divine architect conserves the actions of the machine, which, in this sense, become just so many fulfilments of his original purpose. Such effects of external upon susceptible bodies differ in little from the action of an acid upon an alkali, being equally the result of special properties pre- viously impressed upon each; and are facts not to be explained but observed. The blood of an ani- mal imbued with the canine poison may have its power of irritation exactly in that degree of modi- fication which produces most vehement effects upon the nerves of voluntary motion, and upon the distributions and connections of the eighth pair; and yet not to be in a state capable of effecting the least impression upon the liver, spleen, kidneys, or uterus: and, on the other hand, the motor and pneumogastric series of the nervous system may be originally endowed with exactly such a degree of susceptibility as enables them to originate those high indications of excite- ment which they exhibit in hydrophobia, with frequent febrile re-action whenever the virus is applied to them through the medium of the blood. The peculiar effects of every individual virus hitherto discovered, prove that this mutual coapt- ation of the stimulus and sentient fibre to each other is not merely a vague supposition of what may be, but an actual induction supported by the analogy of every known example of inoculated virus. We repeat then, that this notion of the hydrophobic poison producing great nervous irri- tation and fever, from which all the other pheno- mena naturally result, is far from being wild and fanciful; and, independently of the names of its distinguished authors, merits due consideration. It has the advantage of embracing nearly all the phenomena, as it is not necessary that the fever should appear on any particular day, or appear at all, just as we see obtain in tetanus and hooping- cough ; neither when it does come, does there seem much excuse for so keen a verbal critic as Dr. Rush terming it malignant. The vomiting, gastric pain, appearances on dissection, as well as the. peculiar character of the matter ejected, the thirst and spasmodic irritation of the throat, and the necessity of some portion of the acrid saliva being received into the stomach, are circumstances which have induced many distinguished men to believe that the virus first exerts its malignant in- fluence upon the stomach, and from this, as a centre, radiates its action to the most distant points of the system which have any consent with the stomach, by that sympathetic irritation which we see prevailing in so many gastric diseases. This view is also ingenious, and comprehends a great many of the phenomena of hydrophobia; but it appears liable to some fatal objections; it does not explain the total absence of gastric symp- toms in many individuals, and of traces of disease in tne tunics of the stomach in many others; and Uiere is frequently no rejection of solid food by hydrophobic patients, or of solids and fluids by dogs, as happens in gastritis, and might be expect- ed to take place if the stomach was in any way the primary seat of hydrophobic irritation. The affection of the respiratory organs also, seems quite too violent to be an effect of mere gastric irritation. Still less tenable was the ancient hypothesis, that the virus of the mad dog first acted upon the liver, producing a large secretion of black bile: that this black bile accumulating, frequently gave rise to the symptoms of melancholy and hypo- chondriasis, diseases which were then supposed to be produced by that fluid : that the black bile then made its way into the stomach and excited hydro- phobia, very much in the same way we have just sketched. There is no black bile, and the occa- sional appearance of bile in the stomach is the effect of the vomiting, not the cause. The same series of objections apply to the opinion which refers the principal focus of hydrophobic action to simple inflammation of the pharynx and larynx. or of the two former, or of the latter alone ; in all these situations the marks of inflammation are often entirely absent. The sensibility of the fauces, the copiousness of the salivary secretion, the thirst and suffocating spasm, bear no proportion what- ever to the presence, absence, or degree of these traces of inflammation which scarcely ever appear at the commencement of the disease, and are there- fore consecutive of some other and later part of it. Besides, the general sympathies of the fauces are not very extensive, and they are so ordinarily the seat of inflammation that it would not be rash to assert that no one case out of a million exhibits a regular specimen of hydrophobia, even in its non- rabid form; while scarcely one case in a hundred is without a regular display of them in the rabid form. This consideration mightily reduces the number of chances in favour of the phlegmasian hypothesis, which counts many able supporters. Authors have conjectured that the initial seat of the virus might probably be somewhere in the respiratory apparatus, in the larynx, bronchi, lungs, diaphragm, thoracic muscles, or all of them toge- ther. This conception has certainly the advantage of coinciding with appearances at a very early stage of the disease, in which frequent sighing, a panting motion of the chest, uneasy respiration, an occasional sense of suffocation and fainting, are generally experienced: it has the further ad- vantage of explaining what takes place in the pharynx, gullet, and stomach, much better than the assuming these symptoms to be primary ; and elucidates the perverted state of respiration consi- dered as their consequence. But the theory affords no rational explanation of the fever, the mental aberration, the salivation, the tremours, the spasms; and these objections seem fatal; for no theory of a disease can be admitted which leaves as much as it illustrates unexplained. We have said enough when we mention M. Dessault's theory of organic worms ; of which the day is long past. It seems hardly necessary to observe, that those ancient authors of the Alexandrian school, who ascribed the seat of the disease to the brain and its membranes, merely did so because they consi- dered these organs as the primary origins of the nerves; the nerves of sense being conceived to HYDROPHOBIA. 529 proceed from the mass of the brain and spinal marrow, while the nerves of motion were believed to spring, by small roots, from the membranes that invest them. This is also the comment of Aurelianus, and we are warranted therefore in affirming that their theory of hydrophobia differed not essentially from that of Mead and Rush, and does not therefore require to be considered apart; since, like these authors, almost all the ancients admitted the absorption of a virus. Themison, Aurelianus, and others of the methodic sect, con- ceived that the virus inflamed and dried up the blood, thereby producing a deficiency of secretion in the fauces and gullet, great thirst, and a general constricted state of the system. In short, it was a well-marked example of the strictum, and accord- ingly directed all their efforts to subdue this state of rigidity by introducing fluids into the colon, plunging the patients into water, and other con- trivances. M. Magendie's method of injecting tepid water into the veins might be expected to answer the same purpose; but it is impossible to prove the existence of constriction in hydrophobia; thirst is not always present; and the whole theory has been long since exploded, as incompatible with the doctrine of the circulation and with the general principles of pathology. Of late years, since the experiments of Legal- lois, Wilson Philip, and Magendie, [and Dr. Mar- shall Hall], respecting the structure, function, and relations of the spinal cord have become so justly celebrated, Dr. Reid of Dublin, and several conti- nental writers, have endeavoured to revive a part of the above ancient theory, and to replace the principal seat of hydrophobia in the spinal mar- row. Some slight dilatation in the vessels of this part, and vestiges of inflammation noted in one or two dissections, seem to be the only new facts upon which, in connection with the light thrown upon the spinal portion of the nervous system by those experimentalists, this idea is at present sup- ported. But it leaves the mental phenomena, the salivation, the spasms of the face, the tenderness and unnatural appearance of the skin, the gastric, and particularly the diaphragmatic irritation, alto- gether unexplained ; for it is scarcely necessary to observe that the nerves of the stomach and dia- phragm originate much above the points where such congestions are observed ; and which, though they be often totally absent, are not therefore to be totally denied, since both men and animals (Gillman's pigs for example) often exhibit a dis- tinct paraplegia some time before death. It is not improbable that the paraplegia here alluded to in man is that which has given rise to the numerous fables of the older authors, of hydrophobic patients rolling themselves up like a ball, crawling on all- fours, and attempting to lap water in the horizon- tal posture, like a dog, &c. " In a state of despond- ency," says Dr. White, of Bury St. Edmunds, "and with agonizing groans, the patient threw himself down, as we thought, in a corner of the room, and soon after crawled about in a restless manner, dragging his legs after him, which proved to us that he fell on the floor from his lower limbs being palsied." Amidst so many ingenious hypotheses, if we are finally asked which of the number appears to us to be on the whole the most consonant to rea- Vot. IT.—67 2u son, we at present say that an explanation of the phenomena which does little violence to the re- cognised principles of pathology may most easily be drawn from the first, which assumes that the imbibed virus, like most other poisons, mainly and initiatively spends its force upon the nervous system. It is a well-known fact that all severe injuries inflicted upon this system, whether in the way of stimulus or depression, manifest the gravity of their influence most remarkably in that series of organs supplied by the eighth pair: and con- versely, experimentalists, as M. Desmoulins, have found that the smallest pressure even of a drop of blood upon the origin of this nerve in animals almost instantly extinguishes life. The affection, then, so strongly marked, of the parts supplied by this nerve in hydrophobia, and the curious cir- cumstance of its never extending its ravages below its pneumo-gastric termination, may perhaps be considered merely as an index of the deadly viru- lence of the cause. Still we have shown above that there is no difficulty in comprehending, with the ancient Gaius, that the poison of rabies exerts a peculiar inveteracy of action upon the origin of the respiratory column and the commencement of the eighth pair, just as the vomiting, dysphagia, and laborious respiration, occurring from a violent blow on the head, may either be assumed as the known ultimate effect of general compression, or as a modification of these by some special injury at the same time inflicted on the origin of the same pair. Diagnosis.—Properly speaking, there is scarce- ly any disease that a careful practitioner would conf^ind with hydrophobia; but in cases where no rabid impregnation is suspected, the disease may be mistaken for phrenitis, mania, fever, or tetanus; and, in the incipient stages, for melan- choly, hypochondriasis, and hysteria. It can only be mistaken for any one of the three latter during a few hours from the commencement. Hysteria and hypochondriasis advance by slow degrees, and rarely have fever, difficulty of respiration, tender- ness of skin, or salivation. Melancholy is altoge- ther a chronic disease, and never has convulsions, spasms of the throat, dread of water, difficult re- spiration, and vomiting among its symptoms. It is true that phrenitis, and what was long classed as a form of it, delirium tremens, have tremours, suspicious fears, tenderness of skin, convulsions and difficult swallowing; but there is no affection of the stomach or respiratory system, no vomiting, no salivation : nay, spasmodic difficulty of swal- lowing occurs not in one case out of a hundred. From mania it is distinguished as soon as the spasms, difficulty of swallowing, and salivation appear. Indeed the mental aberration, the aver- sion to certain objects, and the fever which is occasionally present in both, seem to be almost the only points of resemblance. Dr. Rush has entered into a long argument in order to evince the identity of fever and hydrophobia ; but though hydrophobia has fever, it does not follow that hydrophobia is the same thing as fever ; or, it, other words, is fever alone. In short, we have often repeated that in many cases of hydrophobia fever actually supervenes ; and that where it does occur, it is seldom a primary symptom The distinction of hydrophobia from tetanus has been PHOBIA 530 HYDRO! made the subject of much discussion. The two diseases seem first to have been compared with each other by Democritus ; but it cannot now be known whether he, or indeed any of the ancients, considered the apparently tetanic phenomena of hydrophobia to arise from the wound alone. On the contrary, they seem almost all to have admitted the existence of a virus ; and from the earliest periods to have attempted to account for the symp- toms by the operation of this poison upon some peculiar series of organs, from the excitement of which they conceived all the visible symptoms to proceed. Democritus traced it to the tendons or muscles; the followers of Herophilus and Erasis- tratus, the great discoverers of the functions of the nerves, naturally referred the virus to that system ; Asclepiades traced it to the stomach ; the methodists to their favourite strictum, Sec. But none who admitted the reality of the disease appear to have disputed the existence of the virus. Dr. Mease, of Philadelphia, in 1793, published an able work on hydrophobia, in which he con- tended for the uncertainty of the virus, and makes out hydrophobia to be purely a nervous affection. Charles Bader, in a dissertation on hydrophobia, published 1792, maintains that there is much less of contagious character in hydrophobia than is generally believed, and draws a formal parallel between tetanus and hydrophobia. The non- rabid form of hydrophobia is occasionally symp- tomatic of tetanus; and both tetanus and hydro- phobia seem to originate most readily from a small punctured or lacerated wound. Both ex- hibit signs of recrudescence in that wound a short time before the spasms supervene; both exhibit paroxysms of universal convulsion, and occasion- ally fever, and both carry off a great majority of patients before the sixth day. These are the chief circumstances in which the two diseases agree ; and to appeal to more minute but very uncertain points of correspondence, as has been done by the writers who contend with such zeal for their identity, would add nothing to the just- ness of the comparison. But we have already shown, when discussing the questions respecting the modus operandi of the cause of hydrophobia, that there intervene many undeniable discrepan- cies between the two diseases; and to these many others must be added. Tetanus, as its name im- plies, consists essentially in a tonic spasm, gene- rally occupying the muscles of the lower jaw, of the neck, of the spine, and the limbs; of the thorax, abdomen, and diaphragm; and always observed more to affect the extensors than the flexors. These contractions of the muscles are occasionally relieved by intervals of ease, but never by entire relaxation ; nay, in successful cases, Dr. Currie assures us the deep indentations made in the face by the terrible contractions of its muscles are visible afterwards for many years, and imprint on the countenance a severer character than it previously possessed. A stiff* immoveable state of the lower jaw, scarcely to be overcome by any ordinary force, is present during almost the whole of nearly every case of tetanus, and has acquired, for that variety of the disease in which the mus- cles of the spine are little extended, the name of trismus, or lock-jaw. On the contrary, the spasms of hydrophobia are always clonic, that is to say, they are always of brief duration, and are succeed- ed by a period of complete relaxation, generally of many hours duration in the beginning of the disease, unless provoked by attempts to make the patient swallow ; and even at the last fatal parox- ysm, tonic spasm, and particularly locked-jaw, are very seldom to be observed. A discharge of saliva is an exceedingly rare occurrence in tetanus; in hydrophobia it is a general and characteristic symptom. Thirst is rare in tetanus ; it is charac- teristic of hydrophobia. Vomiting and gastric pain or uneasiness scarcely ever occur in tetanus; they are so general in hydrophobia as to be mis- taken by many for the essential circumstances of the disease. It is only in rare forms of tetanus that attempts to drink bring on guttural spasms, a dread of fluids, and their violent rejection when introduced ; but in hydrophobia this is the pathog- nomic trial which fixes the character of every case, with a very few unimportant exceptions. In tetanus, the mind is almost always clear to the last; in hydrophobia, almost from the beginning, numberless deviations from the usual habits of thought and action indicate an incipient stage of mental aberration, which often passes on to deli- rium or raging madness. In tetanus, fever is rarely present; in hydrophobia, it is frequently present. From tetanus, many recover ; from hy- drophobia, none recover. Tetanus takes its rise from cold or from any sort of wound ; hydropho- bia from the bite of a rabid animal. Tetanus, though the usual result of small punctured and lacerated wounds, rarely follows from the bite of a rabid animal; hydrophobia with much greater frequency in proportion to the number of persons bitten, it is said so much as one out of every twenty-five. Tetanus seems more frequent in warm climates; hydrophobia in cold climates, or at least indifferently. Tetanus seems to occur almost any time after the injury ; hydrophobia chiefly from the thirtieth to the sixtieth day. It has never been contended that the bite of a tetanic animal communicates tetanus ; but it is acknow- ledged that the bite of a hydrophobic animal com- municates hydrophobia. The countenance of a tetanic patient bears no resemblance to the physi- ognomy of hydrophobia: in the former the eye is natural, and the general aspect is that of suffering; in the latter, the eye is preternaturally bright and glistening, the face occasionally exhibiting fright- ful convulsions, and the pain of the diaphragm is not characterized by a constant sense of the ster- num being dragged towards the spine, as is the case in tetanus; while tetanus, on the other hand, scarcely ever exhibits that laborious panting re- spiration, that tremour of the whole muscles, and that intolerant sensibility of the surface and of the organs of sense, which distinguish hydrophobia. Indeed it is perhaps only by reasoning upon the uncommon as if k were the ordinary case, that any person, although exposed to the illusion of his own ideas in the retirement of his closet, could mistake the one disease for the other. Morbid Anatomy.—Whoever pursues with care and attention the various dissections of hydro- phobic patients which have at different times been published, will be obliged, however reluctantly to admit that the pathology of rabies canina is still involved in considerable obscurity, and that no HYDRO! distinctive pathological character of the disease has as yet been satisfactorily determined. The brain has been examined with much care and attention. In some instances the dura mater has been found to assume a darker hue than usual. The capilla- ries of the tunica arachnoidea and pia mater have also been met with minutely injected with blood. This state of these membranes occurred in the dissection of a case published by Dr. Marshall, as well as in several others on record. Trolliet has noticed the gorged condition and dark colour of the plexus choroides. Effusion of serum has been observed between the dura mater and tunica arach- noidea ; between the latter membrane and the pia mater; between the pia mater and brain ; and also in the ventricles. The substance of the brain itself has been detected in a harder state than natural in one or two instances ; in others, it has been found to have undergone a certain degree of "ramol- lissement." Both Bonetus and Lieutaud, however, have alluded to cases in which this organ presented no marks of disease. Inflammation of the pharynx and oesophagus has been noticed in several dissections of hydro- phobic patients; but cases are on record in which no inflammatory appearance in these parts has been observed. On examination of a patient of Dr. Rutherford's, who died of rabies canina, Dr. Monro was unable to detect any morbid alteration, either in the pharynx, oesophagus, larynx, stomach, or intestines. In one instance it will be shown that we have met with an abrasion of the internal membrane of the oesophagus. In a fatal case of this disease, too, related by Dr. Ferriar, a morbid appearance presented itself in the lower part of the oesophagus. About two inches above the car- dia, the epidermis of the oesophagus was abraded in irregular points, and exposed an inflamed sur- face of a dark red colour; still lower, the abrasion became linear and extended into the stomach itself. The edges of the epidermis surrounding the abra- sions were unequal and elevated. A similar affec- tion was traced along the lesser curvature of the stomach, but growing fainter in its progress to the pylorus, where it was least discernible, and about which it seemed to terminate. The whole of the inflamed parts bore a striated appearance resembling the effect of corrosion, darkest in the oesophagus, and lighter and more indistinct towards the py- lorus. In two cases mentioned by Dr. Vaughan no inflammation of the oesophagus appeared on dissection. The internal coat of the stomach has been discovered in a highly inflammatory state in not a few instances of rabies; and dark purple-like suffusions have also been observed upon it. This organ has also been found to contain a smaller or greater quantity of coloured matter. It has been supposed that this inflammatory condition of the mucous, membrane of the pharynx, oesophagus, and stomach, satisfactorily accounts for the sense of suffocation, extreme thirst, morbid antipathy to liquids, and burning heat along the whole oeso- phageal tube, mostly experienced by the hydro- phobic patient; but it must be recollected that such a state of these parts is by no means constantly present, as is proved from the cases related by Dr. Hamilton and other writers; and hence it is not essential to the existence of the disease. From the examinations of M. Trolliet, it appears that H 0 BIA . 531 the mucous membrane of the trachea and bronchi afforded evidence of inflammatory action, and was covered over with a considerable quantity of frothy mucus ; and the membranes of the brain, particu- larly the pia mater, exhibited marks of great vas- cularity. The frothy matter he supposed to be the product of the inflamed mucous membrane. " La bave ecumeuse des hydrophobes," he ob- serves, " est un produit de la membrane muqueuse enflammee, puisque nous l'avons toujours vue dans les parties des votes aeriennes oii cette membrane etoit vivement coloree, et qui etoient le siege de la douleur. Elle est chassee sur les levres de l'hy- drophobe dans la dernier periode de la maladie, comme le mucus altere dans l'agonie d'une per- sonne affectee de phthisie ou de catarrhe, lorsque la respiration est stertoreuse et laborieuse." La- louette has also noticed this peculiar frothy matter in the trachea and bronchi:—" Une humeur," he remarks, " que Ton peut comparer a une salive ecumeuse qui enduit toute l'arriere bouche ainsi que le larynx, le pharynx, la trachee artere, et les grosses divisions des bronches. Elle se trouve en plus ou moins grande quantite chez les differens sujets." That the lining membrane of the trachea and bronchi is sometimes in a state of inflamma- tion cannot be denied, but we are satisfied that Trolliet's view of the pathology of rabies is too limited; for it will be found, upon a comparative examination of the number of dissections of hy- drophobic persons on record, that the stomach has been more frequently met with in a morbid condition than the trachea, bronchi, or any other part of the body. The salivary glands have oc- casionally been observed of increased size and vas- cularity. In some instances there has been in- flammation of the pulmonary tissue, but more frequently great venous congestion. Dr. Ferriar was almost disposed to consider the disease as dependent on the obstruction of the pul- monary circulation, but his conjecture has not been supported by subsequent pathological investigation. The pleurx have been noticed in a thickened and inflamed state; and we meet with fatal cases of hydrophobia in some of the earlier medical records, in which various derangements of the heart, peri- cardium, liver, spleen, and mesentery are described; but it is impossible to peruse these dissections, without being convinced that the morbid changes enumerated are merely accidental, and the result of other causes than the virus of rabies. Some pathologists of eminence, amongst whom may be mentioned the names of Salin, Brera, Sanders, and Reid, supposed that they had satisfactorily proved that the symptoms of hydrophobia proceeded from a morbid condition of the spinal marrow ; but it may be correctly stated that their opinions have not been confirmed by the general experience of the profession. In some examples of this disease, (as in the two which we shall notice,) unequivocal marks of vascularity of the membranes of the spinal cord have been present; but, generally speaking, not the least vestiges of inflammatory action either in the medulla spinalis or its investing tunics have been discovered. In one instance, related by Mr. F. Godrich, the whole cord was considerably in- flamed ; and opposite the two last cervical and dorsal vertebrae the cellular substance was studded with dark patches of coagulated blood, the thee* 532 HYDROPHOBIA. vertebralis thickened, and the cord in an active state of inflammation. The larynx and pharynx bore not the slightest vestige of disease. We may, however, venture to assert that no such connection as that of cause and effect exists between an in- flammatory state of the spine and the phenomena of hydrophobia; for it is well known that effusion of serum into the theca vertebralis, and other signs of increased vascular action in the spine, have been frequently met with in diseases very different from the one under consideration. As dissections of hydrophobic patients are by no means frequent, it may be instructive briefly to detail the chief morbid appearances detected in five fatal cases of this disease which have come under our own observation. In one, where the patient died in seven days from the period of his first ex- periencing pain in the bitten part, and in fifty-six hours from the commencement of the hydrophobic symptoms, the following morbid alterations were observed:-—Brain.—Vessels of the dura mater preternaturally distended with blood, the vessels ramifying in a distinct manner. Pia mater some- what distended, and a larger quantity of blood interposed between the membranes than usual. Left ventricle with the usual quantity of fluid. The substance of the brain of the usual consist- ence. When pared off in slices, the surfaces showed numerous brown spots. The vessels of the basis, or cerebellum, were more than usually turgid, and somewhat more of fluid effused than usual. Pha- rynx and larynx.—No appearance of inflamma- tion. Thorax.—Lungs perfectly sound. Heart flaccid. No coagulum in its cavities; two ounces of fluid within the pericardium. Oesophagus.— Upon opening the oesophagus, a substance was found lying closely within the orifice without filling up the cavity. This membrane was nearly the length of the oesophagus; when inflated with the blow-pipe, it assumed a tubular appearance. The abrasion of the internal membrane seemed to ex- tend as far as this substance. The external mem- brane of a deep red colour. The whole internal surface dotted with purple-like suffusions. Stomach. —Contents about one pint, the external membrane of a deep red colour. Its inside covered with broad dark purple-like suffusions, especially about the cardiac orifice. The intestines sound; the liver of the usual healthy character; appearance of bladder natural. The same marks of disease usually exist in most cases of hydrophobia after death, with the exception of the remarkable membrane found in the oesophagus of the one now described, which was considered by all present a portion of the internal membrane of the oesophagus. In another instance, on opening the head, the sinuses were found gorged with blood, and the vessels of the arachnoid and pia mater exhibited marks of highly increased vascular action. The lateral ven- tricles contained a small quantity of serous fluid, and the plexus choroides was of a pale colour. The substance of the brain was softer than natural. The vessels of the spinal arachnoid and pia mater were minutely injected. The lungs and the bron- chial mucous membrane were perfectly healthy. The heart and its large vessels were also sound. The 'bring membrane of the pharynx and oesopha- gus was somewhat redder than usual. The sto- mach presented some few slight ecchymoses ; the intestines were free from disease. In a third case in which the body was carefully examined by a very distinguished anatomical teacher, Mr. Turner, there was considerable vascularity of the pia mater, with slight serous effusion in the lateral ventricles. The substance of the brain was of a firm consist- ence. Strong adhesions existed between the costal and pulmonary pleura in both cavities of the chest. The lungs were in a state of great congestion, and when cut into, a considerable quantity of bloody fluid flowed from their substance. The membrane of the trachea and the larger bronchial ramifica- tions were here and there marked with dark purple- like suffusions, and had assumed throughout a darker hue than usual. On an inspection of the inside of the fauces, pharynx, and oesophagus, a scarlet uniform redness was observable. The heart was sound. The stomach exhibited evident marks of congestion, if not of inflammation. Numerous small dark-coloured spots appeared about the su- perior orifice, and might be traced along the larger curvature of the organ. These spots very much resembled the marks of small shot. All the other viscera of the abbomen, with the exception of the liver, which was slightly indurated, afforded no marks of disease. The pia matral tunic of the spine, like that of the brain, was much more vas- cular than natural. The fourth instance was that of a boy, nine years of age, who was bitten by a mad dog about three months previously to the occurrence of the symptoms of the disease. He was under the care of a highly respectable surgeon, Mr. Brownbill, of Salford, to whom we were in- debted for an opportunity of attending the inspec- tion. The patient died in sixteen hours after the malady had fairly developed itself. Within the cranium nothing unusual could be detected, except a slight turgescence of the vessels of the pia mater, and rather more distension of the choroid plexus than usual. The fauces, oesophagus, and parts adjacent were in a natural state, but the effects of inflammation were very evident upon the lining membrane of the trachea and the larger bronchial tubes. The lungs were sound, but somewhat dis- tended with blood. The stomach contained a small quantity of brownish fluid, but no diseased appear- ances were detected in it. The other abdominal viscera exhibited nothing peculiar. The spinal marrow was inspected with much care, but there were no marks of inflammation either in its mem- branes or substance. In the fifth and last case we have witnessed, where death occurred in thirty- four hours after the first unequivocal symptoms of the disease had been present, the following were the appearances on dissection. The brain was in a natural state. The fauces and lower part of the oesophagus afforded slight signs of inflammation; the vessels on the inner coat of the stomach were much more distinctly marked than usual; and a few spots of extravasated blood were observable along the cardiac extremity of the organ. The other abdominal viscera were sound. Nothing unusual presented itself either in the trachea or bronchi. The lungs were somewhat turgid with blood. The spine was free from disease. All the attention we have been able to pay to the anatomical character of rabies canina leads us to agree with Dr. James Johnson in the fol- lowing remarks: « That it cannot be denied, but HYDRO] that the most evident indications of inflamma- tory action attend the symptoms, and distinguish the pathology of hydrophobia; that we have often inflammation of the oesophagus, pharynx, and larynx, and occasionally of the brain and spinal cord; yet it is generally admitted that these ap- pearances are more the consequences than the cause of the disorder, and that although frequently present with, they are by no means essential to the existence of hydrophobic action." That they are not essential to the existence of the disease is proved by the fact that, in several cases on record, in which the post-mortem examinations have been made by eminent and experienced pathologists, no morbid appearances have been detected in any organ or tissue of the body. Some of the mor- bid appearances noticed above are no doubt pro- duced by the violence of the convulsive motions which invariably accompany the disease. Lalou- ette, an able French writer on rabies, has re- marked, " L'ouverture de plusieurs cadavres de personnes mortes a la suite de la rage, ne m'a presente aucun phenomene particulier a cette maladie. On ne trouve nulle part aucun signe de phlogose sanguine, ni d'inflammation. Je n'ai observe nulle part aucun signe de dissolution, aucun engorgement ou phlogose ■ humorale ; au- cune gangrene interne, ni meme aucuneapparence de disposition a cette diathese." Treatment of HydroplioTiia.—The reader will in all probability be prepared, from a perusal of the preceding account of the pathology of hydrophobia, to anticipate the conclusion, that in a disease on whose nature anatomical investi- gation throws such feeble light, the treatment must necessarily be unsettled, and in a great measure conjectural. Dr. Good correctly observed, that the mode of cure in this affection is a field still perfectly open for trial; for, at this moment, we have no specific remedy, nor any plan that can be depended upon, after the disease shows itself. There is, perhaps, no malady to which mankind is liable, that has called forth such a host of reme- dies for its removal, and alike defied their single and united powers. The long list of the materia medica has been ransacked to discover some one article capable of arresting the progress of this disease, but all have hitherto proved inert. It would be absurd to do more than simply name several of the substances to which ignorance and superstition have attached importance in the treat- ment of hydrophobia. Amongst these may be classed the celebrated pulvis antilyssus, the theria- cas, the alysma-plantago, the rhus coriaria, the Scutellaria, the genista, the Ormskirk medicine, and the tonquin powder. Each of the above remedies has had the title of a specific attached to it, and enjoyed for a time unmerited reputation. In the consideration of the treatment of hydro- phobia, it appears to us proper to notice, first, the prophylactic measures which are indicated; and, next, the means to be employed after the disease has been once developed. It is fortunate that the community at large are now more strongly convinced than formerly of the extreme folly as well as danger of resorting to the use of the several vaunted specifics for the pre- vention of hydrophobia, and thus delaying appli- cation to the well-informed and regularly educated 2 v* 'HOBIA. 533 practitioner on the immediate occurrence of the bite. It cannot be too strongly impressed upon the minds of the public, that not a moment is to be lost in soliciting judicious medical aid after the bite of a rabid animal; for, the longer the delay, the greater the danger of the virus entering the system and producing the disease. We shall en deavour to point out the prophylactic plan which seems to afford the surest ground for a proper confidence and security against future mischief. The wound should be well and perseveringly washed from the earliest moment of its infliction. The patient may himself adopt this simple prac- tice until surgical aid be obtained. Dr. Haygarth has suggested that the ablution of the wound may be well effected by directing upon it a continued stream of water from the spout of a tea-kettle, held up at a considerable distance. " If the canine poison," he observes, " infused into a wound were of a peculiar colour, as black, like ink, we should all be aware that plenty of water and patient dili- gence would effectually wash out the dark dye, but this could not be effected by a slight and su- perficial ablution." After the bitten part has been well and thoroughly washed, it then becomes a question what further means should be employed to prevent absorption of the virus. Upon this point, it will be found that scarcely any two prac- titioners are agreed; some giving the preference to excision, and others to the actual or potential cautery. The use of the actual cautery has been chiefly recommended by some of the earlier writers, and is a practice but seldom adopted in the present day, though it is by no means destitute of advan- tage under particular circumstances. The appli- cation of caustics alone to the wound has been relied upon by some eminent practitioners. Mr. Youatt, who may perhaps justly be considered the first living authority on canine madness, has warmly advocated the use of the caustic. He re- commends the nitrate of silver. Troillet prefers the hydrochlorate of antimony. Earle, in his evidence given before a Committee of the House of Commons in 1830, says that he does not place much reliance on any caustic, except strong nitric acid, for it acts very deeply, whereas « other caus- tic, for instance, caustic, potash, when there is any wound, becomes decomposed by the blood, and does not penetrate to the depth that nitric acid does; and nitric acid forms a dry eschar." Other surgeons, on the contrary, strongly advise the em- ployment of the potassa fusa. Mr. Youatt con- siders the lunar caustic perfectly manageable, and, when sharpened to a point, as capable of being applied with certainty to every recess and sinu- osity of the wound. " The potash and the nitric acid," he observes, " will destroy the substances with which they come in contact, but the combi- nation of the caustic and the animal fibre will be a soft or semi-fluid mass. In this the virus is suspended, and with this it lies upon and remains in intimate contact with the living fibre beneath. Then there is danger of re-inoculation; and it would seem that this fatal process is often accom- plished. The eschar formed by the nitrate of silver is hard, dry, and insoluble. If the whole of the wound has been exposed to its action, an insoluble compound of animal fibre and the me- tallic salt is produced, in which the virus it 534 HYDROPHOBIA wrapped up, and from which it cannot be sepa- rated. In a short time the dead matter sloughs off, and the virus is thrown off with it." Mr. Youatt informs us that he has been bitten four times by dogs decidedly rabid, and at each time he freely applied the caustic to the wound; and he has remained free from the complaint. He has also operated on more than four hundred persons of whose disease there could be no question, and has not lost a patient. His experience is opposed to the practice of keeping the wound open for several weeks after the application of the caustic, for he supposes, that if a minute portion of the virus should perchance remain in the wound, by applying stimulating ingredients to the part there is considerable risk of exciting the absorbents to action, and producing that disease which would not otherwise have had existence. " Destroy the part at once by the knife or the caustic," he ob- serves, " and then adopt the mildest means speedily to heal the wound." The testimony of Mr. You- att in favour of caustic is unquestionably very weighty, and entitled to the utmost consideration; but still the fact cannot be concealed, that in the hands of other practitioners, the results of the use of the caustic have not been equally favoura- ble. In the case of Rowley, noticed by Dr. Ha- milton, caustic was very carefully applied to the wound by Mr. John Hunter shortly after the in- fliction of the bite ; still the hydrophobic symp- toms appeared, and the youth died. It would not be difficult to multiply the cases of failure after a fair trial of the caustic. Mr. Youatt allows that every surgeon must decide for himself respecting the c jmparative value of caustic and the knife, but he requests that those who prefer the caustic may be no longer exposed to so much gratuitous abuse. He does not condemn the use of the scal- pel, but gives a decided preference to the caustic, and only employs the knife in order fairly to get at the wound. It appears, however, from the facts already before the public, that the general expe- rience of the profession is in favour of an imme- diate excision of the bitten part, as affording the best security from danger. Some practitioners have strongly recommended the conjoint use of excision and the caustic. We shall now briefly give our opinion of the best and most certain means of preventing the disease. It appears to us that complete excision of the bitten parts, when at all practicable, ought to be adopted without a moment's unnecessary delay for the trial of caustic or any other external irritant; for it is but seldom that any bad effects ensue from the bite, when this simple operation is carefully and effectually accomplished, and we really consider the medical man who omits this practice guilty of unpardonable neglect towards the unfortunate being who may be doomed, from his want of energy, to writhe under the agonies of this most horrible malady. Indeed the excision of the wounded part should always je employed even in cases where the animal is only supposed to be rabid ; for though some degree of momentary pain may be occasioned by the knife, this is of trifling consequence when compared with the mental tranquillity which must result from the conviction of" a perfect immunity from the disease t y the operation. The force of the above remarks will be felt, when it is considered that canine madness is incurable, according to the present state of our knowledge; for we are satisfied, from careful and extensive research on the subject, that when the symptoms of this disease have been once fairly developed, notwithstanding the most vigorous and diligent attempts of medical men to remove them, no cure has ever yet been effected, but the unhappy sufferer has had to struggle with torments such as the imagination cannot conceive, and which must be witnessed in order to be believed. This is a melancholy truth for man- kind to know. When excision has been neglected on the first infliction of the wound, still we con- sider it highly proper that it should be performed at even a distant period from the bite; for it seems to be an established fact that the virus of a rabid animal does not, like other morbid poisons, such as small-pox, cow-pox, syphilis, and plague, always produce its effects within a limited time. Dr. Todd Thomson has expressed his opinion that the hydrophobic virus is not regulated by the usual laws of morbid poisons, and on that account he is- inclined to believe that it remains in the bitten part, and the individual is safe till the habit becomes predisposed to the action of the poison, so that the part may be advantageously excised in the intervening time. A case is related by Professor Rust where the wound was excised thirty-one days after the bite, and after the hydro- phobic symptoms had appeared, and still the pa- tient's life was saved. When the wound is so situated that the whole of the bitten parts cannot be completely removed, then of course we must trust to the application of caustic, to scarification, or the actual cautery. Under these circumstances it is of the highest importance that the caustic be care- fully and effectually used, for the safety of the patient in a great measure depends upon the manner in which this operation is in the first in- stance performed. In order to ensure the removal of every part with which the dog's teeth may have come in contact, (for the smallest portion left may produce the disease,) it is necessary accurately to ascertain the depth of the wound, and the direction in which the teeth have penetrated. Unless the excision be carried beyond the bite, the operation fails to afford the patient a security from future danger. The surgeon cannot use too much care in remov- ing the bitten part. We are informed that in one case Mr. Hunter removed the parts, as he thought, freely, and there was nothing on the under surface of the piece cut out that led him to suppose that he had not gone beyond the bite. But on exam- ing the surface of the wound, he found a part in the middle which was hollow underneath, which showed he had not gone deep enough, but had left a ridge as it were over part of the passage made by the dog's teeth, and which could only he discovered by examination after the operation. (Dr. Hunter, Transactions of a Medical Society.) Though we have strongly recommended that the wounded part be cut out whenever it can be done with safety, still we see no objection to the appli- cation of caustic afterwards to the excised surface, as affording additional security from the greatei probability of every particle of the virus being re- moved or destroyed. With proper deference to HYDRO the experience of Mr. Youatt, as given above, respecting the impropriety of keeping the wound in a state of suppuration, we must observe that the facts stated on eminent German authority in favour of the practice seem to be incontrovertible. Dr. Wendt states that from the year 1810 to 1824 one hundred and eighty-four persons bitten by dogs were admitted into the Breslau hospital; of whom half were bitten by dogs absolutely mad, or supposed to be mad, and from the whole two only died. It is true, that besides keeping up a copious discharge from the wound for six weeks or longer, mercury was employed internally so as to induce salivation ; still by far the greatest stress was placed on the external treatment. It is also mentioned in a very able review of several Ger- man essays on hydrophobia, (Ed. Med. and Surg. Journal, 1825,) that at Zurich "the treatment consists of deep scarifications of the wound, the besmearing it with pulvis lyttae, the application of a blister to the part, the keeping up a discharge from the wound and the blister during six weeks, and the rubbing-in of mercurial ointment till symptoms of approaching salivation come on; internally, belladonna or calomel is given." In the same journal an account is given of the treat- ment pursued by T. M. Axster, senior surgeon of the large hospital at Vienna; and that of Dr. Hausbrand, district physician at Braimsberg, in cases of bites from animals. During twenty-seven years, Mr. Axster states that not a single old pa- tient was ever brought back to the hospital with hydrophobia. Besides using internally, during three or six successive days, a grain of pulvis lyttae with six grains of cane. ocul. and sugar, he applied externally over the wound a blister, and . dressed it with the pulvis lyttae or some stimu- lating lotion during the space of six weeks. Dr. Hausbrand first employed active bleeding in the earliest stage of the disease, then made deep scari- fications of the wound, encouraged the flow of blood, washed the wound with salt and water, applied an ointment composed of unguentem ba- silicum and powdered cantharides, and kept up the suppuration during the space of three months at least. Internally, he directed the patient to take for three evenings a powder with camphor and opium, to drink elder tea, and keep up a co- pious perspiration. Eleven persons bitten by dogs actually mad, treated in this manner, remained perfectly free from the disease. We have noticed these four prophylactic modes of treatment chiefly with the view of showing the nature and efficacy of the local means employed, and the evidence in support of the practice of continuing a discharge from the wound during several weeks. It must be recollected, however, that caution is necessary in drawing a positive conclusion in favour of any particular prophylactic measure, as the disease is by no means a necessary consequence of the bite; foi it is a fact founded on the observation of a considerable number of cases, that upon the average not more than one person out of twenty- five who have been certainly exposed to the bite of a mad dog has become infected with the dis- ease. In noticing the inefficacy of the Ormskirk medi- cine, pulvis antilyssus, tonquin remedy, &c, Dr. Hunter says the question may be here asked, ad- 'HOBIA. 530 mitting the frequent failure of these remedies, have they not sometimes prevented the disease! The answer would certainly be in the affirmative if every person bitten by a mad dog who did not use some means of prevention were seized with the disease. But this is not the case; for in the human species the proportion of those bitten who are seized with hydrophobia is much less than of those who escape, even where no means of pre- vention are employed ; we can, therefore, infer nothing in favour of these prophylactics, because they have been given in cases in which no hydro- phobia has supervened. (Hunter, opus ante cit.) The application of a tight ligature to the af- fected part, at a short distance above the lacera- tion, is strenuously recommended by Dr. Good, from the first, even before the process of ablution, and the measure is sanctioned by the authority of Ambrose Pare, Troillet, and other eminent writers. " Analogy," says Dr. Good, " is altogether in fa- vour of this operation, for it is well known to be one of the most important steps we can take in confining the poisonous effects of the rattlesnake and other venomous animals, and of mitigating its violence by the torpor which follows." We have had no experience of the beneficial effect of the ligature after bites from rabid animals, but we see no objection to the adoption of the practice. Cup- ping-glasses have also been applied to the wound. Celsus even recommended them. (De Medic, lib. v. p. 199.) More recently, the cupping-glass has been strongly advised by Dr. Barry, who has per- formed a variety of ingenious experiments relative to the absorption of several vegetable, mineral, and reptile poisons. It has been his aim to prove that absorption cannot take place in vacuo, and cer- tainly the results of his experiments seem to us satisfactorily to establish the fact. We conceive that the cupping-glass is likely to prove a highly efficacious remedy in cases of wounds inflicted by poisonous or rabid animals, and we strongly re- commend its early and diligent application after a careful excision of the injured part; for it by no means supersedes the use of the knife. Mr. Youatt rather objects to the cupping-glass, for he expresses a fear lest the virus, forced from the texture with which it lies in contact by the rush of blood from the substance beneath, may inoculate or become entangled with the parts of the wound; still he thinks that it may be useful after excision of the part, but as connected with the caustic, that it can be of no avail. Amputation has been deemed advisable by some surgeons when the bite has been situated in a part, as in one of the fingers, to which a cupping-glass could not be effectually applied; or when a limb has been bitten in many places, or very deeply in parts not admitting of excision, as through the tarsus or carpus. Mr. Samuel Cooper thinks that under these circum- stances immediate amputation might be warrant- able before the accession of the symptoms. He has noticed a case that occurred at Guy's Hospital some time ago, in which a limb was amputated after the symptoms of hydrophobia had appeared, but without the least check being put to the com- plaint. " The performance of amputation," this able surgeon justly observes, " previously to the commencement of the symptoms, is a very differ ent practice from that of amputating parts aftei 536 HYDROPHOBIA the symptoms have begun." (Good's Study of Medicine, last edition.) It may be proper here to allude to the plan pro- posed by Dr. Marochetti for preventing the de- velopment of hydrophobia. He believes that the hydrophobic poison, after remaining a short period in the wound, fixes itself for a certain time under the tongue, at each side of the fraenum, where one or two little tumours or vesicles appear, in which may be perceived with a probe a fluctuating liquid. Dr. Marochetti states that the usual time of the appearance of these small knots is within the third and ninth day after the bite, and that if they are not opened within the first twenty-four hours after their formation, the poison is re-ab- sorbed into the system, and all hopes of the patient's recovery are banished. He, therefore, strongly recommends that such persons as have the misfortune to receive a bite from a rabid ani- mal should be examined under the tongue imme- diately, and that attention should be paid to this part during six weeks ; for if these vesicles do not appear in this time, he considers the patient to be perfectly secure from future danger. When, however, they are detected, he directs that they should be instantly opened with a lancet, and then cauterized with a red-hot needle; and that the patient should gargle assiduously with a de- coction of broom, and take daily one pound and a-half of the infusion of the tops of the same plant, or four drachms of the powder. ' Professor Rossi has also published a case in the Annali Universali, in which a cure of hydrophobia is said to have been effected by taking a glassful of vinegar, and the genista lutae tinctoria internally, and by having the sublingual glands cauterized three successive times. In the examples of hydro- phobia which have fallen under our own observa- tion and that of some other practitioners, the knots or vesicles under the tongue, described by Dr. Marochetti, have been looked for in vain; and, indeed, their supposed presence seems to be a mere anatomical delusion. It may be correctly said that Marochetti's statements have not been confirmed by the general experience of the pro- fession, so that practitioners may be undeceived in any expectations of security they might be in- duced to form from adopting his process to the neglect of the means noticed above; for the re- sults of such misplaced confidence would be irre- mediable. We venture to repeat our conviction of the imperative necessity, in every case of injury from a rabid animal, of deeply and effectually cutting out the bitten part when it can be done with perfect safety, and of the propriety of keep- ing up a free discharge from the wound for several weeks by the aid of some active external irritant; and that when the operation of excision is inad- missible, recourse must be had to scarification, lunar caustic, or the actual cautery. Amongst the chief preservative means that have been employed internally in conjunction with the local plan of cure, we may merely mention bella- donna, cantharides, mercurials, emetics, volatile alkali, broom decoction, and chlorine: for it would be a waste of the reader's time to present him with a detailed examination of the individual efficacy of these several remedies as preventives nf the fatal consequences of the bites of rabid ani- mals, since the most ample experience has proved them to be altogether unavailing, and therefore undeserving of future confidence. To the vaunted specifics before named no further allusion is ne- cessary. Having thus considered the prophylactic mea- sures which are indicated, we may next notice the means to be employed after the disease has been once developed. This part of our inquiry is attended with some degree of difficulty, because no successful method of cure has as yet been discovered, after the cha- racteristic symptoms of hydrophobia have once appeared. " There is, indeed, no disease," as Dr. Good justly remarks, " for which so many reme- dies have been devised, and none in which the mortifying character of vanity of vanities has been so strikingly written on all of them. In the loose and heterogeneous manner in which they have descended to us, they seem, indeed, to have fol- lowed one another without rational aim or inten- tion of any kind." The whole subject of treat- ment is difficult and afflictive. We scarcely know how to reply to the important question,— What plan of cure is a practitioner to adopt when he meets with a case of rabies ? but it is necessary to attempt an explanation of the mode of treatment which, on the whole, seems to be the most suita- ble for adoption. The limits of this article would be extended to a very unnecessary length, were we to do much more than enumerate the various remedies that have been tried in this disease; but a brief notice of them is required, for without a knowledge of what has been attempted, much time must be lost in useless trials and fruitless repetitions. Amongst the various articles in the materia medica which have been employed for the relief or cure of hydrophobia, opium is entitled to be first mentioned. This drug, in various forms and in very large quantities, has had the most full and ample trial; but experience has too often proved its inefficacy in this disease. Dr. Vaughan exhi- bited fifty-seven grains of opium in the course of fourteen hours with little or no effect upon the symptoms ; and in one case Dr. Babington ad- ministered one hundred and eighty grains in eleven hours, without any benefit, and without even procuring sleep. (Medical Records and Re- searches.) In another instance Dr. Marcet gave opium, iron, and arsenic, to a great extent, but with a like unsuccessful result. Magendie intro- duced opium in large quantities into the veins of rabid dogs, but without producing its ordinary narcotic effect; and Dupuytren and he afterwards injected eight grains of the extract of opium, in solution, into the crural vein of a young man labouring under hydrophobia in its severest form; but the experiment only afforded temporary relief, for he expired on the fifth day from the attack of the disease. Dr. Richard Pearson strongly re- commends the injection of warm water in very small quantities, and impregnated with narcotic substances, into the veins of hydrophobic patients, for the purpose of subduing the spasms which pre- vent deglutition. This object being attained, he proposes the administration of a strong cathartic, copious dilution with mucilaginous liquids, cam phor, and other antispasmodics; and after the HYDROPHOBIA. 537 operation of these medicines, sponging the body with cold water and vinegar, and giving at the same time internally the nitric or muriatic acids, and lastly some of the vegetable tonics. Dr. Booth considers the acetate of morphia as far pre- ferable to opium for injection into the veins of the hydrophobic sufferer, as its dose and powers are more definite than those of the latter drug. In conducting the injecting process, he suggests that twenty-four minims of the solution of acetate of morphia (equal to four grains of opium) mixed with two drachms of distilled water, be introduced into the cephalic vein ; and then, after waiting for about ten minutes to observe the effect, that the operation be repeated at like intervals until a de- cided sedative impression be produced. (Booth on Hydrophobia.) Dr. Brandreth made trial of in- jection of the acetate of morphia, as recommended by Dr. Booth, in a well-marked instance of hydro- phobia, and found that it mitigated the sufferings of the patient in a most decisive manner. In a case of more recent occurrence, we have ourselves witnessed the injection of the acetate of morphia, but we regret to say that it altogether failed in diminishing the violence of the symptoms, and retarding the fatal progress of the malady. The operation was skilfully performed by a very re- spectable surgeon, Mr. Barton, in the presence of Dr. Hull, Mr. Fernely, Mr. Boutflower, Jr., and other medical gentlemen. Dr. Ward has strongly advised opiate frictions in hydrophobia; and in more than one instance they have succeeded in calming the irritability of the system, and obtain- ing a temporary abatement of the distressing spasms of the muscles of respiration and degluti- tion. Upon the whole, it may be correctly as- serted that opium possesses some claims to future confidence as an antilyssic remedy. Mercury is another substance which has been highly lauded for its efficacy both in preventing the disease, and removing it after it has actually appeared. It has been very freely employed internally and by fric- tion, on the authority of Dessault, Kaltschmid, James, du Choisel, Andry, Selig, Konigsdorfer, Walther, and other writers; but unfortunately (as an able reviewer justly observes) there are too many cases on record of persons in whom the external wound has been improperly managed, dying of this complaint, notwithstanding the exhi- bition of large doses of mercury, to warrant much reliance on this remedy alone. (Edinburgh Me- dical and Surgical Journal, vol. xxi.) Belladonna has also enjoyed the reputation of a valuable re- medy in hydrophobia; but the success which seems to have attended the administration of this drug in the practice of Brera and Massahen, has not been present in a number of cases observed by different physicians. Acids (particularly the oxy- muriatic and acetous) have been freely used and warmly recommended by Aselli, Previtali, and Brugnatelli; but their inefficacy has been proved in several instances. In the case of a young man named Brassendale, which came under the notice of Dr. Bardsley, the aqueous solution of chlorine was fairly tried, but with an unsatisfactory result. Alkalies, cantharides, antispasmodics, as cam- pnor, assafcetida, musk, and castor ; diuretics, oil, internally, and by friction; arsenic, prussic acid, ttramonium, white hellebore, acetate of lead, and Vot. II. — G8 < the warm bath, have also been used, but witn no better effect. Venesection has long been considered a power- ful remedy in hydrophobia, and has been fre- quently employed to a very great degree. It has been chiefly advised by those authors who believed in the inflammatory nature of the disease. Mead, Nugent, Fothergill, Shadwell, Ferriar, Hartley, Innes, and more recently Tymon and Schoolbred have been the warmest advocates of an early and vigorous use of the lancet; and several cases have been quoted, on the authority of some of these writers, in proof of the efficacy of the practice. Having carefully perused these histories, we feel a difficulty in admitting that the patients were really rabid. Rutherford, Parry, and Troillet have employed profuse and repeated depletions, some- times even to deliquium, but without any curative result. Indeed, the evidence of Troillet on this point may be deemed conclusive. " Gueyette," he relates, " a ete saigne trois fois jusqu'a defail- lance, et malgre la perte de sept livres de sang, la rage a continue sa marche funeste. Une termi- naison si contraire a celle que nous avions lieu d'attendre nous a fait jeter un regard plus attentif sur l'observation du Doctor Schoolbred; elle n'a pu soutenir l'epreuve de l'analyse; et nous sommes convaincu que son auteur s'est laisse egarer, comme Nugent, par quelques symptomes, qu'une erreur trop commune a fait attribuer exclusive- ment a la rage. La saignee a defaillance, que des medecins celebres avoient deja conseillee, sera abandonee de nouveau." (Traite de la Rage, p. 367.) It appears also from the experiments of MM. Magendie, Dupuytren, and Breschet on rabid dogs, that profuse venesection was of no avail in arresting the disease. The cold affusion has been attended with pal- liative effects. In the case of Nixon, who was admitted into the Manchester Royal Infirmary, the patient experienced much relief from having cold water dashed upon his body. He not merely staled how grateful the practice was to him in re- moving the burning heat of skin and other dis- tressing symptoms, but even solicited its occa- sional repetition. Electricity and galvanism have also produced a diminution of suffering in more than one example of hydrophobia. In less than half an hour from the period of the electrical ma- chine being put in motion, Dr. Bardsley's patient. Warren, became more calm and tractable, ana expressed a desire to drink some water, which he was able to perform with comparative ease and readiness, and with no small marks of pleasure and even triumph. (Medical and Physical Jour- nal, vol. xiii. p. 159.) [Dr. Mease (Amer. Med. Intelligencer, Sept. 1, 1840,) has strongly urged the application of a solution of potassa so as to inflame the surface along the spine, as advised by Dr. Hartshorne in tetanus.] Tobacco has occa- sionally been prescribed, and with apparent bene- fit. The fumes of the plant have been introduced into the rectum ; an infusion of the leaves has been employed in the form of enema; and it has been applied externally as a cataplasm to the scro- biculus cordis. Though this drug has failed in preventing the fatal termination of the disease, still it has been shown to have the power of control- ling the violence of the spasmodic actions of the 538 HYDROPHOBIA — HYDROTHORAX. muscles of the throat. The guaco juice has been highly spoken of by Sir Robert Kerr Porter as a cure for this affection; but it has been freely ex- hibited in the London hospitals in more than one instance of hydrophobia, and without success. A few months ago, Dr. Elliotson employed this re- medy, but it totally failed. That able physician has also prescribed the carbonate of iron in large doses. One hydrophobic patient took nine ounces of the carbonate in the course of eighteen hours, but it proved equally inert. In the case of a boy under the care of Mr. Brownbill, to which we have before alluded under the head of pathology, we made trial of the strychnia ; but it seemed to exert little or no influence upon the symptoms. In this instance the inhalation of the nitrous oxide gas was also attempted on the suggestion of Mr. Jordan, and produced for a short time some degree of exhilaration and propensity to laughter; but owing to the extreme difficulty experienced in continuing the process, the further effects of the gas were not ascertained. Dr. Bright has advised the adoption of mineral tonic remedies combined with some of those diffusible stimuli which are useful in calming the irritability in many hysteri- cal attacks. He has proposed the injection of the muriated tincture of iron into the rectum, as being a powerful chalybeate, and in some cases possess- ing the quality of allaying spasmodic action. (Medical Reports, part ii. p. 607.) Violent sweat- ing, through the influence of highly heated air, has been recommended to the notice of the pro- fession as a remedy in this affection ; but we are not aware that it has been sufficiently tried to en- able us to determine its real claims to further use. We have seen the hot air bath of great advan- tage in a very severe instance of traumatic teta- nus ; and hence it may be deserving of trial in hy- drophobia. Tracheotomy has been proposed by Mr. Mayo, as an experiment in this malady. Dr. Hunter has alluded to two cases in which the re- lief obtained by running was very remarkable ; in one the amendment was so considerable, that the patient did not look like the same person after running about a quarter of a mile. This experi- ment, however, has not been since adopted. [For an account of the various agents employed in hydrophobia, see Staub, art. Hydrophobic, in Encyclop. Worterb. der Medicin. Wissenschaft. xvii. 234: Berlin, 1838. To avoid the severe spasms, which are induced by the sight of any thing glistening, it has been advised that the suf- ferer shall be kept in almost perfect darkness; and it has been suggested by M. Allier, (Medi- cinisch. Zeitung, 1834, cited in Brit, and, For. Med. Rev. July, 1840, p. 279,) that at the com- mencement of an attack, compression of both carotids may be used with advantage.] Having arrived at the conclusion of our inquiry into the history and treatment of rabies, and ex- amined the various means that have at different times been proposed, with the view of arresting the progress and subduing the symptoms of the disease, it is painful to be obliged to confess that no specific or successful mode of cure have up to the present period been discovered. It has been shown that men of the first eminence have di- rected their utmost attention to the subject, but Have unhappily failed in establishing a remedy for this justly reputed opprobrium of medicine. Under these circumstances, humanity seems to dictate the adoption of those measures which best serve to soften the torments of the unhappy pa- tient. As far as we are capable of judging from recorded facts, we should say that the liberal ad- ministration of stimulants and cordials, the inter- nal exhibition of opium in very large doses in the interval of the exacerbations, injection of narco- tics into the veins, opiate frictions and opiate clysters, abstraction of blood from the upper part of the spine by cupping, electricity, the tobacco injection, and the cold affusion, are the means which have had the most decided power in pro- ducing a remission of the more distressing symp- toms of hydrophobia, and thus alleviating the agonies of the wretched sufferer. We think there is reason to hope, from the more correct information we have of late obtained respecting the manner in which the disease affects the animal, and from the frequent and careful per- formance of experiments with the virus itself, that a more intimate acquaintance with the nature of the poison may yet be obtained, which may at length lead to the establishment of a successful method of treatment. In order to forward so de- sirable a result, it becomes each member of the profession to make new experiments on the sub- ject ; to watch with minute attention every case that occurs in the course of his practice ; faith- fully to notice every circumstance of importance connected with the malady, and to adopt any un- tried plan of cure founded on rational principles. " It would, perhaps, at length contribute," the late Dr. Fothergill has justly remarked, " to remove this uncertainty, if those who are applied to on these interesting emergencies would consider themselves as obliged, by the honour of their pro- fession and the ties of humanity, to note with all possible precision and impartiality every incident in the progress of this disease; and whether they pursue the hints here suggested, or take up more rational ones from their own store, would commu- nicate the result to the public. By this method the field of conjecture would be contracted, and our successors directed to new objects of investi- gation. The result would be not less honourable to those who engage in the search, than beneficial to mankind in general." The prescribed limits of this article will not permit the consideration of the several judicious plans which have been proposed by some eminent and enlightened members of the profession for ex- tirpating canine madness from the British isles. J. L. Bardsley. HYDROTHORAX. —From Mwp, water, and BiZpaZ, the chest. Water in the chest. This term is now confined to designate the effusion of serum into the cavities of the pleura. Although so celebrated an author as Laennec has divided hydrothorax into idiopathic and symp- tomatic, we are by no means inclined to coincide with his views. If idiopathic hydrothoras mean any thing, it means a disease in which effusion of serum is the only affection, and in which there is neither inflammation of the pleurae nor serious disease in any other organ. Such an affection we have never seen, nor have we found upon record HYDROTHORAX. 539 any satisfactory example of it. At the same time Laennec himself has stated that even in the dead body it is not always easy to distinguish between this, which he terms hydrothorax, and chronic pleurisy ; the fluid effused exhibiting every varia- tion from a limpid, pellucid* serum to concrete albumen in the form of false membranes. Dr. Forbes has observed, in a note to this place in his translation of Laennec, that English authors are better acquainted than the French with the irv- flammatory origin of many dropsies ; and from the hint thrown out, we have little doubt but that with us he is inclined to refer all such cases to different degrees of pleurisy. That effusion of serum is the first symptom in this disease Laennec himself has stated, and that he has found it so marked as to dilate the chdst within a few hours from the commencement of inflammation. The cases also which he has given as illustrating idio- pathic hydrothorax tend still more to confirm this view of it; for although the first patient recovered once under the use of acetate of potash, she had in a few months afterwards a fatal attack of pleuro- pneumonia on the right side; thus showing a tendency to inflammation in the pleura; and her recovery on the former occasion might have been owing to the effusion which thus, if we adopt Dr. Parry's views, resolved the inflammation. In the second case, not only had the patient suffered from organic disease of the heart, but while the lower two-thirds of the right pleura contained a limpid fluid, the upper portions were united by plentiful cellular tissue, which was strong and obviously of long standing, and necessarily the result of pre- vious inflammation. Rayer, in the article Hydro- thorax, in the Dictionnaire de Medecine, also adopts this view of the affection we are consider- ing, and remarks, that although Lieutaud has no- ticed four cases out of seventy in which no organic lesion is mentioned, yet they are related with so much brevity as to leave very considerable suspi- cion of their being incomplete; more especially as Morgagni has not left a single example of hydro- thorax in which some such lesion did not exist. For a more complete development of this part of our subject, we refer, therefore, to the article Pi-eurist, (for the affection in question is really a pleurisy, and must be treated upon the princi- ples applicable to that disease,) only here calling particular attention to what appears to us to be the fact, that there is no such disease as hydrotho- rax independent of inflammation of the pleurae or organic disease of some other part. That affection, however, which Laennec has termed symptomatic hydrothorax, is of very fre- quent occurrence, and, to use the language of this author, there is scarcely any disease, acute or chronic, general or local, in which it may not exist. Affections of the lungs and of the heart, however, are those which it most frequently accompanies, and it is by interfering with their functions that suspicion of the presence of effusion is often first excited. In this as in most other diseases, no one symp- tom will suffice to detect its existence: we must have recourse to its past history as well as to its present state; and when the symptoms appear to fail us, the greatest advantage may be derived from percussion and auscultation. Symptoms and Diagnosis.—Were we accu- rately to speak of the symptoms of hydrothorax, we should be compelled to say with Laennec, Rayer, and other modern authors, that there is really no symptom of the disease excepting oppres- sive dyspnoea. It would, however, be dismissing the subject too hastily to remain here, for we may certainly trace its history somewhat more satisfac- torily. As we have already stated, that which has been termed hydropleuritis is, in fact, an acute pleurisy, and the fluid effused is ill-maturated pus, or serum mixed with the common products of inflammation, pus and coagulable lymph. In all these cases also the pleurae exhibit more or less alteration, in being more vascular than usual, or in being covered with fictitious membranes more or less firm. When, therefore, the fluid poured out in such cases is very considerable, they must be regarded, not as dropsy of the chest, but as cases of empyema, and will require the treatment appropriate to this affection. (See Empyema.) Omitting, therefore, any fur- ther mention of these cases, we proceed to the history of symptomatic hydrothorax. As this is the consequence of a great variety of maladies, so the early symptoms are rather refer- able to the original disease than to the effusion. Thus, when effusion follows disease of the heart, the early dyspnoea, the starting during sleep, the inability of lying down, the difficulty of mounting an ascent, are dependent on the original malady, and are frequently observed when little or even no fluid is discovered in the cavities of the pleurae. These symptoms are, however, unquestionably ag- gravated by the supervention of dropsy, and when the latter originates from organic disease of the heart, it is itself an additional source of exhaustion to the system, and materially accelerates the fatal termination. To whatever affection of the thoracic viscera hydrothorax is to be traced, the earliest symptom of effusion is an cedematous state of the eyelids, occurring chiefly in the morning. This is some- times so little remarkable, that it escapes attention until inquiry be made by the medical attendant.; and often it is only remembered when the feet and ankles have been observed to swell in the evening. That there is no exception to this rule we will not venture to assert, but in all the cases which have been presented to our notice, we have never yet met with any. The progress of the disease from this point is exceedingly variable, and this variable- ness seems to depend much upon the nature of the original affections. In diseases of- the heart the early progress is usually slow, the breathing being manifestly more difficult than before the external oedema was perceived, but for some time not ag- gravated in any remarkable degree. Gradually, however, the external oedema increases, and, pari passu, the thoracic oppression, the difficulty of lying down, the dyspnoea, &c. become more dis- tressing. At first, probably, little attention is paid to the difficulty of assuming the recumbent posture, the patient satisfying himself with having his head raised by more pillows. The necessity for having additional pillows continually augments, till at length perfect orthopnoea is established, and he is only able to sleep in a chair. The dyspnoea undei goes also at times very severe exacerbations, tbti 540 HYDROTHORAX. cause of which is not very readily ascertainable. In a tray painter, whom we examined a few years ago, these paroxysms came on every morning be- tween two and three o'clock, and lasted for an hour or more. He was compelled by the sense of suffocation to start out of bed, and while the attack lasted he placed himself against an open window, gasping in the most terrific manner for air. We saw him only three days before his death, which took place suddenly, and on examination the lungs were found to be cedematous; upwards of two quarts of serum were contained in the cavities of the pleurae, and a few ounces of coffee-coloured fluid in the pericardium. The only other morbid appearance in the whole body was hypertrophy of the left ventricle. While the symptoms now re- ferred to continue to increase, the face likewise becomes more and more cedematous; the cheeks assume a purple hue, and the lips become livid and at times almost black. The duration of this state varies considerably in different individuals, some- times lasting for weeks without any alleviation of symptoms, sometimes admitting of great relief by medicine, and intervals of almost perfect ease; at other times its progress is extremely rapid, a few days only intervening between the first symptom of effusion and dissolution. The termination is in many cases very sudden, and in fat individuals sometimes a very slight effort is sufficient to break the thread of life. It is no unusual circumstance for such persons to die while in a privy, apparently in the act of evacuating the bowels, the slight straining which they are then compelled to make being more than the system is able to bear. In the symptoms which we have now enumer- ated, we have endeavoured as much as possible to confine ourselves to those which may fairly be re- garded as the consequence of effusion. They are, however, in general so much complicated with the symptoms of the original disease, that probably, notwithstanding these precautions, we may have been led into error. It must, however, be remem- bered that the original disease during this time is not stationary. Valvular concretions may con- tinue to increase; aneurisms become more and more dilated; or whatever other organic change the heart may be the subject of, be proceeding, independently of effusion, to a state inconsistent with health and life. Accordingly, the symptoms of these changes are aggravated at the same time: the palpitations become more frequent and more severe; frightful dreams, sudden starting from sleep, &c. &c. more and more marked; and the vital powers are manifestly daily yielding. It ought not to be forgotten that these two diseases thus acting upon each other, may give rise to such a congestion in the lungs as will be best relieved by bleeding. Much caution and attention, how- ever, ought to be paid to the state of the patient before we conclude that this is the case, since if bleeding be unnecessarily resorted to, it will un- questionably debilitate the patient and hasten his dissolution. What we have now said refers to hydrothorax as dependent upon disease of the heart; it sometimes, however, succeeds to bronchitis and pneumonia; and in this case the progress is somewhat different. The palpitations and other cardiac symptoms are usually wanting, and there is nothing more mani- fested than increased dyspnoea. Previously to this becoming very marked, however, the face and feet swell as in the former instance; the patient then requires the head and shoulders to be raised, and at length, as in the farmer case, he is unable to lie down at all, but remains constantly in a sitting posture. In these cases the termination is seldom so sudden as when the heart is diseased, neither does the countenance exhibit in the same degree the purple and livid appearance. This, however, may be owing to the fact, that the effusion is sel- dom so great when the consequence of disease of the lungs, as when attended by cardiac disease; and it seldom occurs till the original disease has so far weakened the system as of itself to threaten a speedy termination. In addition to the symptoms and history now given, we have yet farther means of diagnosis in succussion, percussion, stethoscopic auscultation, and admeasurement. Succussion, as has been already explained under the article Auscultation, consists in forcibly shaking the patient's body and observing the sound thereby produced ; and, at the same time, to pro- duce any appreciable sound, it requires the pre- sence of both a gaseous and a liquid fluid in the chest. In hydrothorax it can only be serviceable when the cavity of the pleura communicates with the external air through an aperture of the lungs, or when gas is evolved within the same cavity without any such aperture. We are not, however, aware that either of these circumstances has been ever noticed in the real hydrothorax, although the former is common enough in empyema arising from the bursting of a pulmonary abscess into the cavity of the pleura. Percussion returns a dull and flat sound over every part of the chest where there is effusion, and ' the extent of the effusion may be partly judged of by the extent of surface which affords the dull sound. There are, however, many other diseases of the chest besides hydrothorax which prevent percussion from affording the healthy degree of resonance, and to distinguish hydrothorax from these we must be indebted to other means, and among these the stethoscope is one of the most valuable. The stethoscope, if employed very early, and while yet the effused fluid is in very small quan- tity, affords that peculiar sound of the voice which Laennec has termed aegophony. This, however, will very rarely happen, for usually the effusion is considerable before application is made for assist- ance. The only information which the stethoscope affords under these circumstances, is a want of respiration everywhere excepting at the root of the lungs. When, however, we have thus learned from percussion and stethoscopic auscultation that the lungs are impeded in their functions, we have yet to learn what the change is which thus prevents the ingress of air, whether the impediment arises from condensation of their substance, whether from empyema or real hydrothorax, or from any other cause, such as aneurisms, tumours, &c, compres- sing their substance. In order to arrive at this information, we must estimate the general symp- toms and those afforded by percussion and stetho- scopic auscultation together. HYDROTHORAX. 541 In the article Empyema, the principal affections have been enumerated which might be confounded with that disease, as tpbercular consumption, he- patization of the lungs, tumours in the cavities of the pleurae, &c.; and for the most part the same means of distinction exist between these affections and hydrothorax. It still remains to be shown what means are afforded us of distinguishing em- pyema from hydrothorax, and this can only be done by an accurate investigation of the preceding symptoms. In hydrothorax the serous diathesis always pre- vails, and there is, at the same time with effusion into the cavities, effusion in the cellular tissue either of the face and ankles only, or of the extre- mities, sometimes of the whole surface of the body. Now, even in empyema we may also have anasarca partial or general, but upon inquiry we shall in this case find that the symptoms of the chest have long preceded the appearance of dropsy, and the latter, instead of appearing the direct consequence of the thoracic disease, would rather appear to be the mere result of debility ; — the cough, the dys- pnoea, the emaciation especially, having usually proceeded to an extreme before there was the slightest appearance of effusion. In hydrothorax, on the contrary, the appearance of oedema of the face and ankles long precedes the more severe affection of the chest: sometimes even the ankles attract attention for a little while by swelling, and then subside for a considerable interval, or they swell so slightly as to be forgotten. In empyema, again, the stethoscope will usually prove that re- spiration is well carried on in one lung at least, although the other may be perfectly useless. This, however, can seldom happen in hydrothorax ; and were we to judge from our own observation, we should even be inclined to say that it never hap- pens. Whenever hydrothorax exists to any extent, that is, whenever there is any considerable quan- tity of serum in the cavities of the pleurae, the lungs participate in the dropsical disposition, and fluid is effused into their cellular texture. This must, therefore, materially impede respiration, and as it must exist nearly equally in both lungs, there can never be the decided difference between the two sides that is observable in empyema. Perhaps we ought not to omit all mention of admeasurement, more especially as effusion, real dropsical effusion, may exist to a much greater degree in one side than in the other. That side in which the effusion is greatest will certainly be more dilated than the other, as is the case in em- pyema ; but if with this difference of measure we unite the indications of the stethoscope, we cannot be in much danger of confounding the two affec- tions. Bichat has recommended an experiment in doubtful cases of hydrothorax which deserves some notice, especially in distinguishing it from empyema. This consists in placing the patient in an horizontal position, and pressing upon the abdomen from below upwards, thus limiting the descent of the diaphragm. The fluid effused into the pleurae is thus forced to compress the lungs, the sense of suffocation becomes most painful, and the countenance assumes a livid hue. Now as distinguishing hydrothorax from any diseases oc- cupying both sides of the chest, this appears 2y scarcely available; but in distinguishing it from empyema, which occupies only one side, it may be a most valuable resource. Dr. Townsend, in the admirable paper upon empyema, to which we have before referred, remarks that if the pressure be made on that side in which effusion is present, no result follows, because this side being already useless, no additional pressure can add to the in convenience; but if it be made on the sound side, this being the only side which is useful for respi- ration, the expansion of the lung is prevented, and the utmost distress induced. In distinguish- ing hydrothorax, then, from empyema, much use may be made of this experiment, although it by no means answers in the manner which its cele- brated author proposed. Prognosis. — The prognosis of hydrothorax is always unfavourable, because it is never a sim- ple disease, but always the consequence of some other malady, which would, even without effusion, eventually terminate in death. This opinion, how- ever, is only applicable to a complete restoration to health, for to a comfortable state it is frequently in the power of medicine to restore the patient. So far as the mere effusion is concerned, it may in many cases be removed again and again; and as this is often the most threatening source of danger, the prognosis may for a time be reversed. Still every fresh occurrence of dropsy of the chest makes even a temporary recovery less probable, and in giving any opinion of the disease we must take into our consideration both the stage of the origi- nal disease, and the frequency with which effusion may have occurred. Under all circumstances our opinion ought to be most guarded, and it is at least wise never to omit the announcement that death may be sudden. Appearances on Dissection. — If we were to enumerate all of those which are at different times found in hydrothorax, we could scarcely omit any long exhausting disease of the human body, certainly none of the thoracic viscera. This would, however, be proceeding much farther than would be useful. Some diseases, however, are much more liable to termirate in hydrothorax than others, and such are thu^e in particular of which the heart, the great blood-vessels, and the lungs, are the subjects. Accordingly, valvular disease of the heart, active and passive aneurisms of the same organ, aneurisms of the aorta and arteria innominata, chronic bronchitis, and tuber- cular consumption, are more frequently met witfr. than any other organic changes in hydrothora?;. Some changes are also observable in the state of the pleura, but this is only very manifest when actual inflammation has been present. We have seen a vascular state of this membrane, and va- rious degrees of factitious membrane deposited upon it. The quantity of fluid varies very considerably. and in our experience it has always been greate. when dependent upon disease of the heart and great blood-vessels than on any other cause. M. Itard places the largest quantity at twelve or four- teen pints, and Portal quotes a case from Wolfius in which sixteen pints were found. Morgagni seldom mentions the precise quantity, but usually states it at some pounds. With one exception, the largest quantity we have met with did not ex 542 HYDROTHORAX. ceed nine pints. In the excepted case, which was an aneurism of the arteria innominate, the quan- tity effused must have been at least fourteen or fifteen pints. The colour of the effused fluid is usually amber, sometimes, however, mixed with coagulable lymph, but this only happens when there has been in- flammation of the pleura. Laennec has indeed very justly observed that from the appearance of the effused fluid alone it is not always easy to decide whether the affection has been hydrothorax or empyema, the serum assuming many grades between a limpid fluid and coagulable lymph. This fact is of great importance in practice, as Dr. Forbes has remarked : it is essential that the phy- sician remember that the inflammatory and serous liathesis may exist together, or supervene one to the other. The plan of treatment must therefore be varied accordingly. Like the effusion into the other cavities of the trunk, the fluid is sometimes of a dark coffee co- lour, sometimes bloody, and assumes every variety of hue between the pellucid serum and blood itself. Treatment. — The same general principles apply to the treatment of hydrothorax which have been mentioned under the article Dropsy. Al- though the original cause of effusion is an affec- tion of some organ of the chest, or some disorder of the general system, yet the immediate source is the serous membrane, and regard must be had to its condition. Even in a very weakened state of the body the pleura may become inflamed and de- mand an antiphlogistic treatment. When this is the case, it is an important object of inquiry how far antiphlogistic remedies may be carried with advantage or even with impunity ; and upon this point some few considerations present themselves to our notice. When towards the termination of chronic dis- eases local inflammation occurs, we have a very different physiological state of the system to con- tend with from that which would be present should such inflammations take place from an im- mediately previous good slate of health : not only under these circumstances have we no general plethora to overcome, which indeed might happen when the system had not been weakened by dis- ease, but there is a positive wasting and probably actual inanition. Now even in common circum- stances it is never advisable to carry bloodletting farther than is sufficient to overcome the imme- diate inflammation, for although no evil result may be at once apparent, no one can have followed the footsteps of some modern bleeders without seeing the most deplorable consequences of over- depletion. Months and even years are often ne- cessary to restore the system to that equilibrium in which the mens sana in corpore sano can again be enjoyed. We have no hesitation in asserting that many of the most lamentable cases of hyste- ria and habitual nervousness owe their origin to this miscalled heroic practice, and in females par- ticularly that helpless capriciousness, which is so often burthensome to themselves and tormenting to their friends, has been derived from repeated bleedings for pains in the side, which have upon mce of acute pleurisy. If then this happen with persons in health when bled improperly, the con- sequences of unnecessarily large bleedings in chro- nic diseases are still more disastrous. In the lat- ter stages of tubercular consumption we have seen patients hurried to their graves by wild at- tempts to cure a pleurisy, without any considera- tion of their previous state, and even in pneumo- nia fatal effusion has instantly followed a large bleeding, when perhaps a moderate one would have restored the individual to health. In the treatment of hydrothorax dependent upon an ex- hausting organic disease, an error in this respect would be almost certainly fatal, for we well know that hemorrhage, even without previous debility, is one cause at least of dropsical effusions. By what we have now said, however, we by no means intend to proscribe bleeding in water in the chest, but merely to urge that due caution be practised in employing it. Two circumstances may occur in hydrothorax which may render bloodletting necessary, the occurrence of pleurisy acute or sub-acute, and congestion in the lungs: the latter is particularly liable to happen when hydrothorax is connected with valvular disease of the heart. In the former case local bleeding is always preferable, both because it may be taken much more immediately from the seat of disease, and also because it has less effect upon the gene- ral strength of the system. Another advantage is derivable also from cupping, which neither gene- ral bleeding nor leeches are calculated to afford, and this is a more permanent determination of blood to the external surface from the action of the cupping-glasses. That cupping has a decided advantage over leeches need hardly be mentioned. In our opinion the latter never ought to be used when the former can be employed. Both the quantity of blood taken is more satisfactorily as- certained, and the patient is not fatigued or in- convenienced in any degree equal to what is the consequence of employing leeches. When it is necessary to draw blood on account of congestion in the lungs, recourse must be had to general bloodletting, and the quantity must be guided by the effect upon the disease. We know of no very certain sign that this congestion has place when hydrothorax is present, excepting the occurrence of hemoptysis; and wherever this hap- pens with valvular disease of the heart, we should not hesitate to bleed, and it will usually be found advisable to repeat the bleeding at longer or shorter intervals. In general it will be necessary to take only a small quantity of blood at a time, some- times not exceeding six or eight ounces; but the benefit afforded by this is very decided, and the debility induced is not enough to prevent recourse being again and again had to venesection for re- lief. Purgatives and diuretics naturally suggest them- selves as the medicines most likely to afford relief in hydrothorax, and to each belong advantages which are not possessed by the other. The re- lief afforded by elaterium and croton oil is un- questionably much more speedy than that which can be obtained by the employment of diuretics. Unfortunately, however, they exhaust the patient in a much greater degree, and cannot be safely employed in a very debilitated condition of the svstem. The mode of giving elaterium has been HYDROTHORAX —HYPERTROPHY. 543 mentioned under the articles anasarca and dropsy, and we have nothing to add to the observations there made. We may make a similar remark regarding digitalis and other diuretics. Here we will do no more than repeat what we have fre- quently said already, that the dropsy is only symp- tomatic, and that it is to the cure of the original affection that we must look for the perfect restora- tion of the patient; and our success in practice will mainly depend upon the accuracy of our diagnosis as to the original cause of the effusion. The last point to which we shall allude in the treatment of hydrothorax is the propriety of tap- ping, an operation which we can scarcely conceive applicable to genuine hydrothorax. Most of the cases in which paracentesis thoracis has been em- ployed, were in fact cases of empyema; and unquestionably there are many instances on re- cord in which complete success was obtained by its performance. In the article hydrothorax, in Good's Study of Medicine, we have but another instance in addition to those referred to by Dr. Forbes, of practitioners confounding empyema and hydrothorax together. He has mentioned a successful case by Dr. Arthur of Dublin, which, without doubt, was an instance of empyema, as it had been the result of a preceding pleurisy. But empyema is usually confined to one side of the chest, the opposite lung being comparatively healthy; and hence, by drawing off the fluid, we have some chance of the compressed lung reco- vering itself, and we at least take off any incon- venience which may arise from the quantity of fluid narrowing the cavity of the sound pleura. In hydrothorax, on the other hand, both sides are affected, though perhaps not in an equal degree; and whenever the effusion is sufficiently great to suggest such an operation, there is the greatest probability that the cellular texture of the lungs themselves is likewise the seat of effusion. Hence it must be always doubtful to which the dyspnoea ought to be referred, effusion within the cavities of the pleurae, or effusion within the cellular tissue of the lungs; and at the best, the usefulness of the operation must be very problematical. It is not, however, very likely, that in real hydrothorax it will ever be proposed. [For the best mode of performing the operation, see the article Empye- MA"] John Darwall. [Hyperemia. (See Congestion.) ] [Hyperesthesia, Supersensitiveness,- from birip, over, and alodvais, « sensibility." Augment- ation of sensibility. This may affect the several senses ; as in nyctalopia, hyperacusis, hyperos- phresia, hypergeusia, hyperaphia, &c. A highly exalted state of sensibility is occasionally seen, in which the sufferer is so impressible or nervous— as it is usually termed—that he cannot bear the slightest unusual impression on any of the senses without fainting, and without the minutest changes of atmospheric density and temperature producing disagreeable sensations. This great nervous impressibility may be caused in various ways. It supervenes, at times, on long protracted and profound mental exertion, on want of sleep, great fatigue, and any thing that ex- hausts the nervous system ; but it more frequently follows profuse evacuations of every kind,— too copious bloodletting, or hytercatharsis; a rigid diet; and still more, abstraction of those excitants to which the nervous system may have been ha- bituated,—as alcoholic liquors or tobacco. Some of the most distressing cases of supersensitiveness, which the writer has seen, have occurred in persons who had suddenly left off chewing 01 smoking. The treatment must, of course, vary with the cause, which must be removed whenever practi cable. A tonic system of management, with a generous diet, and a thorough change of all sur- rounding influences, must be advised. Narcotics, especially hydrocyanic acid and lactucarium, have been recommended, but they are rarely of service. The more active narcotics—as opium— are often found, indeed, to be positively injurious. The supersensitiveness may be diminished whilst the patient is under their influence, but it recurs to a greater extent when the narcotic influence has passed away. Rqbley DrJNGL1S0N.-, HYPERTROPHY, (from WJp and rpo.er the confines of insanity, so the lighter comprehend several varieties of constitution char- acterized by increased susceptibility, and in which, some time or other, it is found that peculiar im- pressions evoke some of the hysteric phenomena. With many of these cases the guardians of edu- cation are more directly concerned than the medi- cal practitioner; and the principles of their man- agement may be gathered from the valuable ob- servations contained in the article Physical Education, in the present work. It is quite certain that the unhappy temper and violent irri- tability of hysterical females, combined wilh their constitutional tendency to the hysteric paroxysm, is in some instances sufficient to bring on, almost at the will of the patient, attacks which occasion much concern to their relatives or friends; we have seen undoubted instances in which a tempo- rary loss of muscular power, a singular diminution of the action of the heart, and an inability to speak, but without loss of consciousness, originated in the desire of a self-willed individual to distress the spectators, or to overcome opposition to some wayward desire; as if the wish to feign an attack brought on a real paroxysm. Frank mentions similar cases, and others against which it is very necessary that a young medical man should be on his guard. (Praxeos Medicae Universae Praecepta, cap. xiv. § lxxii. 22.) It occasionally happens, however, that indivi- duals whose education has long been completed, and whose temper and intentions are blameless, are driven by the intolerable sufferings of a highly susceptible nervous temperament to consult a phvsicai.. who will be more likely to be of ser- vice to them in proportion as he regulates the treatment of them according to the principles of the prevention of hysteric paroxysms. Rank, fortune, and reputation, are insufficient to coun- terbalance the evils attendant on such a tempera- ment ; and, unfortunately, those who are most subject to its distresses seldom possess the firm- ness and perseverance indispensable to a perfect cure. Modifications of Disease by Hysteria.—It may be supposed that a disease capable of simulating so many others may modify some rather remark- ably. The most important of its modifications are seen in the course of fever. Riviere, Baillou, and even Morgagni, entertained the idea of a dis- tinct hysteric fever as a species; but M. Louyer Villermay justly considers such cases as having been nothing more than examples of anomalous symptoms belonging to fever. We have seen nothing in practice to make the opinion of the former authorities credible: it seems to have been purely founded on theory. But the incipient symptoms of fever, its progress, and the circum- stances of convalescence, may be much modified by the hysteric constitution. Irregularity in the respective frequency of the pulse and the respira- tion ; an hysteric fit, of the comatose description, ushering in the febrile stage; a disposition to de- lirium in a state bordering on steep, yet in which the patient is conscious of what is passing around her; a very singular exaltation of the tone of the voice, without increased loudness; a state ap- proaching to catalepsy, but with consciousness remaining; sudden and unexpected, but not al- ways complete recovery ; and transient attacks of mania; we have on several occasions observed : and in almost every instance in persons living an easy and indulgent life, and, with the exception of one or two cases in upper servants, seldom among the poor. In the course of a severe attack of fever in a young lady at school, great alarm was one evening occasioned by the supervention of what was sup- posed to be croup. There was laborious breath- ing, a loud croupal sound, and great distress appa- rently existing in the throat, almost amounting to suffocation ; and the patient was unable to speak. Similar attacks recurred every night for three or four nights, lasting for an hour or two. These gave place to paroxysms of severe spasm in the stomach, occurring with equal regularity; and these disappeared on the supervention of what might be termed paroxysms of sleep, which came on with a febrile exacerbation every afternoon: in the midst of cheerful conversation, intended to make the patient forget her sleep, she would drop instantaneously into a state of sleep the most pro- found, lasting however, generally, not more than a quarter of an hour, sometimes continuing about an hour. On awaking from this sleep the spasm of the stomach sometimes recurred, and there was occasionally a disposition to the croupal pheno- mena. This was a tedious and severe case, and excited great alarm in the patient's friends, al- though there was never any great appearance of danger in the estimation of a medical observer. On the importance of remembering that these and other odd accidents may occur in fever it is quite unnecessary to dwell. Few things are more HYSTERIA. 569 gratifying to the physician than to be able, rely- ing on his knowledge, to be calm and assured when all around him are in a state of agitation and dismay. The patient who was the subject of the above case had been some months previously affected with rubeola : the eruption came out, and seemed to be disappearing at the usual period, when it suddenly broke out anew, and to such an exces- sive degree as to make it impossible to recognise the features of her face : whether or not this pe- culiarity was also connected with the hysterical constitution we cannot take upon ourselves to de- termine. In another case of an hysteric young lady we have happened to witness two attacks of continued fever, with an interval of four years between them. On each occasion very severe hysterical symptoms have come on, recurring every day, or every other day, or observing longer periods, principally in the form of short spasmodic agitations about the chest and neck, followed by a disposition to cry- ing, with more rapid agitation of the chest, appa- rently connected with irregular contractions of the diaphragm : a feeling of suffocation often en- sued, sometimes with a temporary suspension of respiration, deep redness or blueness of the face, often only in spots or patches. The addition of such symptoms to the usual disorders of the fe- brile state constitutes a state of extreme and com- plicated disturbance and suffering, in which it is difficult to distinguish the effects of the fever from the hysterie accompaniments. Pain in the head, pains in the limbs and back, difficulty in moving, costiveness, dysuria, and many other symptoms, exist in such cases at the same time ; and there is usually much tenderness of the spine, sometimes with, sometimes without uterine irre- gularity. It would be impossible to enumerate the modi- fications which may take place in other diseases : any unusual assemblage of symptoms, or remark- able inconsistency in their respective severity or order, may awaken inquiry, and will generally be found to depend upon some degree of the hysteri- cal character in the patient. The development of hysterical symptoms in the course of other maladies is occasionally dependent on weakness, either produced by the continuance of the dis- ease or by certain accidents in its progress, or by particular kinds of treatment. Thus, in the de- bility of the stage of convalescence from fever, and after hemorrhage, and after parturition, and after the employment of very free bleeding, the occurrence of unmeaning laughter or tears, and other parts of the hysteric attack, are not at all uncommon, and always require some attention to their cause. Whether hysteria has supervened upon some other disease, mixing with and modifying it, or has been in any other way produced, it has a ten- dency, when severe, long-continued, or frequently recurring, to produce further mischief, and new complications. Inflammatory actions, for instance, take place at or near the extremities or origin of previously irritated nerves; or, as some authors have expressed it, the disease of the system of innervation becomes combined with disease of the Vol. II. —72 2x* vascular system; and morbid changes take place in the brain, spinal marrow, nerves, or some of the organs supplied by them. In the course of a long hysterical disorder, and yet more readily in the course of a fever in an hysterical patient, the tenderness of the spine may become excessive: and disordered sensations and impaired powers of motion will indicate that something more exists than mere irritation. These symptoms may dis- appear as the patient recovers strength; but they sometimes attain a degree of intensity requiring especial attention, and even inducing an appre- hension of danger. The spinal tenderness in these cases is very different from that excessive sensibility to the" slightest touch which some hys- terical patients evince during the hysteric attacks, and which is of a very evanescent character, often alternating with, or perhaps accompanied by, an equally morbid sensibility of the limbs, or of the articulations. Hysteria is one of the disorders of which the consequences are much less serious, as far as the life of the patient is concerned, than its more vio- lent phenomena would lead an inexperienced ob- server to fear. It can hardly ever, perhaps, be considered as in itself fatal. The secondary dis- eases to which we have already said it may lead may be fatal. Congestion or inflammation in portions of the brain may occasion death ; or the patient may die apoplectic. M. Louyer Villermay has quoted a case of a young woman of fifteen, in whom a most violent hysterical attack ensued on the sudden suppression of the catamenia in con- sequence of terror. The paroxysm continued more than two days; nothing was done for the patient's relief, and she died on the third day, being only fifteen years of age. The patient had complained of a feeling of suffocation, as if a tight collar was fastened round her neck; the hypogas- tric region was tumid ; she could not swallow ; she was convulsed ; the action of the heart was tumultuous; in short she had had every symptom of violent hysteria. On dissection, the stomach was found contracted, and strongly incurvated, (fortement revenu sur lui-meme); the left cavities of the heart were empty, as were also the pulmo- nary veins and the arteries; whilst the right cavi- ties, the pulmonary artery, and the veins, were gorged with black blood, chiefly coagulated. The cerebral veins and the sinuses of the dura mater contained much blood; but there was no appre- ciable alteration of the brain or spinal marrow, or their coverings, or in the nerves. The ovaries were very large and very firm, and enveloped in a partially transparent tunic, (une sorte de tunique albuginee, mais transparente dansplusieurs points.) In the interior of the ovaries there was a large collection of round vesicles, filled with an abun- dant mucous fluid, which required for its escape the separate puncture of each vesicle. (Traite des Maladies Nerveuses, p. 70.) The same author is one of the very few writers on hysteria who have especially devoted a section to the appearances found in fatal cases. Hs adduces the testimony of Riolan, Blancardus, Binninger, Vesalius, Diemerbroeck, and Morgag- ni, as to morbid appearances in the ovaria more or less resembling those mentioned in the above mismanaged and most unfortunate case; without 570 HYSTERIA. however, concluding that such alterations, or any changes in the state of the uterus, are constant. We spoke, some pages back, of the superven- tion of jaundice on hysteria, but this, like the accurrence of phthisis, can only be looked upon as an accidental complication. It may sometimes, however, happen that the patient, worn out by the long continuance of the malady and repeated paroxysms and frequent agitations, may become peculiarly liable to the supervention of the last mentioned disease; or may become affected with a slow fever, the body gradually wasting, and the strength decaying, and a premature death at length ensuing. But among the peculiarities of the hysteric con- stitution, are to he reckoned some unexpected recoveries from states which seem to furnish an utterly hopeless prognosis. Of such singular cases and their termination we generally have an outline in the expression which all must on some occasion or other have heard employed, that such a patient fell into an odd state, and remained so for a year or longer ; that nothing could be made of her case, and that at last she got better, nobody very well knew how or why. These curious re- prieves are sometimes from what has appeared to be atrophy, or pthisis, or paralysis; but they have, we believe, occurred after a stiong image had been presented of other incurable diseases and of impending death. M. Georget very properly guards the practitioner, therefore, against forming and pronouncing too hasty a prognosis in all cases of hysteria ; observing that not only do such occasional recoveries sometimes unexpectedly take place, but that the course of diseases of a fatal character is often much more prolonged in the hysterical than in those of a different constitution. (Vol. ii. p. 288.) Hysteria in Males.—We have met with a few instances which we consider to have been decided examples of hysteria occurring in males. The subject of one was a gentleman who had devoted himself with too great intensity to his studies, being designed for holy orders. After leading a life of great retirement at Oxford, and, in opposi- tion to his temperament, of strict chastity, his mind became irritable, and he could not obtain refreshing sleep. On several occasions he was suddenly seized with violent sobbing, gasping, and anhelation, attended with a fear of immediate death by suffocation. During these attacks his face was flushed, the carotids pulsated strongly, and the heart was much disturbed ; but he retain- ed his consciousness. We were also acquainted, some years ago, with two gentlemen who were singularly intemperate in drinking, and in both of whom excess sometimes induced fits of sobbing and crying, with palpitation, a weak pulse, a loss of muscular power, a great dyspnoea, painful con- striction of the chest, and fear of impending death. In cases of melancholia we have found the patients complain of violent agitation of the stomach and bowels, with a disposition to shed tears. We have known the silence of a sick-house unexpect- edlv disturbed by the uncontrollable and loud laughter of a patient dangerously ill of fever. Very decided hysterical symptoms came on during convalescence from fever in a boy who was a patient of the University dispensary : his mother was much troubled with hysteric fits; the boy's affection was evidently caused by debility, and disappeared as he regained strength. Sydenham relates the following case, in which the cause and the result were the same. It deserves to be quoted, both as an illustration of the practice of that great physician, and on account of the im- portant relation of such cases to the theory of the causes of hysteric disorders in general. " I was called," says he, " not long since to an ingenious gentleman, who had recovered of a fever but a few days before. He employed another physician, who had blooded and purged him thrice, and forbid him the use of flesh. When I came, and found him up, and heard him talk sensibly on some subjects, I asked why I was sent for; to which one of his friends replied, if I would have a little patience I should be satisfied. Accordingly, sitting down and entering into dis- cussion with the patient, I immediately perceived that his under-lip was thrust outward, and in fre- quent motion (as it happens to fretful children, who pout before they cry), which was succeeded by the most violent fit of crying I had ever seen, attended with deep and almost convulsive sighs; but it soon went off. I conceived that this disor- der proceeded from an irregular motion of the spirits, occasioned in part by the long continuance of the disease, and partly by the evacuations that were required in order to the cure; partly also by emptiness and the abstinence from flesh, which the physician had ordered to be continued for some days after his recovery, to prevent a relapse. I maintained that he was in no danger of a fever, and that his disorder proceeded wholly from empti- ness ; and therefore ordered him a roast chicken for dinner, and advised him to drink wine mo- derately at his meals; which being complied with, and he continuing to eat flesh sparingly, his dis- order left him."* This subject is of so much importance, particu- larly as regards the alleged dependence of all cases of hysteria on some disorder of the uterus, an opinion which cannot be admitted without materially influencing our practice, that we shall quote one or two more examples from authorities which cannot be called into question. In Dr. Whytt's work on Nervous Disorders, which has already been more than once referred to, and which deserves, even at this day, an at- tentive and entire perusal, the following case is related, the connection of which with hysteria of the periodical character appears unquestionable. " A boy of ten years of age, of a very sensible nervous system, who, in December 1747, had been seized with a palpitation of his heart, fell from his horse about the beginning of January. From this time the palpitation left him; but in a few days after he was attacked with a violent headach, returning sometimes once a day, at other times only every third or fourth day. During the fit his pulse became smaller and quicker, and often * Op. cit. p. 381. Cases of hysteria in men are also mentioned by Louyer Villermay and by Georget: the latter quotes the words of Piso, (or Lepnis, an author of the 17th century, whose name is latinized according to the custom of the time.)—Hysterica symptomata om- nia fere vis cum mulieribus communist sunt. Caroli Pisonis Select. Obs. et CovsiL, Sec. We have no opportu- nity of referring to the original. HYST intermitteo., nis feet were cold, but, by the violence of the pain, a plentiful sweat broke out and re- lieved him. As these headachs continued to in- crease, the patient lost his stomach and flesh, and looked pale. By the use, chiefly, of an electuary of the bark and valerian, in less than three weeks the pain of the head abated greatly ; but his ap- petite grew worse, and he often complained of a nausea. These symptoms, however, were all removed in four or five days, by some warm stomachic and cordial medicines, but were suc- ceeded by an intolerable pain across the middle of his belly, which, in the space of eight days, re- turned five or six times, and not only affected his pulse, as the headach had done, but sometimes occasioned a difficulty and pain in making water. This pain no sooner left his belly than the head- ach returned with greater violence than ever, so that the boy used to faint in some of the worst paroxysms. It had no certain periods, coming sometimes twice a day, sometimes only once in two days, and was attended with a sense of suffo- cation from wind, and a lump in his throat. He was easiest in the night, when he slept or lay quiet, but any considerable motion of his body always raised his headach. Before the fits he was observed to be uncommon lively, and disposed to laugh. On the 21st of February, at two in the afternoon, he was seized with fits of involuntary laughter, between which he complained of a strange smell, and of pins pricking his nose: he talked incoherently, stared in an odd manner, and his complexion changed to a livid colour; imme- diately after he was seized with convulsions, and then fell into a fainting fit, which lasted near half an hour." The remainder of the case may be abridged. Purulent matter was subsequently discharged from the nostrils and the right ear, with some al- teration in the situation of the pain, which shifted to the back of the head, and then to the left side of the abdomen, " between the short ribs and os ilium, confined to a space little larger than the breadth of a shilling. This pain was often so severe as to make him ready to faint: sometimes it shifted, and then he was seized with fatiguing fits of involuntary laughter." This case appears to have resembled some of those mutable examples of the disease which are more commonly met with in females, and in which the relief given to one affection is but the signal for the raising up of another, constituting cases comprehended in Dr. Marshall Hall's excel- lent description of " Disorder of the General Health." The fact of hysterical disorders appearing in male subjects is supported also by the highly respectable testimony of Dr. Ferriar. (Medical Histories and Reflections, vol. i. p. 128.) " Men," he says, " are frequently attacked by complaints which approach to the hysterical type. In the following instance a young man was affected with regular hysteric fits, in consequence of continued vexation and anxiety. In spring, 17S9, I was desired to visit a patient about seventeen years of age, on account of fits with which he had been seized a few days before. I was told that they began with great dejection of spirits, sighing, and uneasiness about the praecordi. He then became ERIA. 571 apparently insensible, but groaned much, and did not recover for a considerable time. He relapsed frequently, from slight causes, and often had three or four fits in a day. He said that he felt the globus hystericus at the approach of each parox- ysm, and he said that he retained his senses, in some degree, to the termination of each. His pulse was weak and hurried; his tongue some- what foul; and his countenance timid. His eva- cuations were natural. I do not recollect the particular nature of his employment, but it was of a sedentary kind. After clearing his stomach by an emetic, I directed some pills to be made up composed of opium and assafoetida, and to be given in such a manner that he took half a grain of the former and four grains of the latter every hour previous to the approach of the coming par- oxysm. On the first day of taking the pills the fit came on, but in a slighter degree. The next day he was ordered to begin at a greater distance from the usual time of the fit. He took by this means three grains of opium, and more than a scruple of assafoetida. The paroxysm was effec- tually prevented by this dose, without producing the smallest uneasiness to the patient. Two of the pills were given at bed-time for a few nights afterwards, and the cure was finished by adminis- tering tonics." In the above case the evidence of the juvantid, taken together with that of the symptoms, seems to leave no doubt of its being an example of hys- teria ; and we shall not dwell longer on this point, except to refer to a remarkable instance of tempo- rary loss of voice from hysteria, occurring in a recruit in the East-India Company's service, and related by Mr. Watson, the surgeon of the ship on board of which the patient was a passenger. (Edin. Med. and Surg. Journal, vol. xi. p. 303.) The subject of this case was a strong healthy man, who complained first of giddiness and head- ach, was then convulsed, and had some of the symptoms of epilepsy, as distortion of the mus- cles of the face, and discharge of frothy matter from the mouth. After an interval of some hours these symptoms returned, with alternate laughing and crying, spasms about the throat, and inability to speak, although he was perfectly sensible. After being twice bled, and having a blister applied to his head, and taking some active purgative medi- cine, he recovered his speech in about forty-eight hours. The account he then gave of himself was that he was prevented from speaking by a tight- ness in his throat, which felt as if something was in it. Mr. Watson observes that but for the super- vention of those symptoms the case would have been considered as epilepsy. It is worthy of re- mark that another case occurred on board of the same ship about a fortnight afterward, of which the subject was an artillery-man, who, however, recovered his speech on the following morning. Mr. Watson, in conclusion, quotes. Dr. Trotter (Medicina Nautica, vol. ii.) as saying, « We found not a few of the cases sent to the hospital-ships subject to very frequent fits of hysteria; and where this singular affection occurred, with as much violence of convulsion as we have ever marked it in female habits, attended with globus, dysphagia, immoderate risibility, weeping, and de lirium." 572 HYSTERIA, These cases and authorities are, we think, suf- ficient to set the question at rest. The cases of hysteria in men must, however, still be considered as rare ; although we have met with few observant practitioners who have not answered our inquiries on this point by stating that they had seen one or two examples very much resembling it. Diagnosis. — The importance of not pro- nouncing serious diseases to exist which are only simulated is almost equal to that of not overlook- ing serious disease when it is really established : in the latter case the patient's life may be sacri- ficed to neglect; in the former it may be destroyed or endangered by unnecessary activity. For these reasons we have already insisted on the propriety of every opportunity being taken to enlarge the practitioner's knowledge of the varieties of hys- teria ; and it is equally necessary that he should keep in mind the tendency of all the violent forms of this disorder to pass to severer and more per- manent lesions of function, and even to lesions of structure. Fortunately, the diagnosis of the most important cases is commonly the easiest; as it is more easy to recognise and verify the symp- toms of severe diseases, the existence of which may be apprehended. Cases, however, will now and then present themselves requiring the greatest degree of circumspection, and the circumstances in which the patient is placed are often of a na- ture to produce agitation and haste, of which the effects are most pernicious. It is only by a care- ful study of the symptoms of diseases of the brain, lungs, heart, intestines, liver, kidney, and other important organs, and by a scrupulous comparison of all their symptoms with the case before him, that the practitioner can escape deception; for many symptoms may be present without real dis- ease, and sometimes serious disease may be pre- sent and yet only partially represented by the ordinary symptoms. The slightest admixture of hysterical phenomena forms a sufficient ground of suspicion, and any great departure from the ordi- nary course and effects of maladies should alone awaken great vigilance. Great mutability of symp- toms, or intervals of ease alternating with symp- toms of much violence, will generally declare the nature of the case at once. There is, in truth, nothing so difficult to be written, or to be learned by reading, as diagnosis, in this as in all other in- stances ; but habits of caution, of tranquil observa- tion, and of careful consideration, may be learned by every practitioner of ordinary capacity ; and, thus disciplined, he will seldom be deceived, even by hysteria. To distinguish hysteria from epilepsy, a disease generally so much more formidable, is of such great importance that almost all who have treated of these diseases have attempted to lay down cer- tain marks of difference between them. Yet M. Louyer Villermay informs us that M. Pinel, on instituting an examination of the patients detained in the Salpntriere as epileptic, found a great num^ ber of women, several of them young women, who ,vere only hysterical, and yet who were sepa- rated from their families and from society. (Traite ties maladies Nerveuses, vol. i. p. 117.) To pro- nounce a young female patient epileptic is often in its consequences only second to pronouncing her insane, the disease is considered to be incurable, to have a tendency to destroy the understanding, and to be transmissible to offspring; none of which terrible evils are associated with the name of hys- teria. The attack of hysteria is commonly less sudden and less violent than an attack of epilepsy. Epi- lepsy is often ushered in by a loud cry ; the pattern falls violently to the ground; the muscles of the face are severely convulsed ; the eyes are dis- torted ; the tongue is protruded and bitten, and frothy saliva forced out of the mouth. In hysteria there is seldom any incipient cry, although the patient may cry or laugh during the paroxysm; the patient, except in the comatose variety, does not fall suddenly, but, feeling the approach of the fit, is usually attacked after sitting or lying down: the muscles of the face, and the eyes, are usually tranquil, and the face is generally flushed, whereas in epilepsy it has often a ghastly paleness. The hysteric patient does not protrude or bite the tongue, nor is there a discharge of frothy saliva. The epileptic patient does not laugh or shed tears, but is in a state of fixed and intense agony ; nei- ther is globus a sensation known to him. After the fit the epileptic patient generally falls into a heavy sleep or sopor. During the paroxysm of hysteria the pupils of the eyes are commonly sen- sible to light, which is not the case in epilepsy. After the paroxysm the hysteric patient often re- members all that has passed, which the epileptic does not. It may be added that epilepsy is most common in men, in whom hysteria is rare; and that the character, habit of body, and history of the cases, will frequently afford instructive cir- cumstances of difference. It was Sydenham's custom, he tells us, always to inquire whether any particular disorder about which he was consulted in women did not chiefly attack them " after fretting, or any disturbance of mind ;" and, in an attempt to make a difficult distinction, such an inquiry, and others of a simi- lar tendency, will sometimes not be found super- fluous. " The patients and the nurses at the Salpe- triere," says M. Georget, " attach the principal importance to the three following characters of epilepsy : the want of precursory symptoms; the complete loss of consciousness ; and the distortion of the mouth and state of the eyes. They say of a case of hysteria passing into epilepsy, that the patient begins «to laugh on one side' and ' to turn her eye,' — a rire de cote, et a tourner Fail." The cases here pointed to, cases of mixed epilepsy and hysteria, are certainly now and then met with ; and their character is of course only to be determined by the assemblage of symptoms in each. The remarkable impression left on the counte- nance by successive attacks of epilepsy is familiar to all medical observers : there are few instances in which the face presents no trace of the storms which have passed over it and over the whole frame. The same protruding eye and dulness and passiveness of look are not seen in the hys- terical ; and when the hysteric character is at all imprinted in the physiognomy, it is rather to be read in a changeful expression, and unquictness and want of repose in the face, which it is not easy to describe. HYSTERIA. 573 Causes. —A mere inspection of the various forms of hysteria would, one would suppose, be of itself sufficient to show that all were not very likely to arise from one kind of cause ; but that, if all the causes are admitted to act on the brain. and through the nervous centre on the parti affected in the paroxysm, still the seat of the pri- mary irritation is various. But, perhaps from the disposition in the human mind to avoid a complica- tion of difficulties, many authorities have ascribed all the varieties and examples of hysteria to some one irritation, as, for instance, to irritation of the uterus. A comparison with one another of the examples of this disorder which have fallen under our own observation leads us to reject all such ex- clusive views of their origin, and to believe that the causes of hysteria may consist of any circum- stances capable of producing a particular excite- ment of the nervous system, or certain portions of it, which excitement leads to all the other phe- nomena. Of the primary irritation we should say that by far the most common seat is the ute- rus and the intestinal canal; but that sometimes the irritation is such as primarily to affect the whole nervous system, as plethora, anaemia, atmospheric changes, and mental impressions. Such being the exciting causes, of the predisposing cause we can only say that it is a peculiar and constitu- tional susceptibility to impressions, with an inhe- rent disposition to institute certain actions affect- ing particular organs and functions, the object of which actions seems to be the relief of the ner- vous system, sometimes by the equalization of the circulation. We are not more able to explain the form of these actions, or the hysterical paroxysm which supervenes on the cerebral excitement springing from the primary irritation, than we are to explain the ordinary phenomena of laughing or crying, arising from a similar cerebral excitement originating in impressions primarily affecting the mind. That certain states of the uterus, causing pecu- liar sympathies in different parts of the frame, are the causes of hysteria, is an opinion of great anti- quity, and has been supported by nearly every ob- server from the time of Hippocrates, who has often been quoted as saying that a woman's best remedy in this disorder is to marry and bear children. Whoever considers the sympathies excited by the changes which the uterine system undergoes at puberty and during pregnancy, and at the cessa- tion of the catamenia; the altered form and cha- racter of the young female ; the capricious wishes and taste, or longings of the state of utero-gesta- tion ; and the morbid actions of what is called the "change of life;" will without difficulty admit that the hysterical phenomena, bodily and mental, may very probably be called forth by peculiar con- ditions of the same dominating system in the fe- male economy. Expensive experience confirms such an opinion ; and the occurrence of hysteria in early life, or after marriage, or at a later period, is so often observed in individuals in whom there are evident signs of the activity of the uterine sys- tem, as to connect the two circumstances together in the firmest manner. Precocious development and disappointed hopes on the one hand, and ex- cessive indulgence, or marriages immature or phy- sically disproportionate on the other, are causes of hysteria of which every practitioner finds illus- trations within the circle of his own practice; as well as of the disappearance of hysteria after a long-desired marriage, or when means are taken to prevent hurtful excesses. In some fe- males hysteria supervenes on puberty, continues to be more or less troublesome until the period of cessation, and then disappears. In others, as was remarked by Hippocrates, it disappears during pregnancy. And in the few cases in which death has seemed to supervene on sim- ple hysteria, disease, as has already been men- tioned, has been discovered in the uterine appen- dages. We cannot therefore be surprised to find that many ancient and modern writers have con- sidered hysteria as being solely a manifestation of a disordered uterus ; and that various theoretical notions have been engrafted, in the different pe- riods of physic, upon this too exclusive opinion ; some of which have been disproved by the pro- gress of anatomy and physiology, such as the de- pendence of hysteria on the ascent of vapours from the womb, and of the symptom of globus on the ascent of the womb itself. To such notions we now only allude as curious remains of an age delighting in medical conjectures, and unpossessed of means of obtaining more accurate knowledge. But the facts on which such theories and prac- tices conformable to them were built, yet remain ; for nature and the laws of the human body are yet the same. In a susceptible female tempera- ment, and in the unmarried state, the system of reproduction, every change in which involves many other changes, acts strongly on the system at large, and in certain circumstances disorders all the functions of the body and the mind ; the di- gestion of food, the circulation of the blood, the judgment, the affections, and the temper ; and in many of these cases all the mischief is removed by marriage, which, by awakening the natural functions and normal sympathies, allays the whole series of irritations or morbid actions. There can, therefore, be no reasonable doubt entertained that in a great many cases—perhaps We might say in the majority of cases—the cause of hysteria is some more or less discoverable irritation existing in some part of the uterine system, exercising its wide influence on the susceptibilities of a nervous system by nature too easily affected by all im- pressions. We may perhaps agree with M. Lou- yer Villermay to call this " a nervous disturbance, an exaltation of organic sensibility of this organ ;" but we must add that his statement of the proofs of such a condition, drawn from the asserted state of the hypogastric region, of the vagina, &c. &c. (Diet, des Sciences Med. art. Hysterie), however consonant with the older doctrines, has an air of inefficient practical observation which would al- most lead us to doubt, with M. Georget, whether or not he had actually ever seen a case of hysteria. The very abuses to which such a theory has ted and must lead, and the unjust suspicions to which it would often give origin, are sufficient to draw even a minute attention to its foundation.* * For an illustration of this the reader is referred to the case of a nun in Sauvages' Nosol. Method, torn. iii. We cannot venture to quote the treatment, although ie corded in a learned language. The substance of the au- cient uterine theory and some of the singular method* of cure which originated in it .nay he read in Senncrtui 574 HYSTERIA. As far as the writer's experience has extended, and from observations made whilst recording very numerous cases, comprehending nearly all the forms of amenorrhcea, hysteria veiy rarely super- venes on the amenorrhcea of young women ; and, compared with its frequency after the age of twenty, very seldom appears before that time. In cases, also, in which the hysteria has most plainly depended on the suppression of the catarhenia, the comatose form of the paroxysm has appeared to be the most common. We have frequently found hysteria coexistent with chronic leucorrhcea and repeated attacks of menorrhagia, in circum- stances clearly indicative of what might be termed an irritable uterus ; in individuals liable to fre- quent miscarriages, and in whom the stomach and bowels suffered much sympathetic disturbance. In these cases then, is, we believe, generally a dis- position to change of uterine structure; insomuch that we should say that a patient who has obsti- nate hysterical symptoms, and now and then a paroxysm, in early life, or between twenty and thirty years of age, has, in a majority of instances, a predisposition to serious uterine disease, requir- ing great attention. As such patients advance in life, it will be found that the symptoms become more troublesome, and the sympathies of the whole constitution stronger; whilst in many of \he cases there takes place a congestion in the vessels of the uterus, or a sub-inflammation, or indolent tumours are formed, or polypi are thrown out from the interior of the uterus, or the uterus descends lower than its natural position, or ma- lignant disease makes its appearance. We should observe, although it seems to contradict the little that is recorded of the morbid anatomy of the dis- ease, that in the most confirmed and striking ex- amples of ovarian disease which we have met with, there have never been any hysterical symp- toms, even of the slightest kind. These observations, which are the simple re- sult of some attention paid to this subject during several years, added to the fact that hysteria some- times occurs before puberty, and sometimes after the cessation of the catamenia,* whilst they con- firm the opinion of the frequent connection of hysteria with uterine disorder, lead us to regard it as having much less connection with the catame- nial function than has been maintained, with a positiveness greater than we think extensive ex- perience would warrant, by some of the most re- cent writers on hysteria. The question is of great practical importance; but we must now leave the consideration of it to the reader. We are ourselves convinced, then, that the uterus is not the only organ of which the irritations may so affect the nervous system as to produce hys- teria; and this not only from the above conside- rations, although supported by additional cases in wnich the uterine functions have continued to be lom. in. lib. iv. pars ii. sect. 3, cap. 4. De sujfocatione uien; and a refutation of much of the theory may yet Be referred to with advantage, in the writings of Willis, r)e Morb. Convuls. and Van Swieten. Willis notices the occasional occurrence of hysteria before puberty, of which we have seen one remarkable example. * tVillis, op. cit. See also Dr. Bright's Cases, vol. ii. case ccxx. This was a case of nymphomania after ces- oation, accompanying uterine disease. M. Georget would consider it a case of cerebral disorder. perfectly performed ,-j- but because there is in many instances of hysteria such evident disorder of other functions, and so manifestly, as it has appeared to us, leading to every form of nervous irritation of the hysteric kind up to the paroxysm itself. We might, indeed, adduce the occurrence of hysteria in men as at once decisive of the question, but wo do not think it absolutely necessary to the argu- ment; although, if such cases are admitted, they( must inevitably be taken as putting an end to it. Among the most frequent causes of hysteria next to uterine irritation, must be placed gastro- intestinal irritation ; whether from excess, or from improper food, or from depraved or deficient secre- tions, or from diminished peristaltic action, and the delay in the intestines of the natural excretions. The extent to which the proper evacuation of the bowels is neglected in female patients is almost in- credible, and is so often the sole cause of the ailment under consideration and of many others, that we cannot wonder at the general acceptation of the aloetic or purgative treatment of their disorders. The presence of worms has sometimes excited hysteria; (the hysteria verminosa. Sauvages, Nosol. Method, tom. iii.) Perhaps it may often be an unsuspected cause : we have seen the most violent and repeated attacks of epilepsy, which had recurred for many months, cease after the passing of one large round worm. All the causes of indigestion may become causes of hysteria to those whose constitution of nervous system is pre- disposed to be acted upon in the specific mode, whatever it be, in which it is affected when the hysteric phenomena are produced. In many cases of hysteria there seems to be a peculiar sensibility of the gastro-intestinal mucous membrane, giving rise to irritability of the stomach and bowels, and thus disordering the nervous system; and such a state may sometimes be the exciting cause of hys- teria, sometimes by its influence only predispose the nervous system to the specific irritation of hysteria on the supervention of any of the other causes. The effect of improper diet, either as re- gards food or drink, in increasing the nervous susceptibility to all impressions, is probably pro- duced by the intervention of this gastro-intestinal exaltation of sensibility, of which indeed, in such cases, there are many proofs. It seems to be in this manner that luxurious livers and excessive drinkers are always at length punished by an un- easy digestion, and by all the pains of what is commonly called nervousness,- which last, increas- ing by degrees, sometimes converts a brave man into a coward, and invariably disqualifies men more and more for great and original undertakings, and even for sustaining the ordinary reverses and agi- tations incidental to social life. When it is con- sidered that the nervous expansion over the intes- tinal tunics has been described as analogous to the expansion of nerve constituting the retina, we can readily believe that much disorder may be effected by irritations of this nervous expansion without necessarily ascribing them to circumscribed attacks of enteritis, as M. Broussais has done. In many cases, in which no positive signs of such inflam- mations exist, the irritations cease or are greatly t For a case of this kind, in which there was hysteria with temporary paralysis and no uterine irregularity, see parry's Posthumous Works, vol. i. p. 37P. HYSTERIA. 575 mitigated on the appearance of faeces indicative of depraved secretions; cases described by the older physicians as abounding in phlegm. The motions in such cases are dark or olive-coloured, sometimes passed with much pain, although not hard, and seldom procured without medicine. The excessive flatus which is the torment of certain hysterical patients is in all probability connected with some morbid condition of the intestinal nerves; may in fact be looked upon as an excess of a natural pro- duct in the intestines, the result of deranged ac- tions. Partly from the stimulus of so much air, and partly from the morbid condition of the intes- tines, which produces it, the muscular fibres of the intestines are thrown into commotion, or at least excited to vehement action, creating a feeling of movement and a rumbling noise which becomes a source of annoyance to the patient. Upon this disordered state spasm frequently supervenes, and it would seem generally to commence in the lower part of the intestines, near the termination of the colon in the rectum, and to ascend, producing the feeling of globus already described.* It happens, however, not uncommonly, that even when the state of the uterus is the real cause of the hysteric disorder, the suppression or insuffi- ciency of its accustomed secretions is followed by such derangement of the digestive organs, that the hysteric phenomena appear wholly to depend upon the latter ; a fact which did not escape the obser- vation of Whytt, who remarks that " when the menses are obstructed, the stomach generally suf- fers first, and by means of its consent with almost every part of the body, gives rise to many of the complaints which follow. Thus the hysteric con- vulsions and other violent symptoms which are sometimes occasioned by a sudden stoppage of the menses, do not seem to proceed immediately from the uterus, but commonly from the stomach and bowels, whose nerves are first affected either by their sympathy with those of the womb, or by the blood which should have been discharged by this organ being partly turned upon the alimentary canal." (Opus cit. p. 177.) But, on the other hand, it is equally certain that attention to the order of the phenomena in hysteria will often detect the priority of the intestinal disorder, which the uterine irregularity seems, in such cases, to follow as a consequence. Such are the complica- tions met with in practice ; baffling to those who trust wholly to their books, and only to be pre- pared for by a careful clinical education; a kind of education not confined to the schools, but within the reach of every practitioner who has access to numerous examples of disease. Either the uterine disorder or the intestinal dis- oider, which are thus seen to have the power of producing each other, may produce the nervous irritation, or the congestion, or whatever morbid * Other irritations of the intestines seem also to com- mence in the lower portion, and to proceed upwards. Diarrhcea commonly precedes vomiting in the cholera. Hernia; excites irritation above the protruded portion of bowel or omentum. The symptom of globus has been noticed in some instances of severe gastritis, and is in such cases supposed to depend on spasm of the cardia extending to the oesophagus. Broussais considers it as indicating inflammation of the whole stomach; but what bears somewhat on the present subject is that in these instances the capacity of the organ has been found greatly contracted, reduced to the capacity of the small intestine. See Gastritis. condition it may be, of the nervous system, or of certain portions of it, wh'ch induces the hysteric paroxysm. Either of them, also, may thus act as a cause predisposing to the hysteric paroxysm, or as a cause exciting it without the supervention of any other known cause. Another cause of hysteria, also, sometimes pre- disposing to, sometimes exciting the paroxysm ; sometimes connected with uterine disorder, some- times leading to it; is a plethoric condition of the body, or of the nervous system, or apparently of portions of that system. The appearance of the patient commonly indicates the presence of this cause in patients who are indolent and overfed ; but as it is often combined with an oppressive feeling of debility, with a pale or bloated com- plexion, and a languid pulse, and as the plethora may exist with reference to the strength of the patient only, it sometimes escapes attention. Both hysterical and epileptic attacks are occa- sionally attended with hemoptysis. We think, also, that it is too common to set down cases of periodical vomiting of dark-coloured or sanguine- ous fluid as dependent on uterine disorder, when, although the menstrual discharge may be rather less than natural, really dependent on plethora. Patients of the description here meant complain of pain of the stomach, distension, flatus, and cold- ness of some portion of the abdomen, followed by the vomiting. The pain and other symptoms alternate with severe pain at the upper part of the head, accompanied with several symptoms which may be called nervous, such as a sense of coldness in the eyes, nose, and face generally ; and they are subject not only to great agitation of spirits on slight occasions, but to severer symptoms, such as temporary insensibility, seemingly connected with fulness of the cerebral vessels. They also often complain of pains and swellings of the hands and arms, and feet and legs; they are soon and much disordered by errors of diet; inclined to be fat; subject to profuse perspirations on making slight exertions; and their bowels are constipated, as well as the catamenia deficient. In such cases the plethoric condition finds no natural or no effec- tual relief; and bleeding and medicine must be the substitutes for the dietetic restraint and proper regi- men which often cannot be enforced, as well as for the vomiting which has already established itself. All convulsive affections seem to be capable of being produced both by plethora and the opposite state of debility, or deficiency of nourishment. This may arise from defective powers of digestion and assimilation, or be a consequence of previous disease of some continuance, as leucorrhaea and menorrhagia; or of a recent confinement, ( Whytt, Opus cit. p. 186, who also refers to a case in the Phil. Trans. No. 174); or of protracted nursing; or arise from various other causes which it is un- necessary to enumerate, including any which may lead to a depravation of the blood as well as to deficiency of its actual or relative quantity. It may be worth while to mention that repeated bleedings and excessive purging may have the same effect. (Sauvages. Nosol. Method. " a re- petitis phlebotomiis et catharticis.") Some of the older writers laid considerable stress on the influence of a gouty constitution in predisposing to hysteria. Facts of this kind art S7G HYSTERIA. not easily verified; and hysteria may occur in a gouty family without being really connected with a gouty constitution. There can be no difficulty, in an age when a new and more enlightened pathology of the fluids seems to be dawning, in admitting so much of the ancient humoral patho- logy as to allow that either a gouty or any other morbific matter in the blood may be the occasional exciting cause of those nervous irritations which characterize a susceptible temperament, just as, in other cases, the same morbific matter, by irritating the nerves of the extremities, appears to excite the common pains of gout and rheumatism. The nervous irritation in these latter examples is suffi- ciently well established ; the existence of a mor- bific matter yet remains to be proved. Climate, seasons of the year, occupations, and sex, have generally been enumerated among the causes creative of a predisposition to what has been termed mobility, and what we have spoken of as increased susceptibility of the nervous sys- tem. The situation of a country, its soil, its cli- mate, and even its government, determine the occupations of the mass of its inhabitants, and by giving greater or less excitement to their faculties, naturally cause more or less activity and enter- prise. The susceptibility which predisposes to various nervous disorders is thus undoubtedly in- creased or lessened. All the disorders of the mind are said to be less common in Spain and in Turkey than in England. But, as regards hysterical dis- orders, it is seldom that we have any reason to refer their origin to causes of such general opera- tion ; except it be to climate and to seasons of the year. Joseph Frank says that his own observa- tion has taughf. him that spasmodic affections of all kinds are more frequent in Italy than in any other countries.* Yet the women of Lapland have been described, although we cannot quote our authority for it, as being so susceptible to im- pressions as to faint on any sudden noise occur- ring near them. We have ourselves often re- marked the increased discomfort of hysterical sub- jects in warm and showery weather; and espe- cially, without such decided reference to increased temperature, their aversion to the supposed dis- turbing influence of a cloudy sky : they sometimes say that they " can feel the clouds." Dr. Mead enumerates hysterical disorders among those which are influenced by the moon ,- returning when there is a new or full moon: and he refers to a case related by Dr. Pitcairne, and to two recorded by Piso,-f- one of which was that of " a lady of quality, whose left cheek and part of the neck were wont to swell very sensibly anout the new moon."^ We have already spoken of the modern disregard of all notions of this kind, (see the article Disease, vol. i. p. 688,) and shall say nothing more on this occasion than that, true or false, fanciful or real, we have hardly ever known a patient affected with a nervous disorder whose attendants did not stoutly assert these much derided influences. * duamvis spasmi nee in regionibus septentrionalibus desiderentur, eos tamen longe frequentius in Italia ob- venire, meiB docent observationes. Prax. Med. Univ. Prrec. t De morbis a serosa colluvie. Piso attributed hyste- ria to a serous colluvies at the origin of the nerves. I Mead. On the influence of the Sun and Moon upon H/'man irouies. and thf cold to the head, the frequent use of the hower-bath, and of pediluvia of warm water, nay be resorted to with benefit. Although blis- ters behind the ears are in these instances, and in ihose of hysterical pains about the face, usually productive of much temporary irritation, their em- ployment is often followed by relief. In very ob- stinate pains, as in nearly all obstinate chronic disorders, a gentle course of mercury has occa- sionally proved useful. (Whytt.) For the relief of those cases in which the symp- toms of phrenitis are simulated, rest, quietness, opiates, and, according to circumstances, purga- tives, and the usual means of equalising the circu- lation, will generally be found efficacious ; and stronger measures are not hastily to be resorted to. In the hysteric asthma, in addition to the ordi- nary treatment of cases in which there is much nervous irritability, the patient may take pills of equal parts of ammoniacum and squill, or of am- moniacum and assafoetida. Dr. Whytt recom- mends equal parts of the two latter in aqua pulegii. We have seen evident relief from plas- ters of assafoetida and ammoniacum applied to the chest. These cases also often require particular attention at the monthly periods, when small doses of the sulphate magnesiae, with tincture of hyoscyamus, given in the mistura camphorae, will sometimes be found to ward off threatening symp- toms. Of all forms of hysteria none are so obstinate as those attended with pain in the left side. We have not found it so constantly connected with tenderness of the spine, nor so uniformly depend- ent on uterine disorder, as Mr. Tate seems to have done. As regards all local treatment of the side itself, we believe it to be a mere waste of time ; nor can we speak with much confidence of medi- cines. We have generally found it difficult, some- times impossible, to produce proper counter-irri- tation in the side; but, on the whole, have seen more advantage gained from repeated applications of the tartar-emetic ointment to the spine than from any other means. After many trials, we prefer using ointment of the strength of a drachm of the antimonium tartarizatum to gii, or giii, of cerate ; one application, the part being previously sponged with hot vinegar, being often sufficient to produce numerous small pustules, by the re- peated evocation of which we have thought the patient much more benefited than by the same counter-irritant applied as a plaster or in any other degree of strength. In our experience, the advantage derived by the patient from the use of this ointment is not generally increased in pro- portion to the suffering it occasions. Leeches, and a succession of small blisters to the spine, are sometimes still more serviceable than the ointment. These cases are very unsatisfactory. The pa- tient sometimes continues an invalid for one or two years, and at length recovers without appear- ing to be under much obligation to medicine ; or sinks into a state of atrophy, hardly able to take any nourishment, a prey to every morbid feeling, and a burden to herself and to all about her.* * For an extreme example, see Dr. Bright's Reports of Cases, vol. ii. The tenderness of the dorsal spine and the pain about the sacrum have been accurately pointed out by Mr. Tate, who has also given some very striking cases in which relief followed his practice in them. Dr. Darwall had previously called the attention of the profession to the tenderness and spinal irritation, and Mr. Griffin has published some interesting cases of it in the London Medi- cal and Physical Journal. Mr. Tate apprehends that the accompanying pain in the side is seated in the intercostal nerve ; although he says he has sometimes thought it must be situated in the nerves of the heart itself. The right side, how- ever, is occasionally the seat of suffering; and we have not observed that the pain, even when in the left side, was often attended with palpitation : a sense of weight is very commonly complained of. We have proposed acupuncturation with sanguine expectations of success, which have ended in dis- appointment. In one case we noticed complete relief ensuing on the coming out of a vesicular eruption in the situation of the pain, and in an- other on the appearance of an ovoid tumour, which subsequently subsided without suppuration. Dr. Whytt, to prove that " complaints of the nervous or hysteric kind often proceed from some morbid humour in the blood," adduces cases in which " an itching between the toes, red pustules appearing on the breast and belly, or some other cutaneous eruption," produced relief. (Op. cit. chap, iv.) Much of the difficulty in these pecu- liar cases arises from the morbid state of the pa- tient's mind : she supposes that she cannot walk or move, or bear the shower-bath and other means; and the kind attentions which it would be inhu- manity to withhold from such apparent afflictions seem to make them more intractable. Hysterical palpitation is often almost instanta- neously relieved by the valerian, or yields to its more continued use. The danger of repeated bleedings in these cases is extreme, or, at least, the mischief thus induced is incurable. The hys- terical diabetes will probably be best treated by opium, blisters, or plasters to the loins, flannel worn next the skin, and other parts of the general treatment: spurious symptoms of calculus in the ureters will yield to anodynes and laxative ene- mata ; and attention to the state of the bowels and surface will best keep off the attacks. The great violence of the pain in these cases sometimes leads the practitioner to use the lancet and other means, which are generally superfluous and often very detrimental to the patient. In the mutable cases, in which various diseases seem to succeed to each other with rapidity, each new aspect of the malady may require new re- sources ; but the general principles of treatment must be kept steadily in view. We have not spoken in this article of electri- city, galvanism, or electro-galvanism, agents which have occasionally been employed in the cure of hysteria ; we fear that their application has hith- erto done little more than prove the inveteracy of some forms of the disorder. (See Electbjcitj and Galvanism.) It may here be observed that hysterical women are very generally disqualified for being good nurses. Sometimes the performance of that func tion may be serviceable to them, but they generallj 588 HYSTERIA. perform it inefficiently ; their liability to feel all impressions too keenly, and the violent agitations of feeling and temper which belong to them, operating unfavourably on the secretion of milk, and causing disturbance in the child's bowels, and perhaps in its nervous system. No part of pathology or practice is more un- satisfactory in its present state, or at the same time more promising of future results, than that which relates to the conditions of the blood. If any cases of hysteria could be clearly traced to peculiar states of that fluid, productive of nervous irritation, the object of our treatment would of course be to effect an alteration in it. The means of doing so would be the regulation of diet, the improvement of the digestion, attention to any function obviously deranged, and a careful general regimen. The effects which have ensued in some recent experiments in which saline substances have been directly injected into the veins, would seem to point to very important results. And if the practitioners residing at watering-places had been less satisfied with general assertions of the universal virtues of the mineral waters of their respective localities, and more observant of the actual operation of these serviceable agents in chronic maladies, reasons might have been found for ascribing some part of the benefit derived from them to their effects on the circulating fluids rather than on the bowels, effects which have long been admitted in the case of the chalybeates, but hardly ever hinted at as regards the saline waters. We should desiderate, however, the perfect establish- ment of facts indicative of such advantage before we should be disposed to send hysterical, and fanciful, and susceptible patients to places resorted to by so many whose idleness and selfishness are their chief complaints. It is not in places devoted in an especial manner to every weak and luxurious indulgence, and in which the honours of medical science cede too often to a miserable waiting upon the caprices of spoiled adults, that we can expect hysterical females to acquire habits of bodily or of intellectual health. Preventive treatment. — When a young lady has had an hysterical attack of some severity, much anxiety is commonly felt to prevent a recur- rence of it; and this may in the generality of cases be thus early prevented by proper attention to the causes which appeared to bring on the attack, and to any peculiarity in the state of her health which has predisposed to it. Where there has been no severe and marked paroxysm, and yet many of the peculiarities of the hysterical temperament exist, the preventive treatment is too often neglected, whilst in the examples in which it assumes peculiar and embarrassing forms, the nature of the disorder is often misunderstood, or, after very insufficient trials, medical and moral means of relief are abandoned. A careful education may undoubtedly prevent the increase of a susceptibility observed to be na- turally too intense; but, although it would be easy to lay down regulations for the accomplish- ment of so desirable a purpose, it would manifest a great want of experience in the ways and weak- nesses of mankind to expect such regulations to be followed with much perseverance. As regards schools, however, it is but just to acknowledge that of late years much more attention has been paid to allowing hours for relaxation and exercise than formerly. Yet the exctcises of ladies' schools are often absurdly enough ordered; the natural amusements of running, leaping, and playing at various active games in the open air being con- sidered ungenteel, and, by a strange inconsistency, the rigid positions of the drill serjeant, the fixed distortion and torture of the feet in stocks, as in- culcated by dancing mistresses, the difficult poises and attitudes of a system which is termed calis- thenic, and sometimes the exercises of tumblers, the climbing of ropes, and the rubbing of tables, are among the approved means of avoiding at once both deformity and the vulgarity of rude and boisterous health. Meanwhile, the nature of their studies is such as hardly to merit the name of mental cultivation. Ostentatious efforts are made to crowd the elements of many accomplishments into a few years, and if the young lady is not afterwards finished by those who profess to instil taste as well as art, and who succeed in effacing all natural and simple tastes and traits of charac- ter, she commonly remains unskilled even in accomplishments ; whilst the want of all love of literature or acquaintance with science, and con- sequently of all companionable qualities of a higher kind, diffuses an ennui over society that every one feels without thinking of its source, and by which the whole moveable community is driven about from one place of public resort to another, without useful objects, without attach- ments, without duties; leading to the habitual neglect of all self-government and the creation of much domestic wretchedness. After the confine- ment of school, the young female is introduced into fashionable life, and exposed to numerous causes of debilitated health. Returning for a few seasons to London blooming from the coast or the country, she leaves town in June the shadow of herself, often bearing in her countenance not only the marks of dissipation, but of expectations disappointed, wounded pride, and a disposition from which all the attractive frankness of youth has been carefully rooted out. Then, perhaps, ensue the mortifications of celibacy, and the mis- ery of growing old without an active and con- tented mind. Concerning the evil effects of these and many other circumstances, the physician may feel a thorough conviction, but as the circumstances are not much within his control, it would be use- less to dwell upon them in the present article. As causes of disease, and especially of hysterical and other various disorders, none will deny their wide and powerful influence but those who have paid no reflection to the operation of human pas- sions in society. From the circles of nobility these follies flow to the families of the country gentry, and from them to the upper ranks of country towns, whose inferiors of every degree imitate them as well as their daily necessities will permit. The dictates of health, of reason, of happiness, are lost in the love of false greatness and over-refinement which hangs over empires devoted to decay. But against such habits it avails little to protest; the physician cannot ob viate them, nor are they " curable by any herbs." He may, however, often with more success devote some portion of his care to the preservation ICHTH of a healthy body. If every function is well per- formed, the nervous system will, it is probable, soon become freed from the morbid susceptibility which disposes the young female on receiving any slight impression to the irregular actions of hys- teria. It has so often been found useful in chronic disorders of an obstinate nature to place the pa- tient in new circumstances, and thus to change the whole series of impressions to which she is exposed, that this resource should not be over- looked. With this intention the hours of rising and taking food, the times of exercise and rest, the nature of the mental occupations and of the bodily exercises, should no longer be the same as customary. Change of scene, change of climate, change of manner of clothing, may all form parts of such a plan. So many of these changes are ef- fected at once by a removal to a watering-place, or to the sea, that the advantage of such a change may overbalance all other considerations, and be advised with great propriety. Nor should it be forgotten that the different parts of what is called an alterative treatment often induce most important changes by slow operations, seemingly effected in the actions or condition of the nervous or vascular systems, or wrought upon less obvious sources of continued malady, existing perhaps in the secretory pro- cesses. (See Alteratives.) By the means now enumerated, numerous, as always happens in diseases little obedient to the healing art, and requiring consequently much dis- crimination in the practitioner who employs them, there is no doubt that many cases of hysteria may be completely cured, and that almost all cases may be more or less relieved. The constitutional sus- ceptibility in some instances of the disorder is so great that relief is all that can be effected, and the protracted character of the malady often leads to its being too soon withdrawn from the care of the physician. Where this is not the case, we believe the failure of the treatment is generally to be ascribed to a want of patience, an insufficient employment of the various resources which we possess, or a want of conformity and perseverance on the part of the patient herself. Even a palliative treatment, if nothing more can be immediately promised, should not be dis- regarded either by the patient or practitioner, it being unquestionably true, as Dr. Whytt has re- marked, that " long-continued palliation may sometimes make a cure; for while the palliative remedies lessen the bad effects of this disorder of the nerves, nature, either by herself or with their assistance, at length expels or subdues the morbid cause." The practical wisdom of this observa- tion may be remembered with advantage in the treatment of all chronic disease. We have dwelt longer on the affections united under the name of hysteria than we should have done if we did not know that it is always a pecu- liar disadvantage'to the practitioner to decide, or to be expected to decide, at once upon a plan of treatment of which the immediate effects are to be observable in each hysterical case. It seemed to us that their proper treatment might be facilitated by considering them with reference to their various origin and complications somewhat more closely than had before been done. The best chance of 2x YOSIS. 589 effecting a perfect cure in any case will depend on the deliberation with which all the circumstances connected with it are considered : the origin, the causes, the duration of the malady, and the present state of the patient, well and duly reflected upon, will usually lead to means of eventual relief, to which hasty and presumptuous prescription can seldom or never attain. J. CONOLLY. ICHTHYOSIS, (Syn. Lepra ichthyosis, (Sauv.;) Lepidosis ichthyosis (Young, Good,-) (from Ix^isi a fish,) fishskin, a cutaneous disease, named from its supposed resemblance to the skin of a fish. In our opinion, Willan and Bateman have erred in classing it in the order Squamae, as it has a much nearer affinity to the papular than to the scaly eruptions. It is characterized by a harsh, papillary, or horny condition of the skin. In other instances, the papillae are elongated into horny peduncles bearing a broad irregular top. Whatever be the cause of this morbid growth, it appears to have a close affinity to that state which produces the common wart. These excrescences frequently suffer partial exfoliation, which affords the scaly appearance that probably may have led to the present arrangement of the disease. Instead of the division of the genus into the two species, ichthyosis simplex and ichthyosis cornea, it would be more consonant with experi- ence to divide it into, 1. ichthyosis fortuita; and, 2. ichthyosis innata. In both species of the disease the eruption some- times appears on distinct portions of the body, whilst the rest of the skin retains its healthy ap- pearance ; sometimes it extends over the whole ol the surface, except the hairy scalp ; and although it is observed directly above and below the flexures of the joints, yet it seldom appears on or around the joints, or, as Dr. Bateman remarks, on the inner and upper parts of the thighs. It also rarely appears in the axillae, upon the palms of the hands, or on the soles of the feet. Species 1. Ichthyosis fortuita, (ichthyosis sim- plex of Willan and Bateman) not unfrequently affects only the extremities, and occasionally the face. The more extended form of the disease is common in children who come from India at rather a later period than usual. It rarely makes its appearance for the first time in adults, and appears to commence by a soiled appearance of the cuticle, followed by a thickened, papillary, and discoloured condition of the skin, which seems, to a casual observer, the effect of want of cleanliness. By degrees the hardness and roughness increase, so as to afford to the finger, when passed over the skin, the sensation caused by a rough file, or sha- green. The colour of the patches soon deepens to a dirty, brownish-black hue; and when care- fully examined, they are found to be composed of small pedunculated horny excrescences, closely im- pinging upon one another ; or, when the disease is general over the body, of conical horny excres- cences, the apexes of which are generally loose and separating, so as to give the appearance of being covered with dirty, coarse meal. In some instances these horny papillae are crowded in va- rious groups, following the variations of the cuti- cular lines : in other instances they form decided 590 patches, like incrustations upon the part; and when the peduncles are long, and the clothes press upon the parts, the papillae overlay one another like scales ; but in no case do they naturally assume an imbricated or scaly aspect. The patches are occasionally separated by whitish furrows; in some cases, when they are distinct, they terminate abruptly, in others they are gradu- ally lost in the healthy skin. When the face is the seat of the disease, it is usually confined to the cheeks ; but in a case mentioned by Dr. Bate- man, (Synopsis, 7th edit. p. 80,) and another, in a young lady, which came under our own care, the patches on the cheeks communicated across the nose, so as to produce the appearance of a pair of large brown spectacles laid upon the face: (Ibidem, nota.) In some instances the mammae in females have appeared completely encased in this horny covering. If the excrescences be picked off, or if they fall off when submitted to the action of the vapour of hot water, they rapidly grow again ; but, in the interim, the skin does not bear any trace of inflammation ; it appears in a healthy state until the papillae re-assume their former horny aspect. In the case of the young lady referred to, the disease, which made its appearance about the age of puberty, was preceded by consid- erable constitutional disturbance, namely, headach, disordered bowels, cold feet, and flushings of the face ; but in general no premonitory symptoms have been observed ; nor is the eruption accompa- nied with itching, tingling, or any uncomfortable feelings. The whole skin, in the more extended form of the disease, is dry, and its perspiratory function apparently impeded ; it has been sug- gested that the urine and the pulmonary exhala- tions balance the defective perspiration, and main- tain the general health of the habit. (Rayer, Maladies de la Peau, tom. ii. p. 305.) Biett men- tions that in some instances the sound or unco- vered parts of the skin perspire more than usual. Few opportunities of ascertaining the condition of the constitution or that of the skin in this dis- ease, have occurred to us ; but the few which have presented themselves Jrave confirmed the view we have given, namely, that it cannot be regarded as a scaly eruption. The chorion is found to be thicker than usual, and the furrows which tra- verse it are deeper than common; the horny pa- pillae are readily detached by maceration. But these investigations have shed very little light upon the nature of the disease. Treatment. — The obstinate nature of this eruption has in many instances resisted every plan of treatment, both local and general. With the exception of the decoction of the root of rumex obtusijblius, no internal remedy appears to have at any time produced benefit. The decoction of this dock root, made with an ounce of the sliced root and a quart of water, boiled down to a pint, and taken in doses of a fluidounce and a half twice or three times a day, purges briskly, and clears the skin in ten or twelve days ; but in cases of long continuance the eruption is likely to return. Dr. Willan strongly recommended pitch, made into pills with flour or some farinaceous matter ; the dose being gradually increased until twenty or thirty of the pills are taken in the course of the iay The pitch seems to operate by stimulating fOSIS. the capillary system, so as not only to enable the skin to throw off the patches of horny cuticle, but to restore the skin to its natural and healthy state.* Arsenic is sometimes useful on the same princi- ple ; but the experience of those who have had the best opportunities of seeing and treating the disease, affords little encouragement to prescribe it. The dock-root, the use of which was first recommended by the writer of this article, is cer- tainly the most effectual remedy which has been hitherto employed: the only objection is its dis- position to purge, which, however, can be mode- rated by the addition of ten or twelve drops of laudanum. In old cases, when the eruption returns, and is successively removed by the decoction of the dock- root, the obstinacy of the case often depends upon a state of the skin which is sometimes only to be permanently relieved by the application of blisters over the whole of the diseased surface : this was the case in the instance of the young lady al- ready mentioned. With regard to external means, almost every stimulant and detersive plaster and ointment has been tried, and each in its turn declared nugatory. The scales have been picked or shaved off, and removed in various ways, but in the greater num- ber of instances without any permanent advantage. Mr. Plumbe found the firm application of adhe- sive straps aid greatly the desquamation, if this term may be employed, of the patches; the dis- eased cuticle was softened, and might be scraped off without pain. " By persevering," says Mr. Plumbe, "in this plan, the skin gradually acquires a healthy texture." (Practical Treatise on Dis- eases of the Skin, 1st edit. p. 334.) Sulphur fumigating-baths have been found useful, and the benefit received is undoubtedly more permanent than when the common sulphureous baths of Harrowgate, or similar springs, are employed; but, nevertheless, in several instances in which we have seen the fumigating baths used, the eruption has returned after they were discontinued. What- ever applications are used, the daily employment of the warm bath, with friction whilst in the bath, and brisk exercise taken immediately afterwards, materially aids the restoration of the healthy con> dition of the skin. The bath should be used in the morning. Species 2. Ichthyosis innata.—This congeni- tal form of ichthyosis, although scarcely percepti- ble at birth, yet even at that period may be recog- nised by the skin being harsher and thicker than usual in infants, and rough when the finger is passed over it. By degrees, as the infant grows, the disease assumes its proper character. In al- most every recorded instance the disease has been hereditary. As in the fortuitous species of the disease, the rigid and scaly state of the skin ie sometimes partial, sometimes general, assuming the appearance as if the body was covered with a coat of mail. The case of the native of Suffolk, known by the name of the "Porcupine Man," and described by Mr. Baker in the forty-ninth volume of the Philosophical Transactions, is the * Dr. Willan generally ordered at first three or four five-grain pills to be taken three times a day; and the number of pills to be gradually increased until a drachm of the oitch was taken for a dose ICHTH ICHTHYOSIS — IDENTITY. 591 Dest illustration of this form of the congenital dis- ease. The face, the palms of the hands, and the soles of the feet, were the only parts free from the scaly covering. The disease appeared about two months after birth, and the scales regularly drop- ped off every winter and re-appeared in the spring. The individual enjoyed excellent health, and had six children, all of whom were covered with the same excrescences. Many other curious examples of congenital ichthyosis are to be found in the Koyal Transactions and the memoirs of the va- rious scientific societies throughout Europe; but as no means that have hitherto been tried have proved successful in restoring the healthy texture of the skin, it is unnecessary to refer to them. The ichthyosis cornea, horny fish-skin of Wil- lan and Bateman, the cornua cutanea of Plenck, (Doctrina de morbis cutaneis,) the appendices cornes of Rayer, (Maladies de la Peau, tom. ii. p. 315,) has been improperly confounded with the congenital form of ichthyosis by Bateman and Rayer; but the horny appendages constituting this affection, which cannot be regarded as a spe- lies of ichthyosis, are rarely if ever congenital, and differ in every respect from the horny papillae of ichthyosis. " They are," as Bateman expresses himself, " purely of cuticular growth, consisting of a laminated callous substance, contorted and irregular in form, and not unlike isinglass in ap- pearance and texture." In every instance they are accidental, and generally connected with some diseased growth, such as wart ; (Morgagni, de Sedibus et Causis Motborum, ep. 65, art. 2. Avi- cenno, canon, iv. fen. 7, tract, iii. cap. iv. Lorry, de Morbis Cutaneis, p. 519) : or they arise in the cavity of encysted tumours of very slow growth. Their extirpation belongs to the province of sur- gery ; the only effectual remedy being excision and the ample destruction of the surface secreting them, at an "early period. [Under the name Ichthyosis sebacea, Mr. E. Wil- son (A Practical and Theoretical Treatise on Diseases of the Skin, Amer. edit. p. 276, Philad. 1843) describes a morbid condition in quality and quantity of the secretion from the sebaceous folli- cles of the skin, which spreads upon the surface of the epidermis, forming a thin layer that dries and hardens, and breaks, in the direction of the linear markings of the skin, into small polygonal portions. These concretions increase in thickness by the accumulation of fresh sebaceous secretions, and become discoloured from exposure to dust and dirt. The small masses have the appearance of scales closely adherent to the epidermis, are hard and dense in texture, and present various degrees of thickness. The best method of treatment is to remove the scaly concretion by means of the warm bath or warm fomentations rendered moderately alkaline by subcarbonate of soda or potassa, several times repeated; after which the sebaceous glands may be excited to healthy action by frequent ablutions with warm or cold water, succeeded by brisk fric- tions with a rough towel, sea-bathing and astrin- gent lotions or ointments, composed, for example, of sulphate of copper or sulphate of zinc. Mr. Wilson (Op. cit.) states, that h\ one case of the disease he obtained much benefit from the exhibi- tion of milk of sulphur. The bowels must be kept open, and the diet be regulated.] A. T. Thomson. ICTERUS. (See Jaundice.) IDENTITY, Personal. —The question of personal identity becomes not unfrequently a mat- ter of vital importance in both civil and criminal investigations. 1. Thus it may be doubted whether a child claiming an inheritance is the same that he pre- tends or is pretended to be, as in the celebrated Douglas* or Anglesea (for the Anglesea trials see 17 and 18 Howel St. Tri. and Harg. St. Tri.) causes; or long absence of the owner of property may give rise to a similar doubt, as happened in the following instance related by Zacchias. (Quest. Med. Legal. Consilium 61.) A noble Bolognese, named A. Casali, left hia country at an early age and joined the army. He was supposed to have lost his life in the wars; but after an absence of thirty years he returned and claimed his property, which his heirs had already appropriated to themselves. Although there were some marks which appeared to identify him, yet the change in appearance was so great, that none who remembered the youth were willing to allow that this was the individual. He was arrested and imprisoned. The judges were in great doubt, and consulted Zacchias whether the human countenance could be so changed as to render it impossible to recognise the person. His opinion was in the affirmative ; in consequence of which, and because the heirs could not prove the death of Casali, the judges restored to him his name and estates. (See also Fodere, vol. i. p. 109.) Thus it might happen that the true heir would not be able to prove his right merely by failing to establish his identity; while, on the other hand, an impostor may succeed where he has no claim, merely by the force of resemblance. One of the most remarkable instances of such an occurrence is that of Martin Guerre, which came before the parliament of Toulouse in 1560. Martin Guerre had been away only eight years, when a certain Arnauld Dutille, depending on his likeness to the absent person, formed the design of taking his place, and actually took possession of the property and wife of the true Martin. Children were born of this union, and he lived in the family more than three years, with the four sisters and two brothers-in-law of Martin, without being suspected. At length, however, it became matter of trial, and three hundred witnesses were examined; thirty or forty of whom deposed that the new comer was really Martin Guerre, with whom they had been on habits of the closest inti- macy. Nearly an equal number swore that he was Arnauld Dutille; while the others were so perplexed by the resemblance between the parties that they would not venture to affirm whether the individual before them was the one or the other. The judges also were completely puzzled, and were on the point of deciding in favour of Dutille, when the arrival of the true Martin exposed the imposture; though to the last the effrontery and * See Journals of the House of Lords, and also Speechef and Arguments, &c. of the Lords of Session of Scotland in the Douglas Trial. London. 17(V7. 592 IDENTITY, impudence of Dutille led many to doubt, and even Martin himself appeared confounded ; so that the judges were still more embarrassed than before his arrival. At last, however, he was fully iden- tified and recognised by his wife and sisters. (From the Causes Celebres.) 2. Secondly, in criminal prosecutions the ques- tion has very frequently arisen, whether a prisoner is actually the person who committed the offence with which he stands charged ; or, where a pris- oner after conviction escapes and is retaken, whether he is the same person that was convicted. The same question also applies in cases of return from banishment. In connection with this branch of the subject, circumstances have frequently occurred evincing the vital importance of the accuracy which should furnish grounds of evidence; and the extreme caution by which witnesses or prosecutors should be guided in depositions. A few years since a gentleman coming into Dublin late in the evening, was stopped and robbed by a footpad. A man was arrested by the police under suspicious cir- cumstances, and, being recognised by the gentle- man, was committed to abide his trial, when he was identified by the prosecutor in the most posi- tive manner; in consequence of which he was found guilty, but, owing to previous good charac- te ecommended to mercy. In a very few days afterwards, the gentleman was surprised and hor- roi-struck at meeting on the road the man who had really robbed him. The mistake here appeared to arise from the imperfect light in which the robbery had taken place, and naturally suggests for our consideration a question which has given rise to some discus- sion, and appears to require notice here, viz. the degree of light which may be necessary to enable an observer to distinguish the features, so that the person may be afterwards identified. In a case which occurred in France in 1809, of a person shot at night, it was stated that the flash of the pistol enabled the witness to identify the features of the assassin. The possibility of this was referred to the Institute, who reported against it. Fodere, on the other hand, believes that if the persons be at a small distance from each other, and the night very dark, such an event might be by no means impossible. A case in point occurred in England in 1799. A man named Haines was indicted for maliciously and feloniously shooting at Edwards, Jones, and Dowson, Bow-street officers, on the highway. Edwards deposed that, in consequence of several robberies near Hounslow, he, together with Jones and Dowson, were employed to scour that neigh- bourhood ; and that they accordingly set off in a post-chaise on an evening in November, when they were attacked near Bedfont by two persons on horseback, one of whom stationed himself at the head of the horses, and the other went to the side of the chaise. The night was dark ; but he swore that, from the flash of the pistols, he could distinctly see that the man rode a dark-brown horse between thirteen and fourteen hands high, af a very remarkable shape, having a square head and very thick shoulders ; and altogether such that he could pick him out of fifty horses: he had afterwards recognised the horse. He also per- ceived, by the same flash of light, that the man at the chaise-door had on a rough-shag brown great coat. A lady, a patient of the writer, lately told him that on one occasion, on her passage from India, she awoke in the middle of the night and heard some one stirring in her cabin, but could see no- thing, it being quite dark; when suddenly the cabin was so completely illuminated by a flash of light- ning, that she could see distinctly a man rummag- ing one of her trunks, and discerned his features so accurately that she identified him next morn- ing ; some of the stolen things were found upon him, and he subsequently acknowledged the fact. We were once present at a trial when a witness swore that the prisoner at the bar was one of a party who attacked and burnt his house, and that he saw him, at a distance of more than ten yards, in the act of putting a burning coal into the thatch; the night being so bright that he could distinctly recognise his features at that distance. This occurred in the middle of December. Sub- sequently, a gentleman of undoubted veracity swore that he recollected the night of the attack, and that it was so dark that he could not see his horse's head as he rode along ! On reference to the almanack, it was found that the moon was at the time in her last quarter. The extraordinary resemblance which is occa- sionally observed between two individuals fur- nishes another ground for extreme caution in swearing to the identity of a prisoner not abso- lutely taken in ipso facto. At the Old Bailey in 1822, Joseph Redman was indicted for assaulting and robbing Wm. Brown. The prosecutor, on his cross-examina- tion, stated that he knew a man named Green- wood, who, with his hat on, so much resembled the prisoner that he should hardly know one from the other ; Greenwood was in custody, and was brought to the bar, when the extreme similarity between the two men struck every one present with astonishment. Redman proved an alibi, and the jury returned a verdict of not guilty. The case of the Perreaus was a remarkable illustration of this fact. Daniel and Robert Per- reau were twin brothers, and in 1775 were tried and executed for a forgery on Mr. Adair. So great was the resemblance between them, that Mr. Watson, a money scrivener, who had drawn eight bonds by order of one or other of the brothers, hesitated to fix upon either ; but being pressed to make a positive declaration, he at length fixed upon Daniel. The name of these unfortunate men is familiar to the public from the well-known exclamation of George III., when asked to pardon Dr. Dodd,—" If I save Dodd, I shall have mur- dered the Perreaus." A very remarkable instance of personal resem- blance was for some years under our own obser- vation in the sons of a poor peasant. They were twins, and so much alike, that one of them, who was very wild, used frequently to bribe his brother to change clothes with him, and go home to take a beating in his place ; the father having no other means of distinguishing them except by their dress. An individual was indicted and tried at New York in 1804 on a charge of bigamy, and the IDENTITY. 593 whole evidence turned on the question of his iden- tity. He was called Thomas Hoag by the public prosecutor, but stated himself to be Joseph Parker. Several witnesses swore that he was Thomas Hoagi among whom was a female that he had married and deserted. It was stated that Hoag had a scar on his forehead, a small mark on his neck, and that his speech was quick and lisping. All these peculiarities were found on the prisoner. Two witnesses deposed that Hoag had a scar under his foot, occasioned by his treading upon a drawing- knife, and that this scar was easy to be seen, and had been seen by them. On examining his feet in open court, no scar was to be found on either of them; and it was further proved, that at the time of his alleged courtship of his second wife in Westchester county, he was doing duty as a watch- man in the city of New York. The jury acquitted him. (Beck's Medical Jurisprudence, p. 223.) 3. We must not omit to mention the necessity that occasionally occurs for identifying the dead, as in cases of murder, accidental death, exhumed bodies, &c, cases which not unfrequently present themselves under very embarrassing circumstances. In January 1817, the body of a woman was found tied to a boat near Greenwich Hospital, and an inquest was accordingly held, but adjourned on account of vague evidence. At the second sitting an old man declared the deceased to be his daughter, who had been the wife of an out-pensioner, and between whom and her husband a fight had taken place with sharp instruments in his presence ; that soon after both parties left his house, and he had not heard of them since. Other witnesses also supported the statement that it was the body of the old man's daughter. A second adjournment took place. The constables in the mean time had sought in vain for the husband, but they found the wife alive, and she was produced accordingly. The coroner reprimanded the witnesses, though the strong likeness between the living and" the dead woman was allowed to be sufficient to impose on even better judges. (Smith's Principles of Forensic Medicine, p. 500.) In swearing to the identity of a dead person, witnesses should be very cautious how they assume any except indelible marks as a means of recog- nition, because so complete an alteration takes place in the features and general appearance soon after death as to deceive even the nearest relatives. A trial took place some years ago in Edinburgh, which illustrates satisfactorily this part of our sub- ject. A prosecution was instituted against four medical students for exhuming the body of a lady. The body was so disfigured that it could not be identified by the friends; the ovaries were, how- ever, examined, and it was reported that there was found in one of them a perfect corpus luteum, which would be sufficient to prove that the remains were not those of the lady in question, who was a virgin, and advanced in years. On the trial there was a total contradiction between the medical witnesses as to the corpus luteum, but the body was afterwards identified by a dentist who produced a cast of the gums which he had taken before death. Even under circumstances apparently less diffi- cult, great doubt may exist as to identity. A re- surrection man was lately tried before the high court of justiciary in Edinburgh for raising the Vol. II. —75 2z* body of a young woman from the church-yard of Stirling. Nine weeks after death, the body was discovered and identified by all the relations, not only by the features, but by a mark which they believed could not be mistaken, she being lame of the left leg, which was shorter than the right. There was a good deal of curious swearing as to the length of time after death that the body could be recognised, but the jury was convinced that the libel was proven, and gave a verdict accordingly. " Now, I am certain," adds the relater (see Beck's Elements of Medical Jurisprudence, p. 223, note, signed Dunlop,) of this case, " that this was not the body of the woman who was taken from the church-yard of Stirling, but one that, at least six weeks after the time libelled, was buried in the church-yard of Falkirk, from which she was taken by this man, who also had taken the other, for which he was tried ; she also was lame of the left leg: thus, though guilty of the offence laid to his charge, he was found guilty by a mistake of the corpus delicti." 4. From the foregoing cases may be collected a general view of the facts or circumstances likely to engage the attention of a witness, or a court, in cases where the identity of an individual may be doubted or disputed, and of the circumspection necessary in giving testimony on such a subject; in doing which we ought always to keep in view the following considerations, at least. Seeing the great resemblance that may exist be- tween different persons, we should hardly ever, after a lapse of any considerable time, trust to our mere recollection of external form or peculiarity of features, except we are able to connect these with some indelible or unalterable mark, such as naevi, cicatrices produced by disease or operations, congenital malformations; with reference to which object it would be very desirable that, medical men practising midwifery should in all cases note down along with the other circumstances of time of birth, &c, any bodily peculiarity of the infant by which it might afterwards be recognised. We once de- tected by this means an attempt at substitution of a child, which would otherwise have certainly succeeded. We should remember and make allowance for the great alteration that may be made in the person and countenance by the mere lapse of time, es- pecially at the season of life when youth is ma- tured into manhood, and by altered habite. When the brethren of Joseph stood before him, " they knew him not." If to time be added the effects of a hot or very cold climate, or disease, the pres- sure of mental anxiety or bodily hardship, the ef fects are still more striking: Danger, long travel, want or woe Soon change the form that best we know ; For deadly fear can time outgo, And blanch at once the hair ; Hard toil can roughen form and face, And want can quench the eye's bright grace, Nor does old age a wrinkle trace, • More deeply than despair. Scott's Marmion [My hair is grey, but not with years, Nor grew it white in a single night. As men's have grown from sudden fears. Bvron. The change in the colour of the hair thus re- ferred to might give occasion to a question of 594 IMPETIGO. identity. It has likewise become a question, whe- ther it is possible to change the colour of the hair by any physical agency. A case which occurred in Paris in 1832, gave occasion to some careful experiments by Orfila (Traite de Med. Leg. i. 127, 142), and by Devergie (Medecine Legale, 2de edit. ii. 536, Paris, 1840,) in order to discover what changes could be induced in the hair by chemical agents : and they have given various methods by which a change from light to dark and conversely may be accomplished. (See, also, Guy, Principles of Forensic Medicine, Pt. I, p. 20, Lond. 1843.)] The return of Ulysses, and his rejection from his own halls, unknown by all, and recognised by his faithful dog alone, although probably no more than a poet's fiction, has been realized in more in- stances than that of Casali. In conclusion, it appears to us that in the case of a person seeking to establish a claim by proving his identity, a more certain mode of examination would be to question the person himself as to his knowledge of facts, however trifling in themselves, but of which he must have had cognizance if really the person he pretends. W. F. Montgomery. [IDIOCY. (See Insanity.)] IMPETIGO, humidor running tetter,* (from impeto, to infest,) is a non-contagious, pustular affection of the skin, terminating in thick lamel- lated scabs or thin scaly crusts. Willan and Bateman, who are followed by Biett and Rayer, enumerate five species of impetigo; but in our opinion there are only two distinct species, the one unattended by febrile symptoms, the other preceded by them ; the first three forms of impe- tigo may be ranked as varieties. We therefore propose the following arrangement: Spec. 1. Impetigo simplex. Var. a. Impetigo figurata. b. Impetigo sparsa. c. Impetigo scabida. 2. Impetigo erysipelatodes. The first of these species (impetigo simplex) appears generally without any obvious premoni- tory symptoms, attacks chiefly the young, and those of a lymphatic temperament; and displays itself in clusters and groups of psydracious, or irre- gular, slightly elevated, small pustules, which, after discharging their contents, continue to exude a thin, acrid ichor, accompanied with much itch- ing, or rather stinging, and a sensation of heat. This discharge concretes into thin, yellowish, semidiaphanous scabs, which turn up at the edges, so as to allow the discharge to ooze from under them. The disease is frequently chronic, or kept up by successive eruptions of the groups of pus- tules. The two first varieties of this species are founded on the manner in which these patches of eruption appear; whether large, circumscribed, oval, or some other regular figure ; or small, dis- seminated, and assuming no peculiar form : the third variety is distinguished by forming one con- tinuous crust over the affected part. * Syn Lepra squammosa (auctor var.); kouba (Jlvi- cenna); ecphlysis impetigo (Oood); phlysis impetigo {Young); dartre crustacee (Fr.); der Kleienausatz (Ger- man); cowrap {Javanese); herez (Arabic). Impetigo figurata. This variety of simple im- petigo generally occupies the face, appearing most frequently on the cheeks, the chin, the sides of the nose and margin of the nostrils: the extremities, particularly the hands, are often the seat of the eruption; it occasionally, also, appears upon the trunk of the body. Although, in general, this variety occurs without any obvious diseased state of the general habit, yet it occasionally follows much mental anxiety, or other depressing affec- tions of the mind, in which case it is accompanied with cardialgia and uneasiness of the stomach, with a sensation of weariness of the limbs, and other indications of low febrile disturbance. At first the patches are small, distinct, red spots, which itch considerably : in a short time, how- ever, they enlarge and are covered with minute yellow psydracious pustules, closely crowded so as to be almost confluent, and surrounded by a red inflamed border. The pustules are flat, and are the source of much heat and stinging pains. In a few days they burst, and discharge their con- tents ; the pus drying and changing into thin semi-transparent crusts, which characterize this species of impetigo; sometimes, however, the scab is thicker and not unlike " the exudation of gum on a cherry-tree." (Rayer, Traite Theorique et Pratique, torn. i. p. 474.) If the scabs fall or are rubbed off, the surface appears red, excoriated, shining as if stretched, and exhibiting minute pores from which an ichorous discharge exudes, which greatly augments the heat and smarting. On the margin of these diseased patches, unbroken psydracious pustules may be observed. When the disease is not perpetuated by successive erup- tions, the crusts gradually dry, and remain nearly stationary for two or three weeks, the itching, heat, and smarting gradually diminishing; they then fall off, leaving the surface red, stretched and shin- ing, and the cuticle so thin as to be liable to ex- coriation from the slightest friction. More fre- quently, however, the ichorous discharge is repro- duced, accompanied with fresh crops of psydra- cious pustules; and the eruption is thus repeatedly renewed and runs its whole course; continuing for many months, sometimes for years. When the disease yields either spontaneously or to the influence of medicine, the amendment is first per- ceptible in the centre of the patches; and some- times, even when this occurs, the border not only retains its diseased character, but fresh pustules show themselves : as the cure proceeds, however, these also gradually disappear, and the whole skin acquires its natural aspect, except that it is co- vered with minute scales, which are reproduced for an indefinite time, more or less protracted accord- ing to the severity of the previous disease. This variety of impetigo simplex does not al- ways preserve the uniform course which has been described. Sometimes the patches enlarge by successive marginal crops; this is particularly the case when they appear on the legs, which are thus often gradually covered from above the knee to the instep. In some instances, the pustules are intermixed with transparent vesicles, not unlike those of some of the varieties of herpes; indeed there seems to be some affinity between the causes of herpes and impetigo; as the two diseases oc- casionally appear simultaneously on the same in- IMPE TIGO. 595 dividual. We have at present a case of severe herpes zona under treatment, in a man who has Bcarcely recovered from a protracted attack of im- petigo sparsa. When these vesicles break, the ichor which they pour out is much more acrimo- nious than that of the pustules : wherever it touches the sound skin, inflammation and a crop of vesicles or psydracious pustules follows. The vesicles appear in tardy succession, and are slower in their progress than the psydracia: when broken, they are little disposed to heal; and the constant irritation of the ichor inflames the cuticle, thick- ens it, and covers it with small ulcers. In this state of the disease the burning sensation and itching are extremely distressing, and much in- creased by friction, or any source of irritation, or even any application, however emollient. Impetigo sparsa differs from the former variety chiefly in the irregular and scattered distribution of the pustules : these appear in small groups, dispersed without any regular order in the ex- tremities, about the neck and shoulders, and oc- casionally on the face, the ears, and scalp. They run the same course as those of impetigo figurata, but the scabs which succeed the bursting of the pustules are thicker, more friable, and do not form in so large plates as the former variety : the sur- rounding inflammation is, however, more exten- sive, and they oftener terminate in ulceration, interspersed with fissures, (See Atlas of Delinea- tions of Cutaneous Eruptions, pi. xv.), and not unfrequently are accompanied with oedema. Impetigo scabida of Willan and Bateman (Practical Synopsis, 7th edit. p. 222) is merely a more severe form of the last variety. It commonly appears on the legs; and the pustules are so nu- merous, and discharge so abundantly, that the greater part of the limb becomes incased in a yel- low crust, variously divided by deep fissures, and not unlike the bark of a tree. When it extends over the joints, the movements of the limb become difficult and painful; and the heat, itching and tingling are greater than in either of the former varieties. When any portion of this crust spon- laneously separates, or when it is removed, the vacuity is quickly filled up by the copious dis- charge poured out from the excoriated surface ; the limb generally swells, and if the eruption ex- tend to the toes, the nails drop off, and the new ones are thick, irregular in their form, and notched. The causes of these varieties of the simple im- petigo are very obscure. There seems to be a peculiar predisposition to the disease connected with the sanguine or the sanguineo-melancholic temperament, with a thin lax state of cuticle. We have already stated that impetigo figurata is some- times preceded by gastric derangements, languor, and headach; and this is true of the other varie- ties; but more generally it cannot be traced to any derangement of the digestive function. In the predisposed, however, it has been observed to follow violent exercise, intemperance, or the use of tainted animal food ; and, like some other cuta- neous eruptions, it has been traced to mental agi- tation and to sudden causes of depression, such as disappointment, grief, and fear ; (Med. Trans. * »ol. i. art. 2. Med. Obs. and Inq. vol. i. art. 19. t Pract. Synopsis, 7th edit. p. 214, nota); and oc- ' casionally to exposure to cold. The first variety in particular seems, also, to be connected with an irritable condition of the system, such as accom- panies dentition in infants, and the appearance of the catamenia in women. The third variety does not appear to be influenced by the changes of season, but the first is liable to recur in the spring, and the second in the autumn, often continuing through the winter and disappearing in summer. Some external irritants acting upon the skin produce pustular tetters closely resembling those of impetigo sparsa ; in this way the eruptions termed grocer's and bricklayer's itch are produced; the former arising from the acrid stimulus of raw sugar, the latter from that of lime, acting on the hands and arms of those who are constantly hand- ling these substances. In both cases the disease is readily distinguished from scabies; it is not contagious, and soon disappears when the sources of irritation are removed. Bateman regards the pustular eruption arising from the application of tartar-emetic, and various stimulating plasters to the skin, as displaying some affinity to impetigo; but the pustules are of a very different character, distinct, elevated, and seated on a hard inflamed base, which is never the case in any of the va- rieties of this eruption. Diagnosis*—The foregoing varieties of impe- tigo may be confounded with several other cuta- neous affections, but attention to two or three of the most obvious characters common to all the varieties furnishes us with the means of forming a correct diagnosis. Thus the nature of the crusts distinguishes impetigo from eczema, which is, be- sides, a vesicular disease ; and from porrigo larvalis and favosa. Impetigo figurata appearing on the face may be recognised also by the character of the crusts, which are thick, soft, and cellular in porrigo, and do not discharge thin ichor, but thick glutinous pus. The hard inflamed base of the pustules of ecthyma prevents impetigo from being confounded with that eruption ; and although, in its advanced stage, impetigo is frequently mistaken for lepra and psoriasis, yet the diagnosis is not ob- scure, if we discriminate between the scaly exfo- liations of the latter and the laminated crusts of the former, or the ichorous discharge of the pus- tules of impetigo, and the complete absence of all fluid discharge in lepra and psoriasis. Between impetigo and scabies the diagnosis is not more difficult : the distribution of the eruption in patches; the copious discharge of ichor; the rough and fissured cuticle ; and the heat and tingling which accompany the itching impetigo, are sufficient guides for recognizing the disease It is more likely to be mistaken for some of the syphilitic scabby eruptions, especially when these appear on the face. A case of this kind is men- tioned as having occurred under M. Biett, in the hospital of Saint Louis, and having been treated for some time as impetigo figurata,- but the na- ture of the scabs, which are large, black, thick, very adherent, resting upon a violet-coloured base, and when separated, leaving deep ulcerations, with the regular, circular form of the eruption, are generally sufficient to distinguish this syphilitic eruption from impetigo. Prognosis.—The only circumstance to be at- tended to in the prognosis of impetigo is the dis- position the eruption always shows to recur : it is 590 IMPETIGO. more likely to prove obstinate in old people, and in weakened states of the system, than in the young and robust; but under no circumstances can it be regarded as a fatal disease. Treatment.—The same treatment is applica- ble to all the varieties of simple impetigo. The internal administration of sulphur, either alone or combined with soda, nitre, and the bi-tartrate of potassa, is strongly recommended by Willan and Bateman in the commencement of the disease; but our experience leads us to agree with MM. Cazenave and Schedel, that the preparations of sulphur have been too indiscriminately employed, and that they have frequently proved hurtful, ag- gravating the symptoms, and favouring the dispo- sition of the eruption to re-appear. The sedative and cooling influence of conium in the common effervescing mixture, with the aid of emollient fo- mentations, or even of simple tepid water, consti- tute the best and most efficient means in the inci- pient stage of any of the three varieties which have been described. In cases of impetigo figurata ex- tending over a considerable portion of the skin, particularly when it attacks the face, M. Biett re- commends moderate bloodletting, either local or general; we have never ordered either, and indeed cannot exactly conceive how the abstraction of blood is likely to prove useful. When fever ac- companies the eruption, we have found no diffi- culty in controlling it by antimonials and calo- mel. If simple impetigo proves obstinate, an altera- tive course of mercurials, either hydrargyrum cum cretEi or Plummer's pill, with sarsaparilla or de- coction of cinchona bark, is generally supposed to be indispensable; but we have found the occasional administration of five or six grains of calomel at bed-time, followed by a brisk cathartic next morn- ing, and the arsenical solution given in the decoc- tion of elm-bark three times a day, more benefi- cial. In many habits, indeed, the skin is peculiarly sensitive to the stimulus of mercury, whether in- ternally administered or applied to the surface; in these cases in particular, mercurial alteratives prove hurtful. Every description of local appli- cation has at one time or another been employed in impetigo ; in some cases even the most soothing and emollient cannot be endured; in others the most stimulant have been applied with advantage. When the discharge is profuse, ointments prepared either with the oxide of zinc, or the white precipi- tate of mercury, or the sub-acetate of lead, have been found most useful in moderating the quantity of the discharge, and allaying the irritation. In a drier and less irritable state of the eruption, the ointment of the nitrate of mercury diluted with six or seven parts of lard or of simple ointment, or the tar ointment, will be found advantageous in securing a more healthy surface when the crusts separate. We have also seen an ointment formed by triturating two drachms of subnitrate of bis- muth with an ounce of simple ointment very ser- viceable in this condition of the eruption. In the hickly encrusted state of the limbs, in impetigo scabida, no local application will prove beneficial until the incrustations are removed, which is best effected by poultices, or by exposing the limb to the vapour of hot water ; after the crusts are re- moved, the surface should be covered with pledgets of lint, thickly covered with any of the mild oint ments above mentioned, or touching the whole with a solution of nitrate of silver. In many instances the irritation is scarcely sup- portable : in such cases we suggested, some years ago, the use of the hydrocyanic acid, in the pro- portion of half a fluidrachm to two fluidounces of water, with half a drachm of alcohol, and two or three grains of acetate of lead, as a lotion which not only soothes the irritation, but disposes th» skin to regain its healthy action : subsequent ex perience has sufficiently established the value of this application. It is proper, however, to men tion that Mr. Plumbe met with two cases in which its application was followed by considerable inter- mission of the pulse, which ceased on discontinu- ing the use of the lotion ; but in these cases both legs were affected, and the lotion was consequently most extensively applied, which may in some de- gree account for the effect it produced. We have never met with any unpleasant result, although we have most extensively employed this form of lotion. In very obstinate chronic cases of impetigo, the baths of Harrowgate, or the artificial sulphur fu- migating baths, generally prove effectual, not only in clearing away the eruption, but likewise in pre- venting its return. With the same view the wa- ters of Bareges, Enghien, Bonnes, and some other of the continental springs, and also the warm sea- water bath, followed by a course of sea-bathing, have proved highly beneficial. In every stage of the disease, the advantage to be anticipated from any plan of treatment depends much on the dis- crimination of the practitioner. In cases accom- panied with much irritability of surface, the inter- nal mea.is should be of a sedative kind ; and local applications, with the exception of tepid water, should be wholly abstained from, until some abate- ment of the irritability admits of the employment of the hydrocyanic acid lotion. In the opposite condition of the disease, the moderately stimulant ointments, with the internal employment of the arsenical solution, will be found the most effectual mode of treating these forms of this troublesome disease. [A solution of creasote (f.gss. ad aquae f.§v.) has been found successful; or an ointment of the same (f.^ss. ad adipis %i.) may be used. (Medi- cinisch. Zeitung, Nov. 30, 1834, cited in the author's New Remedies, 4th edit p. 217, Philad. 1843.)] Under all circumstances the diet of the patient should be milk and farinaceous matters, with a very moderate proportion of animal food once a day ; wine, spirits, and every description of fer- mented liquor, must be sedulously avoided. Impetigo erysipelatodes, the second species of this eruptive disease, closely resembles, in its com- mencement, the ordinary appearances of erysipe- las, with slight febrile symptoms, which are fol- lowed by a puffy swelling of the upper part of the face, accompanied with redness and an cedematous state of the eyelids. The inflamed surface, on close examination and running the finger over it, appears papular, and in a day or two it becomes covered with psydracious pustules, that break and discharge a hot acrid fluid, which irritates and often excoriates the sound surface on which it IMPETIGO —IMPOTENCE. 597 flows. This state of the eruption, which often covers the greater part of the face, and extends to the neck and chest, is attended with the same heat, itching, and tingling, that accompanies the varieties of simple impetigo; it continues in this condition for some days, the discharge, as it diminishes, concreting and forming thin yellow scabs, in the interstices between which fresh pus- tules appear, and run the course already described. The disease continues for an uncertain period, sometimes for two or three months, and, in disap- pearing, it leaves the skin red, shining, and in the dry brittle state which follows the other varieties of impetigo. This form of impetigo is liable to be confound- ed with eczema impetiginodes in the commence- ment, even by those acquainted with both dis- eases; in the advanced stage, however, the pustular form of the eruption sufficiently charac- terizes it. In some instances of the impetiginous eczema, a few psydracious pustules may be ob- served intermingled with its vesicles, but the latter greatly prevail. Treatment.—The febrile symptoms which pre- cede this eruption indicate the necessity of anti- phlogistic measures in the commencement. Saline purgatives, with antimonials and nitre, generally alleviate the fever, after which decoction of cin- chona bark, acidulated either with muriatic or dilu- ted sulphuric acid, may be administered with advan- tage. When the after stage of the disease proves particularly troublesome, and runs on for two or three months, a slight alterative course with sar- saparilla generally succeeds in completing the cure; or when it can be obtained, much benefit is derived from sea-bathing, or a course of Har- rowgate water. As local applications, nothing farther is required than tepid ablution, and guard- ing the excoriated surfaces with the ointment of oxide of zinc. [In some troublesome affections of the skin, especially of the hands, conjoining the characters of impetigo with erysipelatous redness and swell- ing, and inducing most intense suffering, the tex- tures were speedily restored to a healthy condition by the external use of cod-liver oil—oleum jecoris aselli—after all other remedies had been tried in vain. (Dr. M. Hall, Lond. Med. Gaz., Sept. 1832.)] With respect to a supposed species of impetigo described by Willan and Bateman, under the title impetigo rodens, we have never seen the disease, and aie rather disposed to regard it as a variety of malignant ulcer, complicated with psydracia. A. T. Thomson. IMPOTENCE.—Impotence or the incapacity of sexual intercourse, and sterility or the inability of procreation without loss of the power of copu- lation, are subjects which require to be considered, first as physiological questions, involving the con- sideration of all the causes temporary as well as permanent from which these defects may arise; and secondly, as a medico-legal subject, forming disqualifications for the matrimonial state, or affording pleas in exculpation of alleged rape or affiliation. Impotence may exist either in the male or female; it is, however, most commonly found in the male, as from the nature and conformation of the genital organs in the female, physical im- pediments to coition more rarely occur, and she is generally enabled to admit the venereal congress at least in a passive manner. Sterility, on the other hand, is nearly confined to the female, for if the male be capable of accomplishing the act of coition, including of course the ejaculatio seminis, no farther question as to his virility can arise. The causes of impotence may be divided into three classes : 1. organic ; 2. functional ; 3. moral. In the human species, as in all the warm-blooded vertebrated animals, the procreation of the species is effected by a congress of the two sexes, and a variety of organs are provided, upon the integrity of which the due performance of this function mainly depends. The male is destined to furnish a peculiar fecundating secretion, which is to be deposited in the body of the female, and for this purpose he is furnished with glands which pre- pare this fluid, and also with a conduit by which it is conveyed to its proper destination ; while the female, being the recipient, offers a cavity into which this secretion is received, and is, moreover, furnished with an organ where the embryo is originally produced by the specific action of the fluid from the male. Without attempting to enter into an explana- tion of the process of generation, which has been rightly designated as " one of those mysteries which the present state of our knowledge does not enable us to explain or even to comprehend," (Bostock's Physiology, vol. 1, p. 72,) it may be admitted as the result of observation and experi- ment, that a failure in any part of this complicated apparatus is attended by impotence or sterility. I. Impotence in the Male.—In order to effect procreation he must possess all the organs of gene- ration in a state capable of performing their re- spective functions, and this leads us to the first class of causes of impotence. 1. Organic.—Organic impotence may proceed from different sources; there may be, (a) defi- ciency of some of the organs of generation ;- (b) malformation of these organs; (c) diseases of some of them, or of the parts in their imme- diate neighbourhood, sufficient to impede the pro- creative function. (a) Deficiency of the penis, whether natural or accidental, is an absolute cause of impotence. A congenital deficiency of this organ is very rare, but it has been observed. " .f'ai traite et gueri," says Fodere, " d'une incontinence d'urine un jeune soldat plein de courage et de vigeur, qui, avec des testicules bien confoimes, n'avait a la place de la verge qu'un bouton, comme un mam- elon, par lequel se terminait l'uretre. II m'assura avoir ete toujours ainsi, et que ce bouton se icn- flait quelquefois en la presence des jeunes per- sonnes du sexe, et qu'il en sortait par le frottement une humeur blanche." (Medecine Legale, tom. 1, p. 364.) Accidental deficiency of the penis is more common. This may arise from amputation or destruction by disease. In a subject lately pro- cured for the purpose of dissection in the College of Surgeons, Dublin, the writer witnessed an in- stance of complete deficiency of the penis from operation. In this subject, which was a very o.d man, the amputation had been performed so long 598 IMPOTENCE. before death that the cicatrix was nearly obliterated, and many who saw the case supposed it to have been one of congenital deficiency. It is difficult to determine the extent to which the penis may be mutilated without destruction of the power of procreation. The glans has been frequently lost without being attended by impo- tence, and both corpora cavernosa have been de- stroyed, but the urethra being preserved, the indi- vidual retained his virility. (Paris and Fon- blanque, Med. Jur. vol. 1, p. 205.) Frank also states an instance of a gun-shot wound of the penis which carried away so much of the organ that it remained curved after cicatrization, never- theless it served the purpose of procreation. (De- lect. Opusc. Medic, tom. iv. p. 313.) From these and numerous similar instances, as well as from the effects produced on the generative function by that malformation, to be presently considered, termed hypospadias, it would appear that in order to insure impotence there must be complete depri- vation of the penis, as a remnant capable of enter- ing the vagini is sufficient for impregnation. That the testicle is the only essential organ concerned in the secretion of semen is now gene- rally admitted, an opinion supported by compara- tive anatomy, as well as by the daily proofs we have in the castration of animals. A different opinion formerly prevailed, chiefly on the authority of Aristotle, who was led to deny the necessity for the existence of testicles, from having seen a bull capable of impregnating a female after castration. But he was led into error by not being aware that if copulation were performed immediately after castration, the quantity of semen retained in the vesiculae seminales would confer fertility on the coitus. The complete absence of the testicles then, whether natural or accidental, must render the in- dividual unfruitful. Congenital deficiency of the testicles is a very rare occurrence, if it ever takes place. Fodere doubts that it does; and the case adduced by Ca- brolio of a soldier addicted to sexual pleasures, in whose body no testicles were found, although the vesiculae seminales were distended with semen, has been supposed by Portal to have been one of those instances in which the testicles are retained in the abdomen during the whole of life, and that they thus escaped observation. It is not to be inferred that an individual is impotent or sterile in whom no testicles are found in the scrotum. We know that in some instances these organs do not descend from the abdomen for some time after birth, and instances are not wanting in which this delay is prolonged through the whole period of existence. In oider to distinguish if the ab- sence of the testicles be real or not, it is necessary to inquire on the one hand into the previous his- tory of the individual, and on the other into his present condition and general habit. The first may indicate the previous existence of these or- gans in the scrotum, and their removal by opera- tion or accident, in which case the external marks of mutilation, such as cicatrices, will be apparent. We do not think, generally speaking, that an ab- solute congenital deficiency of testicles can take place without producing in the constitution the general phenomena by which the character of the mate is obliterated, and that of the female simu- lated. In these cases of apparent absence of tes- ticles, therefore, if the usual general signs of virility are observed, if masculine activity and vigour, combined with a well-developed muscular system, a strong deep voice, with the usual covering of hair on the chin, breast, and pubis, and at the same time no cicatrix indicating castration, are present, we must be cautious in condemning the individual. However, it is necessary to be circum- spect in inductions from the general habit. Marc knew a man in Paris whose features, thin beard, smallness of hands and feet, and voice altogether feminine, indicated a defect in genital organization, yet in whom none such existed ; the testicles oc- cupied their proper situation, and the man had many children. (Diet, des Sciences Med. Art. Im- puissance.) Fodere considered the retention of the testicles in the abdomen as a source of in- creased vigour and fecundating power. " Ces organes paraissant tirer du bain chaud ou il se trouvent plonges, plus d'aptitude a la secretion, que lorsqu'ils sont descendus au dehors dans leurs enveloppes ordinaires." (Med. Leg. tom. 1, p. 370.) This is at variance with the opinion of Hunter, whose views on the subject seem more correct, as he considers the delay in the descent of the testicles to arise from imperfection in their development. However, this imperfection does not go the length of rendering the organ useless, and therefore, when the other signs of virility are present, we are not justified in taking the absence of the testicles from their usual situation as an absolute proof of impotence. " Nous avons vu en France, dit Voltaire, trois freres de la plus grand naissance, dont 1'un possedoit trois testi- cules, l'autre n'en avoit qu'un seul, et le troisieme n'en avoit point d'apparens; ce dernier etoit le plus vigoureux des trois." (Mahon, Med. Leg., tom. 1.) [The writer has met with a marked case of absence of testes in the scrotum, the individual possessing full virile powers. In this case the testis of one side presented at the internal abdom- inal ring, and gave occasion to great swelling and intense suffering, which passed away under ap- propriate treatment, the testes remaining in the abdomen. Cases of absence of the testes are, however, rare. Dr. Marshall states (Hints to Young Medical Officers in the Army, p. 83,) that on the examination of 800 recruits, he found 5 in whom the right, and 6 in whom the left tes- tide was not apparent. He met with but one in- stance in which both testicles had not appeared. In certain cases the testes are drawn up against the abdominal ring, so as to encourage the idea that there are no testes in the scrotum ; and Pro- fessor Gross (Western Journal of Medicine and Surgery, May 1841, p. 355) has given the cases of two boys—one 14, the other 11 years of age, who were said to have been castrated, and a med- ical practitioner deposed to the absence of testes which, however, were found to be in the groin, a lit- tle below the external ring, whence, by a little traction, they could be easily forced down intc the scrotum.] Complete extirpation of the testicles, although it deprives the individual of the power of procrea- tion, is yet not accompanied by total extinction of venereal desire, and it has been observed that IMPOTENCE. 599 eunuchs of this description retain the power of copulation in an imperfect manner. This is so well known in the East, that the eunuchs who have charge of the seraglios are deprived of the penis as well as of the testicles. This power in the castrate is alluded to by Juvenal, (6th Satire,) and it is said that the unfortunate victims of ava- rice and bad taste in modern Italy are by no means deficient in capability of erection and pene- tration. However, this imperfect power of copu- lation does not remove such persons from the class of impotent, as the most important part of the function, the emissio seminis, is wanting. Monor- chides, or persons with but one testicle, are not deprived of the power of procreation. This was at one time doubted, and in the year 1665 the parliament of Paris decided that such an imper- fection rendered the matrimonial contract invalid, But numerous instances in man, as well as in the inferior animals, have completely disproved that opinion. It must be admitted, however, that if the remaining testicle be small, extenuated, and withered, and if a sufficient length of time has been passed in unfruitful matrimony, such a de- velopment must afford a strong probability of sterility. [It has been a question whether procreation be practicable after the removal of the testes. As regards man, it is probable that the effect of the operation would prevent copulation until after the sperm contained in the vas deferens had been re- moved by absorption or otherwise ; but in another work, (Human Physiology, 5th edit. ii. 327, Philad. 1844), the author has satisfactorily shown that it is possible in animals.] (b) Malformation. — Impotence may be abso- lute when the genital organs exist, but are mal- formed or pathologically altered. The penis varies from the natural formation in different ways that have been accounted causes of impotence. Mere diminutiveness of this organ, where the subject is otherwise vigorous, cannot be included under this head ; and it would appear that the genital organs, although originally of di- minutive size, are capable of considerable develop- ment even after the age of puberty. Of this the case related by Mr. Wilson is a good example. "I was," says he, "some years ago consulted by a gentleman on the point of marriage respecting the propriety of his entering that state, as his penis and testicles very little exceeded in size those of a youth of eight years of age. He was then six- and-twenty, but never had felt the desire for sex- ual intercourse until he became acquainted with his intended wife; since that period he had expe- rienced repeated erections, attended with noctur- nal emissions ; he married, became the father of a family, and these parts, which at six-and-twenty years of age were so much smaller than usual, at twenty-eight had increased nearly to the usual size of those of an adult man." (Lectures on the genital organs.) But excessive size, more par- ticularly excess in length, may be considered as a relative cause of impotence, from the contusion and laceration inflicted on the female at each at- tempt at intercourse. Such cases as these are very rare. P. Zacchias cites an instance in which the female was always thrown into syncope from this cause. The orifice of the urethra is occasionally formed in an irregular manner, and this constitutes the most common malformation of the penis. It sometimes opens in the perineum, sometimes on the dorsum of the penis, constituting the malfor- mation termed epispadias; but most frequently in the under surface of the penis; this defect is called hypospadias. This malformation was con- sidered by Mahon, P. Zacchias, Faselius, and Hal- ter, as an absolute cause of sterility, but certainly without sufficient foundation ; for there are nu- merous instances recorded in which impregnation has been effected by individuals in whom the urethra opened in an unusual manner, provided the orifice was in that portion of the penis that entered the vagina. Kopp relates the case of a peasant at Hanau, in whom the urethra opened on the under surface of the penis at the distance of eleven lines and a half from the extremity of the glans, notwithstanding which he was the father of five children. (Annates de Med. Poli- tique, t. iii.) Simeons of Offenbach gives eight cases of hypospadias. The first and second were married and had children ; the first six, and the second four. The third and fourth were brothers; the fifth and sixth were the sons of the first ; the seventh was remarkable as having had an action for a divorce against him, and the eighth was an infant. (Diet, des Sciences Med. t. 24.) Fodere quotes four cases of hypospadias, in all of which the power of impregnating was preserved, (Med. Leg., tom. i. p. 367) ; and Belloc states that he knew at Agen a man who had the orifice of the urethra at the base of the frenum of the glans, and who left four children perfectly resembling himself, two of whom had the same malformation. (Cours de Med. Legate, p. 129.) From the cases on record in which impregnation has taken place without the possibility of intromission, it is clear that the emissio seminis in any portion of the vagina is sufficient for this purpose, and that it is not necessary that this fluid should be carried to the uterus, or to any great distance within the vagina. We shall have occasion to revert to these cases in speaking of female impotence, but at present we mention them as affording an explanation of the subject before us. It may, therefore, be assumed that malposi- tion of the orifice of the urethra does not necessa* rily constitute a cause of impotence, unless the opening be situated in a part that cannot enter the vagina. Even in the latter case, impregnation may be effected by artificial means. The experi- ments of Spallanzani, (ffiuvres de Spallanzani, t. iii. p. 224,) who succeeded in his attempt to im- pregnate animals by injecting semen into the uterus, led Mr. Hunter to adopt the same course in the case of a man by whom he was consulted in consequence of malformation of the urethra. (Trans. Royal Soc. 1:799.) The orifice of the canal was in the perineum, through which the semen escaped during coition; and Mr. Hunter directed him to collect this fluid in a syringe and instantly inject it into the vagina. The experiment succeeded, impregnation took place, and the fe- male was delivered of a child in nine months [The inference is, however, just, that if tho semen be not projected far up in the vagina, and in the direction of the os uteri, impregnation U not likely to be accomplished:—r fact, which it 600 IMPOTENCE. might be of moment to bear in mind, where the rapid succession of children is an evil of mag- nitude. The writer has elsewhere (Op. cit. ii. 368, Philad. 1844) referred to two cases, in which procreation appeared to be prevented by the existence of epispadias opposite the corona glandis.] A contracted state of the prepuce, by which the emission of the seminal fluid is impeded, may be a cause of impotence, but this is easily removed by operation. A more serious case is that in which the prepuce adheres to the glans, and the orifice of the urethra itself is contracted. The writer has at present under his care a boy, eleven years of age, in whom a malformation of this kind exists. The reflected portion of the prepuce adheres uni- versally to the glans, and is firmly attached to the orifice of the urethra, which opening is so con- tracted as scarcely to permit the passage of an eye- probe. The urine is, of course, voided in drops. If this case be permitted to go on to puberty with- out relief, there is strong reason to imagine that impotence would be the result. Malformation of the excretory ducts of the tes- ticle may also prove a source of impotence. Mr. Hunter (Animal Econ., p. 47, plate 5,) represents a case in which the epididymis, instead of passing to a vas deferens, terminated in a cul-de-sac. A similar conformation sometimes occurs in the vesiculae seminales, where, instead of entering the urethra, they terminate, after being joined by the vas defe- rentia, in shut sacs. It is evident that when such a disposition of parts exists on both sides, the semen, although secreted, cannot be ejaculated, and, therefore, the individual is rendered absolutely im- potent. (c) Diseases. — The diseases of the genital organs which cause impotence, may be divided into those affecting the penis, and those affecting the testicles. Of the former may be enumerated excess or defect of muscular or nervous energy, inducing priapism, or paralysis. Priapism gives rise to a temporary impotence when the erection is so vigorous as to close the urethra in such a manner that the semen cannot pass into it. Defect of energy in the vessels, nerves, or muscles of the genital organs, sometimes prevents the influx of blood to the corpora cavernosa in a quantity suf- ficient to cause erection, which produces a state of atony approaching to paralysis, constituting the anaphrodisia paralytica of Dr. Cullen. This is a disease not unfrequently met with. Instances of it are given by Chaptal, Gessner, Weicard, quoted by Fodere, (Med. Leg. tom. i. p. 382,) and also by Mahon, (Ibid. tom. i. p. 58,) in which it was removed by local stimulants. Strictures in the urethra, when the canal is greatly diminished, may oppose such a barrier to the exit of the semen as to render the individual impotent; but it is extremely difficult to ascertain to what extent, a stricture may exist without pro- ducing this effect. We know that many persons in whom strictures in this canal are found, do not lose the procreative power, and therefore, unless in extreme cases, where the finest bougies are with difficulty passed, we should be cautious in assum- ing this as a cause of impotence. The opening of the conjoined ducts of the vesiculae seminales and vasa deferentia may be closed by scirrhous enlargement of the neck of the bladder, by enlarge- ment of the prostate gland, a scirrhous state of the veru montanum, or by disease of the duct itself. Fodere alludes to the cases of two individuals mentioned in a French Journal, (Journal de Me- decine de Paris, Ann. 1680,) who having full powers of copulation could never expel semen. On examination after death, the seminal ducts of one were found filled with matter of stony hardness; and in the other the extremity of these ducts was callous and blocked up. All these causes produce inability for procreation by obstructing the passage of the semen, although this fluid be duly secreted. But the cause of impotence may lie in the se- creting organ itself, the texture of which is so altered by disease as to interrupt the performance of its natural function. Thus scirrhus, cancer, scrofula, when they affect the entire substance of the testicle, produce such an obliteration of its intimate structure that the seminal fluid is no longer formed. The form of disease described by Andral must be considered as belonging to this class: « Un etat d'induration grise ou blanche du parenchyme avec disparition des conduits seminiferes; le testi- cule represente alors une masse homogene, dure, ou l'on ne trouve plus aucune trace de son orga- nization primitive." (Anat. pathol. tom. ii. part xi. p. 669.) But in order to constitute complete impotence, it is necessary that both testicles should be implicated, and that the disease pervade the entire organ ; for a small portion of the gland re- maining uninjured may be still.capable of secreting semen in a quantity sufficient for impregnation. " In the first method adopted in the East for mak- ing eunuchs, we are informed that the masculine efficiency was destroyed by bruising the testes, (a method of castration still pursued in some places with regard to animals,) and destroying their functionary powers along with their organization. Instances of generating, however, seem to have occurred among eunuchs made in this manner, and are explained on the supposition that part of the testes remaining uninjured was still capable of preparing the necessary secretion, and furnishing it to a certain extent." (Dr. J. G. Smith, Forensic Medicine, p. 450.) Local injury may be followed by atrophy of the testicle, and it is well known that a state of com- plete inaction, such as is observed in those who have maintained a strict monastic life, is often attended by a similar result. Elephantiasis is said to cause a wasting of the genitals and a loss of all sexual appetite, but this is denied by other authorities. (See Elephantiasis.) A species of idiopathic atrophy of the testicles is described by Baron Larrey, which affected many of the French troops on their return from Egypt. In these cases the organs became soft to the touch, and gradually diminished in size without any pain. Fodere mentions that he observed in some young deserters condemned to work at the canal of Aries, that the testicles melted away just as if they had never existed. (Med. Leg. vol. i. p. 369.) Diseases of the neighbouring parts may also prove a source of impotence by affording obstacles to the venereal congress. These are extraordinary obesity and very large scrotal hernia and hydrocele. Obesity, when extreme, must be considered a dis- ease ; of this, Martin, king of Aragon, furnishes IMPOTENCE. 601 a striking example. « He is stated by historians to have been so corpulent that neither mechanical contrivances nor medical treatment could render him any assistance towards the accomplishment of venereal congress." (Paris and Fonblanque, Med. Jurispr. vol. i. p. 204.) Large scrotal hernia and hydrocele, by distension of the integuments, cause recession of the penis, and render coition imprac- ticable. Besides, these tumours are considered by Fodere to impede the secretion of semen either by causing too great tension of the spermatic vessels, or by so compressing them that their diameter is obliterated. This effect, however, must be of rare occurrence. 2. Functional.—One of the most remarkable changes that take place in the transition from youth to manhood is the development of the sexual organs, and the new train of sensations by which it is ac- companied. Puberty is the season of life in which the generative function is called into active opera- tion, and unless impaired by excesses or disease, it usually continues in vigour until the sixty-fifth year. "The genital organs (says M. Virey) offer two states during life, in the young and old, which are the frozen zones of existence ; the intermediate state is the torrid zone of life. The infant has nothing to give, the old has lost all." (Ryan's Med. Juris, p. 124.) This doctrine, however, must not be received without limitation; for in- stances of precocity, as well as of protracted gene- rating power, are not wanting. Dr. Ryan (Loc. cit.) cites some examples of children precociously developed, even before the fourth year ; and he alludes to a case of a boy described by M. Virey, who at seven years of age was as fully developed as an adult, and who made the most furious attacks on his female acquaintance, and absolutely deprived one of them of that which she could never regain. Instances of vigorous senectitude are also occa- sionally met with. Of these the case of the cele- brated Thomas Parr is, perhaps, the most striking. He married at the age of one hundred and twenty, and was compelled to do penance for an amour in his hundred and fiftieth year. But looking on these as exceptions to the general rule, it may be said that extreme youth or old age is incompatible with the exercise of the generative function. There are, moreover, certain states of the body in which, although the genital organs be perfect, impotence may nevertheless exist, in consequence of incapability of erection. This may arise from constitutional frigidity, or what may be termed the apathetic temperament. The offspring of infirm aged persons, of parents too young, or of those worn down by debauchery, often present examples of this condition. The appearance of persons of this temperament is thus described by a French writer: (Diet, des Sciences Med. art. Irnpuis- sance.) "The hair is white, fair, and thin, no beard, countenance pale, flesh soft and without hair, voice clear, sharp, and piercing, the eyes sorrowful and dull, the form round, shoulders straight, perspi- ration acid, testicles small, withered, pendulous, and soft; the spermatic cords small, the scrotum flaccid, the gland of the testicles insensible, no capillary growth on the pubis, a moral apathy, pusillanimity and fear on the least occasion." Im- potence arising from this cause is usually incurable. A more common source of impotence is a par- Vol. II. —76 3 a ticular weakness of the generative organs arising from too early coition, from abuse of venereal pleasures, or from indulgence in the pernicious crime of masturbation. In persons whose organs are debilitated by these causes, erection does not take place, although the mind be highly excited by lascivious ideas. The erector muscles have lost power from over-use, and are to a certain extent paralysed; and if semen escapes, it is clear, serous, without consistence, and consequently deprived of prolific virtue. Among the causes of general debility capable of producing impotence, have been reckoned defect of nourishment, bad quality of food, and unwhole- some regimen. But we would observe that these influences must be exerted to the very extreme before they can produce the effect described, for in this city (Dublin), where misery, poverty, and starvation exist to a degree perhaps unparalleled on the face of the globe, procreation proceeds with extraordinary rapidity; and it has fallen to the writer's lot, through his connection with the Coombe Lying-in Hospital, to witness the birth of numberless infants whose unfortunate parents had not for years partaken of a wholesome meal. The habitual abuse of spirituous liquors, long watching, excessive evacuations of blood, bile, saliva, or faeces, as they tend materially to depress the powers of the constitution, may prove tempo- rary causes of impotence. To this class Marc (Diet, des Sciences Med. art. Impuissance) adds the sedative action of opium, hyoscyamus, and tobacco. The influence of the narcotic gases, in consequence of the sedative effects they produce on the sensitive system, sometimes gives rise to a temporary impotence. Of this the following case given by Fodere is a good example. " J'ai traite un homme Eige d'environ quarante ans, qui, ayant echappe a un et^t apoplectique occasione par la vapour du charbon, reste tellement impuissant pendant six mois, qu'il etoit absolument insensible a toutes les caresses que sa femme, qu?il aimoit jusqii' a la jalousie, mettait en usage pour l'ex- citer. II reprit completement ensuite son etat naturel." (Med. Leg. tom. i. p. 382). Certain substances, as the nymphaea or water-lily, nitre, camphor, colchicum, and indeed most of the diuretics, have been supposed to exert directly sedative effects on the generative organs. That this specific action can cause impotence is proba- bly too much to assert, although some writers have done so; but from the beneficial effects we have obtained from the use of nitre and camphor in cases of over-excitement of the generative ap- paratus, attended with nocturnal emissions, it would appear that these substances are possessed of properties that tend to moderate the venereal appetite. We have heard of a patient rebelling against the continuance of the use of colchicum, in consequence of its impairing his virility. Dr. Paris takes nctice of a peculiar species of impo- tence arising fiom debility which deserves notice. « It depends," says he, " upon a want of consent between the immediate and secondary organs of generation ; thus the penis acts without the tes- ticles, and becomes erected when there is no semen to be evacuated ; while the testicles secrete too quickly, and an evacuation takes place without any erection of the penis " 'Med. Jur. vol. i. p. 209.) 602 IMPOT E N C E . We have already alluded to the effects of strict chastity on the testicles. In this state of decay impotence is the final resutft. There are some diseases which stimulate the generative organs, such as gout, rheumatism, hemorrhoids, calculus in the bladder or kidneys : in the latter disease the constant irritation propagated to the glans penis frequently urges the sufferer to coition even during the most severe pain. But there are others which extinguish venereal desire during their continu- ance. These are nervous and malignant fevers, which engage the sensorium from their commence- ment, and are accompanied with general weakness and prostration of excitability; and diseases of the brain and spinal cord, occasioned either by internal or external causes. Hennen (Military Surgery) mentions a case of a soldier who was rendered impotent by a blow on the occiput. With reference to the effect of diseases on the genera- tive function, Fodere mentions a circumstance worth being remembered, which is, that it is possi- ble that certain diseases may produce such an alter- ation in the constitution, that an impotent man may find himself cured of his impotency on their ces- sation. He adduces the instance of Avenyoes, who stated he had been without offspring during the whole of his youth, but became a father on recovering from a severe fever. Zacchias states a similar instance. An artisan lived twenty-four years with his wife without having children, when he was attacked by an acute disease, from which he recovered ; the fruit of his convalescence was the birth of a son, after which he had many chil- dren. It is well known that persons recovering from acute diseases are often extremely salacious. Dr. Dunlop (Beck's Med. Jur. by Dunlop) gives an instance of this on the authority of a friend who visited the hospitals in New York, and who stated that patients recovering after the yellow fever exhibited most furious sexual passion, to the great inconvenience of the nurses and their assistants. 3. Sloral.—We have already treated of those causes which produce permanent impotence, and of those disturbances of the constitution which during their continuance suspend the generative function: we have now to observe upon those causes which in a sound constitution, with perfect genital organs, are capable of suspending their action, but the cessation of which leaves them free to fulfil their office. These are strong mental emotions, such as too ardent desire, fear of not being loved or of being incapable, shame, timidity, surprise, jealousy, hatred, disgust, in short any thing by which the mind is forcibly arrested. A temporary impotence from this class of causes is by no means a rare occurrence. Of all the causes just mentioned, the fear of incompetence is most frequently productive of impotence. It was a knowledge of this fact that led Hunter to adopt the remarkable mode of treatment which proved so successful in a case of impotence. He pre- vailed on the person to promise on his honour to pass six nights in bed with a young woman with- out attempting sexual intercourse, and before the allotted time had expired, the patient's only fear was lest the force of desire should induce him to nreak his promise. Similar instances have oc- curred to most medical men, and have been cured by the same means. The facility with which the most vigorous man is rendered impotent by this cause, led to the supposition that supernatural agents were concerned in effecting it, and the natural credulity of mankind soon confirmed the idea. This belief in the powers of enchant- ment, or, as the French term it, " nouer I'aiguil- lette," has prevailed in most ages and countries. We have accounts of it in the East, in Egypt, among the Greeks and Romans; and even some of the early fathers of the church, St. Jerome and St. Augustin, are said to have been imbued with it. Like other forms of enchantment, persons were found who made it their business to practise it, and even princes were subject to their dominion. Nero and Amasis were, at the suggestion of their concubines, rendered impotent by incantation. In this process there was always something to arrest the imagination; some drug was administered, some obscure and unintelligible words were pro- nounced, or written on paper with blood, and tied about the victim's neck ; a lock of his hair was tied, with certain mysterious ceremonies, or some equally absurd practice pursued, no matter what, so that the proper impression was made upon the mind, and as long as this continued it had the power of preventing erection by the very fear of failure. The progress of knowledge has done for this species of witchcraft what it has done for others, and it is now confined to the lowest and most ignorant people. II. Impotence and Sterility in the Fe- male.— It is necessary to distinguish between these two conditions in the female, as it is quite possible for a woman to be impotent and not sterile, and sterile but not impotent; in other words, there may exist a malformation of the genital organs of such a nature as to prevent in- tercourse, on the removal of which she becomes fruitful; and, on the other hand, she may be per- fectly competent to copulation, yet never conceive. The latter is by much the most common, and is believed to occur more frequently in the female than impotence does in the male. Strictly speak- ing, impotence can only be said to exist in the female when the vagina is incapable of admitting the penis. By this incapacity, however, sterility is not always insured, as it will appear from cases to be presently alluded to, that impregnation has taken place when intromission was impossible. But laying aside these instances, as exceptions, it may be stated generally that an impervious va- gina is attended with impotence. Such a condi- tion of the female organs may be the result of various causes existing either in the hard or soft parts. It is rare to find the impediment originating in the former, but Fodere alludes to a malforma- tion of the pelvis, such as considerable depression of the pubis, or exostosis, as capable of opposing the act of generation : we cannot, however, believe that deformity of the pelvis caused by approxima- tion of the pubis and sacrum can offer such a barrier as he supposes; and we are strengthened in our disbelief by the many instances recorded, in which impregnation took place notwithstanding the highest degree of deformity. But an exosto- sis, when it attains a great magnitude, may very well prove an obstacle to coition. The cause of impotence is more frequently found in the soft IMPOT parts, and this may be either absence or occlusion of the vagina. Cases in which the vagina was altogether wanting are not numerous, but there are some recorded, and of these one of the most remarkable is detailed in the Causes Celebres. (Tom. vii. and x., Vingtieme cause.) We will not give the case at length, but the leading facts were the following. A young woman in Paris was married in her twenty-fifth year to a young man named La Hure. Six years were passed without consummation of the marriage; and then the woman was examined by a midwife, who declared all the external organs of generation wanting, and their place occupied by a solid body pierced by a small hole. The woman admitted that Bhe had never menstruated; nevertheless she had always enjoyed good health. A surgeon, named Dejours, who saw the case at this time, supposing it one of simple occlusion of the vagina, proposed to divide the barrier, in hopes of reaching and laying open the cavity. He accordingly carried a scalpel to the depth of two fingers' breadth, but instead of reaching a vagina he was still opposed by solid resisting parts. Finding this, he judged that he had nothing to hope for in going further, and that he should run great risk of wounding the bladder or rectum. He therefore endeavoured to keep open the wound he had made by the intro- duction of tents, and this opening remained during life. Matters continued quiet for eight years more, when the husband, disgusted with his wife, demanded a divorce. The woman died at Lyons ten years afterwards, and on examination it was found that the place of the vagina and uterus was occupied by a hard compact substance, in which no cavity could be traced. Not long ago a case somewhat similar was exhibited to the Society of the Faculty in Paris, in which no uterus or vagina existed, and the perineus was pierced by a small hole, which was the termination of the urethra. A more common case is that in which the cali- bre of the vagina is so diminished as to resist the intromission of the penis. Several instances of this malformation are to be found in writers on legal medicine and midwifery, one of which we may mention, as it affords a striking example of the manner in which nature accommodates parts to the offices they are called on to perform. A young girl, married at the age of sixteen, had the vagina so narrow, that a goose-quill could scarcely enter it. A young and vigorous husband had failed in all his attempts, and some of the faculty who were consulted declared copulation impracti- cable. Nevertheless, after eleven years this wo- man became pregnant without any increase in the dimensions of the vagina. Her friends of course despaired of the possibility of delivery, but about the fifth month of pregnancy the vagina began to dilate, and at the full time it had acquired a size sufficient to permit the passage of the infant. (Mem. de l'Acad. des Sciences de Paris, 1712.) In the celebrated Joan of Arc, the Maid of Or- leans, according to the account of two physicians who were ordered to examine her, the vagina was found so contracted that coition must have been impracticable. Malformation of this kind is fre- quently removable by appropriate treatment. In a case that occurred to Benevoli, he employed emollient fomentations and tents, and by gradually E N C E. 603 increasing the size of the latter, succeeded in removing the imperfection. In those cases in which the uterus is divided longitudinally into two chambers, it sometimes happens that the septum is prolonged into the va- gina, even to the vulva. (Andral.) In this con- dition of parts, if the intervening membrane be firm and rigid, it may oppose a barrier to coition. The vagina may be also too short and terminate abruptly in a cul de sac; this disposition of parts may be congenital, but it may be also the result of difficult labour. When congenital, it is usually attended by absence of the uterus. The inflammation that sometimes follows diffi- cult labours (particularly if instruments have been incautiously used) has been known to cause ad- hesion of the side of the vagina, and so cut off all communication with the uterus. The writel is acquainted with a very remarkable instance of this accident at present in the Coombe Lying-in Hospital, Dublin. The sufferer is a young healthy woman, in whom there is a fistulous opening be- tween the bladder and the vagina, and just beyond the opening the sides of the vagina adhere firmly. She applied at the hospital in hopes of obtaining some relief from her miserable state, which she said was in consequence of a tedious labour, during which instruments of some sort were em- ployed. It is remarkable in this case, that although the outlet for the menstrual discharge is closed, there is no indication that it is poured out by the uterus, for none of the signs of confined menses are present. We are therefore inclined to suppose that the cavity of the uterus itself has been oblite- rated by the inflammation, and consequently that an operation would not be attended with success. The vagina is frequently found closed at its orifice : this may be caused in different ways. It is sometimes produced by neglected inflammation and excoriation of the labia in children, and even in adults; and this has extended in some cases to a complete closure of the canal, so that no passage has remained but a small one at the superior an- terior part for the discharge of urine. Dr. Ryan (Manual of Med. Jurisprudence, p. 129) states that he has seen four cases of cohesion of the la- bia externa at the age of puberty, so complete that only a small probe could be introduced at the superior commissure. Dr. Merriman once met with an instance where the entire opening of the labia was so perfectly closed, in an infant of two years old, that there was not the smallest aperture through which the urine could escape. (On Diffi- cult Parturition, 3d edit. p. 221.) We find in the works of Ambrose Pare, Ruysch, Fabricius Hil- danus, Benevoli, and others, examples of complete obstruction of the vagina, either at its orifice or at a greater or less depth, by a membrane of such strength as to resist intromission. Dr. Merriman (Loc. cit., p. 216) relates the case of a young woman whom he was called to attend in her first accouchement, and on proceeding to make an examination he found it impossible to introduce his finger into the vagina, that passage beinjj closed by a membranous expansion about ont>- tenth of an inch in thickness. This membrams occupied the entire opening of the vagina, with the exception of a small aperture through which a pea could hardly have passed. It was finally 604 IMPOTENCE. ruptured by the child's head, and delivery was safely accomplished. The same author gives another case related by Dr. Tucker, in which the obstruction was even more complete. " The labia pudendi were observed to have the usual situation and appearance; but being expanded, they were discovered to be connected to each other by a strong opaque membrane, nearly a finger's breadth, not distinguishable from their external skin in tex- ture and appearance, which was stretched from tbe surface of the perineum (of whose outward skin it seemed likewise a continuation or produc- tion) over the longitudinal sulcus between the la- bia, and over the clitoris, quite to the pubis. About the middle of this membrane there was a circular aperture, with a strong ring, just large enough to admit a female catheter one-eighth of an inch in diameter." In this case the membrane was so strong that it resisted the forcible impulse of the child's head during several pains, and was at last divided artificially from the aperture to the frenum labiorum. These and many similar instances on record are the cases to which we referred in speak- ing of hypospadias, as confirmatory of the doc- trine laid down there, viz., that an emissio seminis at the orifice of the vagina is sufficient for im- pregnation, and they afford instances of what may be considered paradoxical, that is, of women being impotent, yet conceiving. The following case from Fodere is so striking that we cannot omit to mention it. A young man had married a young woman, with whom, although he had frequently made the attempt, he could never consummate the marriage, " a son gre." At the end of three months he demanded a divorce, although she de- clared herself pregnant. She was now examined by many skilful surgeons, who found a hard cal- lous membrane placed at the mouth of the vagina; this they divided, and the operation succeeded so well that the husband relinquished his claim for divorce. The woman was delivered, in six months after the operation, of a male infant at the full term, and of great vigour. From these cases it is plain that this hypertrophied state of the hymen, although it affords a barrier to copulation, is yet capable of removal by operation, and therefore it cannot be considered as a permanent cause of im- potence. Narrowness of the mouth of the vagina is sometimes accompanied with a communication between that canal and the bladder or rectum. Fodere states two cases of this description, in both of which sterility prevailed. Procidentia of the uterus might be supposed to create impo- tence, were it not that some very remarkable in- stances of thecontrary are recorded. In the fourth volume of the London Medical and Surgical Jour- nal, may be found a description of two cases of this disease, in both of which impregnation took place, although the natural orifice had been fixed without the vulva for years. We now come to speak of sterility, or of those cases in which, the vagina being pervious, impreg- nation does not occur. This may depend upon imperfect development or total absence of the Uterus, obliteration of its openings, diseases of this organ, obstruction or disease of the fallopian tubes, and absence or disease of the ovaria. That form of imicriection in the uterus in which one-half of the organ is wanting, and which case is at- tended with but one ovarium and one fallopian tube, does not entail sterility. Chaussier relates a case of this kind in which seven children were born at the full time. (Andral.) But there is a variety sometimes found which must render the woman barren; in which the uterus is so small that it is with difficulty found in the pelvis, and the fallopian tubes appear to terminate in the ex- tremity of the vagina. We have already said that unnatural shortness of the vagina is frequently connected with absence of the uterus. Columbus dissected a woman who had always complained of great pain in coitu, in whom he found the vagina very short, and no uterus at its ter- mination. A similar case occurred to Dupuytren: (Repertoire d'Anat. Pathol, t. v. p. 99) : the vagi- na was only one inch in length, the ovaria and fallopian tubes were well developed, but no uterus existed. Fodere states that this malformation may be discovered during life by the smallness of the breasts, &c.; but in the case mentioned by Dupuytren the breasts were well formed, the ex- ternal genitals developed, and the whole appear- ance was feminine. It is plain that sterility must attend this defect. The different orifices of the uterus may be obliterated, and thus impregnation will be pre- vented. The opening of the fallopian tubes has been found closed ; and this may be owing to a simple continuation of the lining membrane of the uterus over it, or to the existence of a particular membrane blocking up the mouth of these tubes, or to an obliteration of the tube itself, which sometimes extends to the distance of some lines from the uterus. When both tubes are thus cir- cumstanced, no utero-gestation can go forward, for obvious reasons. But the mouth of the uterus itself is occasionally obstructed either by an ad- ventitious membrane stretched across, or by an agglutination of its sides; and when this is the case, sterility is the result. Besides the closing of the uterine extremity of the fallopian tubes, these canals are sometimes impervious throughout their whole extent; some- times the obstruction is situated about the middle, and at others the fimbriated extremities alone are blocked up; and this latter is frequently caused by an intimate adherence between them and the ovaria. (Morgagni. Baillie. Richerand. Andral.) The ovaria are sometimes wanting. This de- ficiency may exist at but one side, a specimen of which is preserved in Dr. Hunter's museum ; and Dr. Baillie takes notice of others in which these organs were deficient on both sides. Dr. Den- man says he was shown two preparations by Dr. R. Hooper, in which the fallopian tubes termin- ated bluntly, and without any aperture, fimbriae, or ovaria. (Denman's Midwifery, 6th edit. p. 42.) Besides these impediments to impregnation, there are certain diseases of the female genital organs, which, when they exist, are found to cause sterility. Polypus in utero is very generally considered to belong to this class; but although the opinion is generally correct, it is not univer- I sally true, for it has happened that conception [ took place notwithstanding the presence of a very large tumour in the uterus. Of this the late Dr. Beatty (Trans, of the Association of Coll. of IMPOTENCE. 605 Phys. in Ireland, vol. 4) has described a very re- markable instance, which occurred in Dublin in the year 1820. The patient was a lady twenty- five years old, who, in consequence of the indis- pasition of her husband, had left his bed in May 1819, to which she did not return until August 1820. In the previous May she first perceived what she termed a " lump in her womb," attended with external swelling and soreness on pressure at the lower part of the abdomen. This swelling was not permanent, but was observed to disappear during the menstrual period. Finding an increase in her unpleasant symptoms, she applied to Dr. Beatty in September, and on the 28th of that month he made an examinatian per vaginam. The os uteri was found dilated to the size of a dollar, and in its opening was a large dense sub- stance with a regular smooth surface. On the 10th of November, while out in her carriage, she had a moderate discharge of blood from the vagina, and upon examination the parts were found as they were a month before. At two o'clock the following morning she miscarried, the embryo was entire, the membranes not being ruptured: the contained fcetus was about three months old—a period corresponding with the time at which the connubial intercourse had been resumed, and at which she had last menstruated ; and just three months after she first experienced uterine uneasi- ness. The tumour was expelled in six days after- wards by pains resembling labour, the uterus was inverted by its descent, but on separation of the slight attachment between it and the tumour it was easily reduced. The weight of the tumour was found to be nearly four pounds. This lady was delivered of a healthy boy on the 10th of February, 1822. This was an instance of preg- nancy during the existence of a tumour of con- siderable magnitude in the uterus ; but we believe it to be an exception to what usually takes place. Inflammation, suppuration, calculous deposi- tions, cancer, cauliflower excrescence, corroding ulcer, the irritable uterus of Dr. Gooch, and any disease in which the texture of the uterus is much engaged, or with which the constitution sympa- thizes strongly, are so many obstacles to impreg- nation, as are diseases of the ovaria, in which the natural structure of these organs is obliterated, and both of them engaged. Leucorrhcea, when profuse, is very often also attended by barrenness ; but this is by no means a constant effect, as we have known instances in which this disease ex- isted to a great extent without preventing impreg- nation. A question has arisen whether menstruation is necessary in order that a woman shall be prolific; and it is generally stated that women who do not menstruate cannot conceive. (Paris and Fon- blanque, Med. Jur. vol. i. p. 214.) This is true when applied to those who have never menstru- ated, but is not in cases that have had even a single monthly discharge. Fodere (Med. Legale vol. i. p. 397, ed. 2me) states that, in the first edition of his work, he had maintained that females who do not menstruate are sterile; but he after- wards was obliged to change his opinion, from having observed some patients under his own care enjoying good health without this evacuation, and bearing many children- One of them was a 3 4 * woman thirty-five years old, the mother of five children, the last of which she was suckling. She was in good robust health, and had never menstruated but once at the age of seventeen years. It would appear that a single occurrence of this periodical evacuation is a sufficient indica- tion of generative power; and although irregu- larity in subsequent years is frequently attended by sterility, it is not to be taken as an absolute cause of it. There is a form of dysmenorrhcea described by Dr. Denman (Denman's Midwifery, 6th edit. p. 90), and Dr. Dewees (Dewees' Mid- wifery, p. 154) of Philadelphia, which both these authors state to be productive of barrenness. The striking peculiarity in this disease is the formation of an adventitious membrane in the uterus, which is expelled after severe and protracted suffering at each menstrual period. This membrane is some- times thrown off in pieces, and at others entire, at which time it bears the strongest resemblance to the decidua, so much so that, when it occurs in unmarried females, it may and sometimes does give rise to most painful suspicions. There is a preparation in the museum of the College of Sur- geons, Dublin, of an entfce membrane of this kind, which might deceive the most experienced eye. Morgagni relates a very remarkable instance in which pregnancy occurred during the existence of the habit just described, but it is probable that there was a suspension of the disease for a time in that case, when the capability of conceiving might exist. It is well known that instances have happened in which persons have lived for years in unfruit- ful matrimony, and being after divorce remarried, have both had children. This is a fact which in the present state of our knowledge we are not able satisfactorily to explain, and we will not delay the reader by offering any speculative opinion upon it. Treatment. — The treatment of impotence and sterility must be influenced by the causes from which they spring, some of which are in- curable, whilst others may be removed by appro- priate remedies. Those cases which depend upon congenital deficiency of the penis, testicles, vagina, uterus, Fallopian tubes, or ovaria, belong to the former; but we have seen that some of those arising from malformation and disease of these parts are susceptible of cure. Such are phymosis, adhesion of the prepuce to the glands with dimi- nution of the orifice of the urethra, priapism, par- tial paralysis, strictures in the urethra, diseases of the neighbouring parts, contracted vagina, occlu- sion of the mouth of this canal by adhesion of the labia, or by a dense hymen, prolapsus and proci- dentia uteri, polypus in utero, leucorrhcea, dysme norrhoea: all these are more or less capable of removal either by operation or general treatment. The cases of impotence which depend upon func- tional or moral causes are much more numerous than those just mentioned, and frequently become the subjects of medical treatment. If old age be the cause, there is little to be don<3; medicinej are useless, and temporary stimulants are often worse. There have been instances of old de- bauchees, who, wishing to make a last attempt, have taken some of the nostrums, such as the Ve netian pastilles, Italian lozenges,' &c. and have perished without success in the very effort. Cases 606 IMPOTENCE — IN CUBUS. arising from debility of the generative organs, from too early coition or the abuse of venereal pleasures, are not unfrequently met with, and in- deed furnish the great mass of dupes to quackery. In the treatment of such cases there are many points that must be strictly attended to. We must be careful to remove from the imagination, or regimen, all that may excite the generative apparatus, while we endeavour to strengthen the system by mild nourishing diet and gentle tonics. We must combat on the one hand muscular weakness, and on the other nervous susceptibility, and so restore the equilibrium between the two systems. The local application of cold water has a great effect in allaying the excitable state of the generative organs, and should be had recourse to at least twice a day. If the impotence be owing to moral or physical irritation, the constitution must be lowered by spare diet, cooling acidulated drinks, exercise in the open air, and removal from all objects which excite venereal desires. This plan of treatment we think preferable to the em- ployment of narcotics, which sometimes produce unpleasant effects, and are always hurtful to the digestive organs. In those cases which are purely the effect of atony of the generative organs, and do not arise from their over-excitement, a different line of conduct must be pursued. The diet should be full and generous, with a liberal allowance of spices and wine; and the exclusion of all objects of a nature to excite the senses need not here be recommended. Frictions to the loins, and the cold bath, will be found useful; sometimes it will be necessary to substitute the warm bath when the cold does not produce the healthy reaction we desire. (See Bathing.) If these means fail, we may then have recourse to stimulating applications to the loins, thighs, and pubis, and electricity may be used with advantage. (See Electricitt.) In the year 1776, Dr. Graham opened an estab- lishment in London, in which were a number of electrical beds, destined to awaken the dormant generative powers in cases such as we have described. Modern systematic writers have discarded that class of medicines formerly grouped together under the name of aphrodisiacs, from their supposed power of exciting a desire for venery : it consisted of stomachics, aromatics, odoriferous gums, bal- sams, resins, essential and volatile oils, perfumes, particularly musk, phosphorus, opium and aroma- tics combined, and cantharides. These, with the exception perhaps of cantharides, seem to act only as general stimulants, and do not possess any specific powers over the organs of generation. Cantharides, as is well known, when administered in large doses, are sometimes capable of inducing a violent state of irritation of the urinary and genital organs, indicated by strangury, bloody urine, priapism, &c.; but this condition can never be induced without other violent constitutional symptoms being also brought on, to the great hazard of life, (Christison on Poisons, p. 456) ; and we are much inclined to doubt that a person labouring under these effects is disposed to vene- real enjoyments. However, cantharides have been employed as an aphrodisiac, and for this purpose they entered into the composition of many secret remedies, such as the Venetian pastilles, Italian lozenges, love potions of Italy and Turkey, &c. to the use of which we believe many have fallen victims. The "remede de magnanimite" of Kcempfer, so called after its inventor, is com- posed of opium, musk, and ambergris, and is ex- tensively employed in the East, where it is taken daily by the great for the purpose of exciting venereal desires. From what has been said in commenting upon the different causes of impotence, it is unnecessary to prolong this article by any further notice of their medico-legal application; we will therefore conclude by deducing, in the words of Dr. Ryan from the preceding statements, the following ge- neral principles:— " 1. To declare either sex impotent, it is neces- sary that certain physical causes be permanent malformations or accidental lesions, and be evi- dent to our senses, which art cannot remedy, and which prevent the faculty of exercising a fecun- dating coition. " These causes, when rigorously examined, are few in number. " The moral causes of impotence ought not to be taken into consideration, as they would serve for an excuse for an individual accused of impo- tence." (Ryan's Med. Jur. p. 133.) Thomas Edward Beatty. INCUBUS, (from incubo, to lie or sit upon,) nightmare.- an affection coming on during sleep, and characterized especially by a sense of weight on the chest, with an inability to move, and some- times even to speak. Various affections attacking a person during sleep produce sensations, often very uneasy, but insufficient to awake him com- pletely ; and although his eyes may be open, and he may be conscious of surrounding objects, he labours under the fancies of some horriblr dream excited by the sensations in question. It is this state of imperfect possession of the faculties, and the absence of volition, which gives the peculiar character of the disease called incubus, or night- mare ; and this circumstance would entitle it to be considered as much a mental as a bodily dis- order. The causes of the sensations are, however, physical, and it is against these principally that treatment can be directed. The usual and severe form is that in which the patient, in the midst of his sleep, generally in the first part of the night, becomes conscious of the sensation of a huge weight on his breast, which oppresses and impedes his breathing. This is ac- companied by a feeling of inability to move, and often to speak, which greatly increases the discom- fort; and the fancy, ever active, embodies these phenomena into some monster, overpowering and crushing the body. Hence the superstitious names, nightmare, incubus, succubus, ephiultes, &c. In many instances the feeling of weight or pressure is less defined ; but there is a sense of general restraint and uneasiness which the mind converts into some imaginary danger, such as falling down a precipice, being pursued by an armed enemy or savage beasts, and the like, with a feeling of weight on the limbs, and an inability to escape; and this becoming so intense as to break the re- maining tie of sleep, the person awakes with a INCUBUS. 607 start, and under the temporary alarm of this ima- ginary evil. Nightmare in all its varieties is, then, a disorder of the function of sleep, (if by such a name we may designate a suspension of other functions,) and it becomes an interesting matter of further inquiry, inasmuch as it in a degree presents an analysis of the state of sleep itself. The power of volition, both in mind and body, is that which is the most completely suspended in natural sleep. Sometimes the other mental faculties are equally bo, but more generally there are trains of thought going on ; and simple sensation, although blunted, is never entirely suspended. Dr. Alison has well established the opinion formerly entertained by Whytt, that respiration is an instinctive motion excited by the sensation of black blood in the lungs; and the movements and changes of pos- ture unconsciously effected during sleep, seem to be of the same kind, and scarcely coming under the head of voluntary motions. When sleep is .coming on, there is, first, an indisposition to per- form voluntary acts, and if no awakening cause be applied, this soon amounts to inability. But the senses may still be awake, and although voli- tion cannot shape or direct them, trains of ideas result from their impressions. When sleep be- comes more perfect, however, the senses become more obtuse, and, unless excited by some consider- able impression, incapable of influencing the other mental powers that may remain still in activity. Such an impression, when produced, if of the painful kind, and insufficient directly to awake the person, will not fail to excite some or other of the varieties of nightmare. The form which it assumes will depend on the nature of the bodily impression, and it will be sufficient to illustrate the subject by one or two examples. In the case to which the term incubus or night- mare is commonly applied, that, namely, of a sense of weight and oppression on the chest, there is, we believe, an imperfect performance of the function of respiration, caused either by a con- strained posture or distended stomach; or in some cases it may be by a slight attack of asthma, ex- cited by acid or other crudities in the alimentary canal. Now such slight impediments during our waking hours are easily obviated by the supple- mentary aid which voluntary efforts can give to the respiratory process : we change our posture, draw our breath more deeply, relieve the stomach by eructation, &c.; and all this with scarcely a consciousness of the ailment, or of the act which relieves it. But during steep these movements are not at our command ; the respiratory act is more limited, and although sufficient for the natu- ral state of the function, becomes inadequate when an embarrassment renders necessary an increased exertion or new movement. In event of this, therefore, black blood gradually accumulates in the lungs, with its consequent effects of conges- tion in the right cavities of the heart, and feeling of oppression and suffocation, which, after tor- menting the mind for a time in some demoniacal form, at length reaches such an acme, as to break the spell of sleep, and awake the sufferer to the possession of those voluntary powers, by the ex- ercise of which the bodily function is restored to its natural state. No sooner is he fully awake than the bodily uneasiness is removed, and he is sensible only of the mental disquietude which his frightful dream has occasioned; and this, joined with the excitement of the restored circulation, may prevent him from readily composing himself to rest again. This we conceive to be a sufficient explanation of the phenomenon of nightmare ; without resorting to hypothetical notions of pres- sure on the solar plexus or nerves of the stomach, which, if capable of producing an effect at all. should do so equally beyond the period of sleep. Incubus may, therefore, be justly placed in con> trast with somnambulism, in which the power of voluntary motion continues, whilst the external senses are either suspended, or their impressions superseded by some internal train of ideas that engrosses the mind. As causes of incubus, we have already named disordered digestion and constrained posture; and we may now add diseases of the heart, and what- ever is capable of interrupting, during sleep, the due arterialization of the blood. We pass on to notice some other causes which may produce effects of analogous character. Such are, pains of any kind, as tooth-ach, ear-ach, &c, which, when insufficient to prevent sleep, often become the demon of a dream, tormenting the sufferer in a thousand different shapes. Cold feet are another common cause of disordered sleep. There is, however, between these causes and that which produces nightmare, this difference; that in the case of these, the person awakes to a con- sciousness of the real cause, whereas the sensation of nightmare ceases with the return of voluntary movement. Various impressions on the sense of touch may engender disturbances of somewhat similar cha- racter. On this subject some remarks by the most celebrated writer of our day are too philosophical to be omitted here. " There is one circumstance in which the sense of touch is very apt to betray its possessor into inaccuracy, in respect to the circumstances which it impresses on its owner. The case occurs during sleep, when the dreamer touches with his hand some other part of his own person. He is clearly, in this case, both the actor and the patient, both the proprietor of the member touching, and of that which is touched ; white, to increase the complication, the hand is both toucher of the limb on which it rests, and receives an impression of touch from it; and the same i» the case with the limb, which at one and the same time receives an impression from the hand, and conveys to the mind a report respecting the size, substance, and the like, of the member touching. Now, as during sleep the patient is unconscious that both limbs are his own identical property, his mind is apt to be much disturbed by the compli- cation of sensations arising from two parts of his person being at once acted upon, and from their reciprocal re-action; and false impressions ar*. thus received, which, accurately inquired into, would afford a clue to many puzzling phenomena in the theory of dreams. This peculiarity of the organ of touch, as also that it is confined to no particular organ, but is diffused over the whole person of the man, is noticed by Lucretius:— ' Ut si forte manu quam vis jam corporis ipse ' Tute tibi partem ferias, seque experiaro' NDIGESTION. 608 INCUBUS — i: A remarkable instance of such an illusion was told me by a late nobleman. He had fallen asleep, with some uneasy feelings arising from indiges- tion. They operated in their usual course of visionary terrors. At length they were all summed up in the apprehension that the phantom of a dead man held the sleeper by the wrist and en- deavoured to drag him out of bed. He awaked in horror, and still felt the cold dead grasp of a corpse's hand on his right wrist. It was a minute before he discovered that his own left hand was in a state of numbness, and with it he had accident- ally encircled his right arm." (Sir Walter Scott's Letters on Demonology, p. 43.) Another case, which Dr. Abercrombie in his interesting work " On the Intellectual Powers," cites from the late Dr. Gregory, is clearly one of the same character with nightmare, and well illus- trates our explanation of its pathology. " Dr. Gregory mentions a gentleman, who, after sleeping in a damp place, was for a long time liable to a feeling of suffocation whenever he slept in a lying posture; and this was accompanied by a dream of a skeleton which grasped him violently by the throat. He could sleep in a sitting posture with- out any uneasy feeling ; and after trying various expedients, he at last had a sentinel placed beside him, with orders to awake him whenever he sank down. On one occasion, he was attacked by the skeleton, and a severe and long struggle ensued before he awoke. On finding fault with his attendant for allowing him to lie so long in such a state of suffering, he was assured that he had not lain an instant, but had been awakened the moment he began to sink. The gentleman after a considerable time recovered from the affec- tion." (Page 274.) In this case, we have little doubt that there was a real constriction or spasm in the glottis, or some of the air-passages, which became sensible only in the confined posture of recumbency, and during the low respiration of sleep. We have little to say of \he treatment of night- mare, as it must depend on the correction of its several causes. Of these, too much or undigested food is among the most common ; hence the pro- priety of prolonging the period between the prin- cipal meal and the hour of rest, as well as of avoiding crude and indigestible articles of food. (See Indigestion.) The symptoms of acidity and flatulence are to be treated in the usual way, by magnesia or alkalies, and essential oils or other carminatives ; and when these fail, ether will often succeed in relieving the stomach of wind, and the nervous palpitation which often follows an attack of nightmare. Nor is it unimportant to pursue measures to prevent the recurrence of this disor- der ; for besides that it "---makes sleep a pairl, And turns its balm to wormwood," the disorder that it occasions in the circulation may, in those predisposed, bring on a fit of epi- lepsy or apoplexy, which not unfrequently occurs during the first sleep. C. J. B. Williams. INDIGESTION.—This word is synonymous with dyspepsia, (from foxnreirrt'w, to digest with difficulty: Th. Si>s and -fVra>;) and signifies in- terrupted, laborious, or painful digestion ; or, in other words, any derangement of that function by which the aliment, after having been received into the stomach, is converted into chyle. The function of digestion is in its nature com- plex, consisting of the harmonious action of an apparatus of several organs, all mutually depend- ent upon the action of each other. These organs, singly, are liable to be disturbed by many differ- ent causes, which may each be again modified in their operation by a multitude of secondary and adventitious circumstances ; and as every separate organ must perform its part healthily to complete the general function, so also the disorders of each individual organ may induce various derangements in the action of the whole apparatus. This view of the matter may give us some notion of the necessary diversity of the disorders of the function of digestion, and may serve to show us that, what- ever common denomination we may employ to denote its general derangement, we must compre- hend different disorders, having their seat in dif- < ferent organs, depending on different morbid con- ditions, presenting various forms, induced by vari- ous causes, and all necessarily demanding various corresponding methods of cure. For though the disorder of one of the subordinate processes may induce the interruption or the disorder of the whole function, and thus may seem to lead only to the same common disease, yet even under this suppo- sition it is not immaterial to ascertain where and in what manner the faulty series has commenced, whether the impediment may have arisen in the stomach, the duodenum, the liver, or in any other organ ; but it is also necessary to be acquainted with the particular modification of the function of either of these organs, for in this consists the na- ture or proximate cause of the disease : just as in the derangement of a watch, though the motion of the entire mechanism may be arrested by the disorder of some of its parts, the artist finds it necessary to discover in which the error lies, whether in the spring, the verge, or the balance, and whether the fault consists in excess or in de- ficiency of momentum or of matter. That which physiology leads us to anticipate, observation fully confirms; for pursuing a con- trary course of investigation, tracing effects up to their causes, we shall have still greater reason for admitting the diversity of the disorders of the func- tion of digestion. Thus it would be contrary to all the common principles universally admitted in reasoning concerning natural phenomena, to sup- pose that the most opposite symptoms could arise from the same pathological state of the digestive organs,—that causes the most contrary could in- duce the same morbid condition, and that methods of treatment in direct opposition to each other could generally overcome one and the same dis- ordered state. Thus,—that an impaired and fas- tidious, and a keen, craving, insatiable, nay, buli- mious appetite ; that an unquenchable thirst and a complete disrelish for liquids; that painful sen- sations of the stomach excited by the presence of food, and others relieved by the presence of food ; that pain before eating and pain after eating; that an exalted sensibility of the organs rendering the patient painfully conscious of the whole process of digestion, and a diminished sensibility of the INDIGESTION. 609 stomach by which a patient, though suffering from, is altogether unaware of, any disorder of the digestive function; that the more easy digestion of solid food by some, and of liquids by others ; the agreement of fat or oily substances with some, of albuminous with others; of saccharine matter with one, acidulous with another; that a deranged state of this function, constantly accompanied with a moist, pale, white, or coated tongue, or with a clean, dry, red, appearance of the tongue; with a clammy, moist, perspiring, or dry, shrivelled, im- pervious skin; with unhealthy, fetid, alvine dis- charges, or with evacuations which betray no sign of disorder; with a perfectly healthy state of the urine, and a highly unnatural state of that secre- tion ; not to mention secondary and sympathetic affections, various, contrary, and incompatible with each other;—that all these discordant symp- toms should emanate from one and the same morbid condition of the digestive organs, is a supposition altogether incomprehensible, and totally at variance with the acknowledged laws of order, constancy, and consistency, which regulate natural events. In the same manner,—that fasts and surfeits; that repletion and starvation ; that taking food too frequently and fasting too long ; that the rich- est viands, the most refined preparations of food, and cold, crude, vegetable fare, without seasoning or condiment; that the varied repast of the most pampered, with every thing to whet and every thing to sate the appetite, and the simple scanty food, greedily devoured for very existence, (whe- ther the potatoe of the poor Irish, the oaten cake of the Scot, or the salted and smoked fish of the Swedish peasant — all three well known to be equally great sufferers from dyspepsia) ; that wine- drinking and water-drinking; that dry diet and fluid diet; that excessive indulgence in sleep and ovL'rwatching; that inactivity of body and exces- sive fatigue; that indolence of mind and intense bent of thought; that the ennui of the fashionable idler, or the wearisomeness of the artisan; that the anxious cares of business, and the languor of in- ertion ; that dwelling in dry, warm, badly venti- lated apartments, and constant exposure to cold moist air; that the too frequent use of the warm bath, and the habitually squalid unwashed skin . —that all these ordinary causes of dyspepsia, so much at variance with each other in their nature and effects, should yet conspire in producing only one disease,—only one pathological condition of the digestive organs,—involves the absurd conclu- sion, that in the actions of the human body the most opposite causes have, in similar circum- stances, the same identical effects. And no less from the different nature of the means by which the disordered conditions may be corrected or removed, than from those by which they may be induced, shall we have reason to affirm that the derangements of the function of digestion are many and various: or we must sup- pose that a dry and a fluid diet; that a full diet and a scanty ; that one of animal food and one of farinaceous ; that a stimulating diet and a cooling; that distilled or fermented liquors and water; that alkalies and acids; that bitters and sweets ; that tonics and demulcents; that stimulants and re- frigerants ; that repletion and depletion ; that sip- ping brandy and sipping ices; that heat and cold ; Vol. II. —7" that the warm-bath and tne cold-bath ; — that means so dissimilar and methods so repugnant to each other, have yet the same operation upon the living body. From this diversity of symptoms, of causes, and of means of cure, it is more reasonable to infer a corresponding diversity in the morbid condition of the digestive organs, than to embrace the ab- surdity,—belied by all experience, and only con- sistent with our superficial learning in the lan- guage and grammar of the Book of Nature,—that the same things can have contrary signs, or that in similar circumstances opposite causes can pro- duce the same effects. It may seem that on this point,—the different nature of the disorders of the function of digestion, we have insisted too much ; and indeed we should have thought it unnecessary to have pressed upon the attention of the profession a matter of such obvious importance, had we not occasion daily to observe the general tendency to apply to all these disorders the same method of treatment, as if they invariably constituted merely one and the same disease. The late Dr. Cullen, by affixing a gene- ral term to these disorders, may be justly charged with having in no inconsiderable degree promoted this error ; but we are likewise not aware that any writer has felt more forcibly than himself its prac- tical inconvenience. « We have established," says he, " a genus of disease under the title of Dyspepsia, and perhaps there was no avoiding it, but it is too general, and under this generality of little use. It comprehends every irregularity in the functions of the stomach ; but these are cer- tainly of great diversity in their nature and causes, and we want more accuracy and precision than we yet have." (First Lines, &c. Thomson's Edition.) In this circumstance of the great di- versity of diseases comprehended under one com- mon name, has originated the chief impediment to the successful medical treatment of dyspepsia ; for it is self-evident that, as its different forms re- quire to be met by corresponding methods of cure, the skill of the physician must mainly depend upon the power of distinguishing them, so as to be enabled to apply to each particular form of dis- order its especial remedy, and also to adapt as nearly as possible the modification of the treat- ment to the modification of the disorder. The perfection of medical skill is most unquestionably the talent of applying to each individual case its precise, and, as it were, its individual cure,—an object which, though difficult of attainment, ought nevertheless to be the constant aim of the physi- cian—the object which he ought unceasingly to pursue, and never rest until he has overtaken. Furthermore, we are very much inclined to sus- pect that a great part of the real secret of specific remedies lies in this, that they, being only appli cable to diseases of one form and few specialties, are on this account alone so constant in their effects. In some degree in confirmation of this opinion, we may observe that when any specific disease, by complication or otherwise, assumes any remarkable deviation of character, then the specific remedy becomes dispossessed of its power. So that the success of these remedies does not so much depend upon any exclusively specific rela tion between the nature of the medicine and the 610 INDIGESTION. nature of the disease, (for we know that syphilis is to be cured by other medicines than by mercury; that psora is curable by hellebore as well as by sulphur; that agues may be arrested by arsenic as well as by quinine,) but upon the medicine having the power of curing a disease which is comparatively constant in its character, its opera- tion not being liable to be frustrated by any pecu- liar modifying circumstances ;—the disease thus specifying the remedy, not the remedy the dis- ease. This view of the matter should afford us reason to hope, that if in diseases less constant in their character and more variable in their accidents, we could meet the specialty of disease by its corres- ponding specialty of cure, we might also hope for an equal success, of which we have already some example and foretaste in the method of treating some diseases ; as, for instance, in the plan of cure followed so successfully by the Peres de la Charite in colica pictonum. It should also teach us that, instead of ransacking every kingdom of nature for specific remedies,— a pursuit literally preposterous,—it is more reasonable, and would most certainly turn to belter account, to seek for specific diseases, or by a proper specification, which is the very spirit and essence of practice, to endeavour to make them such. This is the object we have chiefly in view in the following article,— rather a sketch than a treatise of dyspepsia,— namely, to decompose the false and artificial genus comprehended under this term, to endeavour to establish a natural one in its stead, and by a pro- per classification of causes, symptoms, and me- thods of cure, to distinguish and define the differ- ent kinds of the disorders of the function of digestion,—eorum tempora et causes in quibus medicinae summa est, (Celsus),—so as to be able to establish a more close and accurate relation be- tween each variety of disorder and its most appro- priate remedy, in order that more certainty and more success may attend its application. " Ide- oque dubitandum non est, quin si medici, missis paulisper istis generalibus, naturae obviam ire vel- lent, compotes ejus fierent de quo ait poeta : " 'Et quoniam variant morbi, variabimus artes ; Mille mali species, mille salutis erunt.' " (Bacon, De Acqmentjs Scientiardm.) On reviewing the labours of our predecessors, we are confirmed in these opinions, for we find that the best observers have recognised great di- versity in the disorders of the function of diges- tion, and that though, masking them each with his own particular theory, they have dis- guised them under particular names, there re- mains a remarkable coincidence in their observa- tions and in their principles of distinguishing them. Thus we find that Hippocrates (Aphor. sect. iv. Aph. 17-20) made a distinction between gastric and intestinal dyspepsia, to which corre- sponded the passio stomachica et ventriculosa of the Methodists. (Cxlius Aurel.) This distinction Was revived by Hoffmann (De Duodeni morbis) and others, was insisted upon by Pinel, (Noso- graphie Philosoph.) and indicated by Ferriar (Med. Hist.), and Warren (Med. Transac. vol. iv.) but was never accurately and precisely laid down before the able and useful lecture of Dr. G. D. Yeats uocr the diseases of the duodenum. (Id. vol. vi.) Thus Celsus establishes several differ- ent disorders of the function of digestion, founded chiefly upon the different morbid conditions of the organs, to each disorder assigning its appropriate remedies.* In the different disorders of the di- gestive organs noticed by Celsus, not, however, to be all admitted as species really distinct, might no doubt be found most of those recognised by more modern writers ; the simple dyspepsia of the soli- dists, the chylopoietic disorder of Mr. Abernethy, and the chronic gastritis of Broussais. In the disorders of the function of the stomach the Metho- dists acknowledged two principal divisions, sto- machica passio solutionis et stricturx, (Cxlius Aurelianus) which were again by many of the sect variously subdivided. The former we shall find equivalent to the simple dyspepsia of the moderns, but in the latter maybe found a strong re- semblance to the dyspepsia from morbid sensibility and irritability of the stomach noticed by Cheyne, (English Malady) ; Whytt, (Nervous Diseases); and Pemberton, (Diseases of the Abdominal Visce- ra, &c.); but more insisted upon of late years by Barras (Traite sur les Gastralgies, &c.) and Dr. James Johnson. (On the Morbid Sensibility of the Stomach, &c.) Others, building upon shift- ing quicksands, founded the distinction of the dif- ferent kinds of dyspepsia upon their symptoms; and thus Galen, who defined dyspepsia to be any deprivation of the alimentary mass in the stomach by which it was changed into something different from its natural product, distinguished dyspepsia into two species, nidorous (xviovwiys) and acid (b&Sris), marking two of the most ordinary effects of indigestion. In this principle of distinction, Galen was followed by the symptomatic nosolo- gists, who carried it to such a height, that the dis- order was decomposed into all its various symp- toms, each being made to constitute a distinct and independent disease. To this error Cullen opposed another, still more pernicious, for he gathered together all the symp- toms of disordered digestion, and thus formed his genus, dyspepsia,- a genus illogically constructed, without species to support or sustain it, in which all previous distinctions were lost and confounded. Cullen, as we have already had occasion to re- mark, was himself more fully aware of the incon- venience of this arrangement than his followers ; but it was not until—recovering the traces of the earliest physicians, and following the more recent examples of Dessault, Richter, Schmucker, and Scarpa,—after having incurred the just criticism of Fischer, a German, and having had the subject boldly unfolded to them by Halle,j a Frenchman, and when the attention of the medical profession of England had been fully concentrated on the disorders of the digestive organs by the writings of Dr. Hamilton (On Purgative Medicines) and * Besides cruditas and concoctio tarda, which are re- peated in several places, we have the following compre- hensive passage: " Faucibus sube;t stomachus; in quo plura longa vitia incidere consuerunt. Nam modo in- gens calor, modo ivflatio hunc, modo ivfiammatio, modo ex- ulceratio afficit; interdum pituita, interdum bilis oritur: frequentissimumque est ejus malum, quo resolvitur: neque ulla re magis ant afficitur, aut corpus afficn. Lib. iv. cap. v. t Reflexions sur le Traitement de la Manie atrabiliare compare A celui de plusieurs autres Maladies chroniques, et sur les Avantapes de la Methode evacuante. Mem. de la ?cc. Roy. de Med. 1806, p. 310. INDIGESTION. 611 Mr. Abernethy (On the Constitutional Origin of Local Diseases,)—disappointed by the gen- eric treatment and dissatisfied with the generic knowledge of dyspepsia, observant practitioners felt the want of better distinctions; and a spirit of specification commenced, which, still in pro- gress, is yet, we hope, far from having reached its utmost limits. Of this spirit the earliest signs, we think, are to be found in Pemberton (Op. cit.), who was followed by Stone (On Diseases of the Stomach, 1806) and by Warren, (Med. Trans. vol. iv. p. 233.) It is to Dr. G. D. Yeats, (Med. Trans, vol. vi. p. 325,) however, that we are in- debted for one of the most important contributions. About this time appeared Broussais, a bold re- former in physic, to whom the world is under deep obligations for subjecting the nature of dys- pepsia to a searching analysis, but who in expos- ing one error plunged into the opposite, perhaps a greater one. With the same object in view, Dr. Wilson Philip, (On Indigestion, 1821,) an origi- nal observer, pointed out some valuable practical distinctions in these disorders ; and though his work may fairly lay claim to be considered the most comprehensive and the most original which we possess upon the subject of indigestion, we are of opinion that, admitting only one primary form of dyspepsia, he laid too narrow a foundation for rearing a complete and correct classification of this disease. Other candidates have since ap- peared in the same field of inquiry, who have more or less helped towards the completion of this work. In chronological order, we find Dr. Ayre, (On Marasmus,) who has chiefly considered one form of the disease ; our esteemed friend, Dr. Marshall Hall, (On the Mimoses, Lond. 1818— Commentaries on some Diseases of Females, 1827,) a physician of fine and distinguishing ob- servation, who, under rthe term of mimoses, has treated the subject of symptomatic diseases with much judgment and discrimination ; Mr. Law, (On the Digestive Organs,) who has made some original observations on the various kinds of cos- tiveness; Dr. Paris, (On Diet,) who, from the physiojogy of the function of digestion, has de- duced some valuable conclusions concerning its disorder : Dr. James Johnson, (Op. cit.,) who has checked and corrected the hasty generalization of Broussais and his adherents ; our excellent friend Dr. Sir James Clark, (On the Influence of Cli- mate, &c.,) an acute and a scrupulous observer, who has very accurately described two different species of these disorders; Mr. Cook, (On the Di- gestive Organs,) an able and observing practi- tioner, who has illustrated his distinctions of the disease with very interesting cases; and lastly, Dr. Mayo, (Essay on Indigestion, 1831,) who has called the attention of the profession to the importance of considering the influence of tempe- rance in the treatment of indigestion. But it is due to the memory of Mr. Abernethy to state, that, though he did not co-operate in the task of distinguishing and specifying the disorders of the function of digestion, he looked forward to its ac- complishment, (The Constitutional Origin of Lo- cal Diseases, &c. p. 17, 48,) and insisted on its importance. It is only matter of deep regret that he should have contented himself in his first position, instead of methodizing and digesting his ample store of accumulated experience, and of thus advanc- ing forward to the consummation of his enterprise. Digestion, like any other function of the body, may be disordered in consequence of some morbid condition of its proper organs, or it may be dis- turbed in consequence of the morbid condition of the body in general, or of some organ in particu- lar. This affords the leading division of dyspepsia into idiopathic or primary, and deuteropathic or secondary, the most important practical distinction of every disease. But the disorder of a function may arise either from some change of action of the organ,—some new modification of its vitality, —or it may depend upon some lesion of structure ; from this is naturally deduced the division of pri- mary dyspepsia into functional and organic. And as the disorder of a function may be either the effect of disease of the whole body, or of some particular organ or apparatus of organs, secondary dyspepsia may be conveniently divided into symp- tomatic, forming only a part of a more general disease, and sympathetic, the consequence of con- sent with the disorder of some other organ. The disorder of the function of an apparatus of organs may either predominate in some particular organ, or may involve the whole apparatus; a consideration which, in the instance of dyspepsia, leads to the distribution of the previous divisions into four natural orders, according as the stomach, or duodenum, or colon is the exclusive or princi- pal site of the disease, or as it involves more or fewer of these parts at the same time ; whilst the different morbid conditions which any of the par- ticular organs, or the whole apparatus may assume, afford an easy method of distinguishing these or- ders into different species. The morbid conditions by which the action of the organ may be modified, have been recognised by the best observers under the terms, atonic, irritable, inflammatory, and follicular or pituitous.- in these morbid condi- tions, easily cognizable and perfectly capable of verification by the symptoms, consist the proxi- mate causes of functional dyspepsia. Those in which the structure of the organ is altered, admit of being distributed according to the nature of the structural lesion, or as the function becomes dis- ordered by change of capacity, sensibility, or in its secretory function. Symptomatic dyspepsia might be divided into species according to the con- stitutional disease in which it might originate, whether fever, plethora, anaemia, asthenia, or any other form of constitutional disorder ; and sympa- thetic dyspepsia would admit of a convenient di- vision according to the organ from whose disorder it took its rise, as the brain, the lungs, the skin, the kidneys, the uterus, or any other organ. Such is our plan of a complete natural classifi- cation of the various disorders of the function of digestion, the result of close and continuous ob- servation, combined with a methodical arrange- ment of cases; those being grouped together whicu coincided in causes, symptoms, and means of cure, and each group being denoted by the pathological derangement on which we supposed them to de pend. Pursuing this course, it will be observed that we have arrived at distinctions nearly coin- ciding with those of our predecessors, a strong proof of their correctness, which, verifying our observation by that of the great masters of our art, 612 INDIGESTION, establishes these distinctions on a long line of un- interrupted experience. But before concluding this part of our subject, we must observe that, whatever objection may be taken to our pathology, to our opinions, or to the terms by which the dif- ferent species are denoted, it will afford no ground for denying the existence of those species; for being founded on observation and formed induc- tively, they must survive any error of opinion ; and the classification, being natural, has this ad- vantage, that as any new species of disorder of the function of digestion, may be discovered and as- certained, (as no doubt, hereafter, many most cer- tainly will be,) their place or niche will immedi- ately be found without the necessity of the whole structure being broken down and rebuilt, as con- stantly happens with artificial classifications. The nature of the present work does not, however, ad- mit of the possibility of following up the whole of this plan, and requires that we should confine our- selves to the first division of the subject, idiopathic functional dyspepsia; but we shall endeavour, by way of help, to avail ourselves of the corre- sponding facts of the other divisions, to confirm, explain, or illustrate any part of this. The fol- lowing outline presents the plan of classification, and enumerates the several species to which we hope to be able to refer the greater part of the va- rieties of this disease. idiopathic functional dxspepsia. I. Gastric. a. Atonic. b. Inflammatory. c. Irritable. d. Follicular. II. Duodena. a. Atonic. b. Inflammatory. 1. Strumous. c. Follicular. ni. Colonic. a. Atonic. b. Inflammatory. c. Irritable. d. Follicular. IV. Gastroenteric . A. Enopathic. The same morbid condition obtaining throughout the whole ali- mentary canal. B. Polypathic. Different morbid conditions existing in different parts of the alimentary canal. I. GASTRIC DYSPEPSIA. The disease consisting chiefly in disordered function of the stomach. i—atonic gastric dyspepsia. Synonyms—Airtxptr,, T:\napovfi, Hipp,- stomachi resolutio, cruditas, Cels,- frigiditas stomachi, Prosp. Alpin ; anorexia, plethorica, arthritica, paralytica ; nausea a cacochylia.; vomitus a saburra" ; flatulen- tia, acida, nidorosa; cardialgia a saburra, paraly- tica; gastrodynia saburralis, Sauvages,- dyspepsia idiopathica ; anorexia atonica, Cullen,- saburra materiae mobilis, Auctor. Var.,- indigestion first *tage of W Philip ; dyspepsie, apyretique, asthe- nique, Broussais,- dyspepsie per asthenie de l'6sto- mac, Andral; embarras gastrique. General Character.—Loss of appetite, some- times nausea and loathing of food, with occasional inclination to vomit, but seldom sufficient to pro- voke vomiting ; thirst after eating, not after diges- tion ; heartburn; acid, nidorous or putrescent eruc- tations ; sense of weight at the epigastrium after a meal; power of digestion more particularly im- paired as regards oily, fatty, mucilaginous, saccha- rine, and acidulous substances; tongue pale, flabby, whitish or slimy, more or less coated ; bowels gene- rally confined ; urine clear and copious, devoid of its natural smell, deficient of urea, sometimes albu- minous, and then disposed to putrefy on standing; pulse somewhat weaker, generally slower than natural; temperature of the body lower than na- tural and unequally distributed ; extremities cold, countenance pale, skin flaccid, eye dull; listless- ness in expression, languor in motion; obtuseness of feeling, mind impaired in vigour, in all things a want of alacrity. These symptoms depending chiefly on the mor- bid condition of the stomach, are subject to con- siderable variation from the presence of crudities, being different as the stomach is full or empty. But the general character of the symptoms is not destroyed by this cause of variation; for, as the different morbid conditions give rise to different symptoms, so the presence of crudities excites symptoms, subject and corresponding to each mor- bid condition. The symptoms also vary as they may happen to be direct or indirect, as they emanate immedi- ately, from the suffering state of the stomach, or, mediately, as the suffering of the stomach is felt and reflected in the sympathetic disorder of some other organ. The variation and diversity of the symptoms of atonic gastric dyspepsia arising from each of these sources, will be noticed in describing this disease according to the two forms under which it presents itself, as it takes place suddenly, or as the symptoms manifest themselves in a slow and gradual manner. a. Acute Form. — In the first case, which might for the sake of distinction be termed acute atonic gastric dyspepsia, corresponding more pre- cisely with the dnexpiTi of Hippocrates, the cruditas of Celsus, and the embarras gastrique of the French, the disorder comes on in distinct attacks or paroxysms, the patient enjoying in the intervals a comparatively healthy state of digestion. As the disease continues, these attacks are repeated at shorter intervals, whilst the interval itself becomes a state of less perfect health, and the disease, growing more and more habitual, at last arrives at that state in which disorder of the digestion is more or less constantly present, though in a degree less severe than during the intensity of the paroxysm. These paroxysms vary in their duration from three or four to twenty-four hours or even longer, being shorter in young, and longer and more fre- quent in older persons and those most disposed to them. As the paroxysms are induced by accidental causes, their return is of course irregular; but, as has just been observed, the liability to them in- creasing with repetition, slighter causes are capable of inducing them, and they are therefore, extern paribus, more frequent in old than in young sub- INDIGESTION 613 Jects, some suffering a paroxysm every two or three days, others once in two or three weeks. The patient may have been feeling dull or heavy, have been losing his usual relish for food, may have observed his bowels less regular, or have been complaining of that peculiar sensation at the root of the tongue, and sometimes through the whole length of the oesophagus, which constitutes what is called heartburn ; but as it is generally during sleep that the paroxysm comes on, it is in the morning that the symptoms of indigestion are first distinctly pronounced. The patient awakes with headach, or feels heavy and languid, devoid of his wonted alacrity, and indisposed to leave his bed. There is rather flatness than lowness of spirits, with sometimes slight confusion or indistinctness of intellect. The tongue feels clammy, sometimes it is also dry; there is generally an insipid taste, but sometimes it is milky or sweetish, occasionally sourish. The appetite is impaired or entirely de- ficient, sometimes with nausea, amounting occa- sionally to a disposition to vomit, and when vomit- ing does occur, phlegm only is thrown up ; or there is a capricious appetite, craving for some unaccus- tomed kinds of food, but which are seldom agree- able if presented. When the attack is slight, the symptoms are occasionally suspended by taking some grateful food, the action and sensibility of the stomach being revived and restored by being gently solicited. Generally there is an aversion to acids, sweets, or any thing insipid. There may be heartburn, eructations of acid, of oily or rancid matter, sometimes of hepatic gas, or a feeling of weight or load at the stomach, giving the sensation that the process of digestion is entirely at a stand. In other cases there is a sense of constriction of the fauces, with a watery secretion from the back part of the mouth. Sometimes the patient is suddenly awakened by a cramp in the legs, or violent spas- modic pain in the stomach, (gastrodynia sabur- ralis,) accompanied frequently with violent retch- ing. The face is pale, the countenance inexpres- sive, and the eye dull and heavy, with sometimes a dark discoloration or puffiness round the eyelids. The pulse is somewhat weaker, generally slower, usually soft, frequently languid and feeble, some- times small and quick, occasionally intermitting. The skin is moist, clammy, and flaccid, and gene- rally cold. The feet and hands are cold, with a general feeling of chilliness or creeping over the skin, sometimes amounting to rigors : sometimes there is a particular coldness, stiffness, or numbness of the fingers. The tongue is pale and flabby, generally moist, and covered with a loose slimy white coat, more or less thick. The bowels are constipated ; sometimes there is a sensation of inaction or of dryness in them. In the commence- ment of the paroxysm the urine is pale and co- pious, less frequently it is deficient: but in its de- cline it becomes high-coloured and turbid, deposit- ing a red sediment of lithic acid, or of lithate of ammonia, or the amorphous sediments of the lith- ates generally. The above is an account of an attack of atonic dyspepsia connected with, or arising from, a state of repletion of the stomach; but the same state may arise from that organ being deprived of its accustomed stimulus or supply, as occurs to deli- cato people when they pass tho hour of their 3d accustomed meal. They have a great sense of weakness, sometimes faintness and trembling; they lose their appetite, have a bitter taste, and a sensation of weight or sinking at the praecordia > their countenance becomes pale and wan, their eyes sunk; they lose their temper and their spirits; their urine becomes hot, scalding, and high-coloured ; if they attempt to eat, they have no appetite or a disgust for food, and if they eat, all their symptoms are increased. They have a difficulty in getting to sleep, or are disturbed with dreams. Giddiness, headach, coldness, trembling, constant yawning, are common attendants of this state of the stomach. The sympathetic affection most universally con- nected with this form of disordered digestion is headach, which, being generally associated with nausea, is well expressed by the common term sick-headach. (Fothergill, Med. Obs. and Inq. vol. vi.) It affects generally one particular part of the head, chiefly the forehead, or is seated over one or both eyebrows, and sometimes in the ball of the eye. The pain is heavy, dull, and over- powering, but seldom acute. With the headach, the whole nervous sensibility appears to be con- centrated in the head, where it is much increased, being accompanied with intolerance of light and of noise. The headach begins sometimes to abate on a vomiting of bitter or acid matter, but sleep is the most constant harbinger of relief. As the headach abates, it leaves a general soreness or tenderness of the head, and the squeamishness and general uneasiness continue for some time after. The other affections frequently observed, sym- pathetic of acute atonic gastric dyspepsia, are a sensation of mistiness before the eyes, indistinct- ness or offuscations of vision, sometimes amount- ing to temporary amaurosis, and more rarely, di- latation of the pupil, without any defect of vision ; deafness, and sometimes unusual sounds in the ear; loss of smell or taste, or depravation of these senses, so that unnatural smells and flavours are perceived, when there is no external impression; in delicate and sensitive persons, fainting, and in women hysterical fits occur; trismus, convulsions, and, in those predisposed, a fit of epilepsy; loss of voice, paralysis, a fit of apoplexy; spasmodic cough, a fit of asthma or of angina pectoris ; neu- ralgia and various local pains, temporary delirium, a fit of mania, urticaria, erysipelas, and some other cutaneous affections. But many of these complaints are more especially connected with one of the effects of this disorder, distension of the stomach, the direct symptoms of which are rest- lessness, a sense of oppression, and anxiety. Causes. — This particular form of dyspepsia most frequently makes its first appearance in early and middle life, from puberty to the age of thirty, less commonly after forty. Women are more subject to it than men. It is more common in cold than in warm climates, in cold than in warm weather; but moist climates and moist weather, whether warm and moist or cold and moist, have a great influence in predisposing to it. The mid die and upper stations of life are most exposed to it. The predisposition to this complaint is some- times hereditary, the person inheriting a relaxed constitution, or one of exalted nervous sensibility. 614 INDIGESTION. but of weak powers; for it affects rather the cold plegmatic and the asthenic habits than the san- guine or bilious temperaments ; and chiefly those of that peculiar relaxed constitution characterized by want of firmness, resistance, and elasticity, by a soft relaxed skin of a pale colour, by a tendency of the hands and feet to be cold, by a languid cir- culation, by the functions of the body being im- perfectly performed, either less actively or irregu- larly, and by the secretions being rather disposed to be copious than scanty, But this particular constitution may be also acquired by certain habits and manner of living, as by want of exer- cise, by indolence of body, by indolence as well as by intense or long application of mind, dispro- portionate to the strength of the body ; by effemi- nate habits and enervating excesses, by the too frequent use of the warm bath, by dwelling in close, warm, ill-ventilated apartments, by steeping in hot soft beds, and by over-indulgence in steep. The habits of certain trades and professions con- tribute considerably to this disease ; the confine- ment to the desk, the sedentary occupations of sempstresses,milliners, mantua-makers, and tailors; those of the loom, of the tambour, of the stocking and lace-frame, and of laundresses who work much over a stove. For all these various reasons, this complaint prevails more in the town than in the country,* and is, as it were, endemic in the hoarding-school, the boudoir, and in manufac- tories ; at court, at college, and in prisons; and under the title of asthenia has been very well de- scribed by Dr. Willan in his account of the dis- eases of London. The habit which predisposes to this disease may also be a consequence of loss of blood, excessive suckling, seminal weaknesses, leucorrhcea, or any cause which exhausts or de- bilitates the system in general; of the habitual use of narcotics in excess, as tobacco, conium, or henbane, which injure the sensibility of the ner- vous system. But the cause which has the greatest influence in disposing to this disease above all others, is habitual incaution in diet, both in respect of kind and quantity of food ; for it matters not whether the stomach be frequently offended by that which it cannot subdue, or mor- bidly distended, and thus rendered incapable of appropriating that which is wholesome. For this reason offences against quantity are not less inju- rious than offences against quality, and both are doubly baneful when the repast consists of many kinds indiscriminately mixed. To these may be added an irregularity in the times of taking food, the meals being sometimes too frequently repeated, or the intervals too long protracted. Where the predisposition is strong, or the pa- tient has suffered long, slight causes are sufficient to produce a paroxysm of this form of dyspepsia ; but where even neither natural nor acquired pre- disposition exists, certain circumstances are capa- ble of producing an accidental fit of dyspepsia, and of thus laying a foundation for its recurrence. Amongst such may be enumerated any sudden or unusual disproportion or want of due relation be- tween the digestive organs and the ingesta, a ne- glected state of bowels, intense application or strong emotions of mind, especially soon after a * At imbecillis stouiacho, quo in nuuiero magna pars mbauorum.—Celsus. meal. A sudden fit of passion, or great joy, will sometimes instantly produce this affection. They will also sometimes remove it; " We have more than once," observes Pemberton, " known a neces- sity for a great exertion of mind to supersede the stomach affection, which has re-appeared on the necessity being withdrawn." Violent exertions or much fatigue of body, either immediately be- fore or soon after a repast; any causes which in- duce sudden distension of the stomach, as a bulky meal of soft, sweet, pultaceous food, over-indul- gence in fruit, large quantities of cold, iced, warm, acid, or sweet fluids suddenly swallowed, more particularly if the process of digestion is still in progress; a sudden change of diet from animal to vegetable food; mucilaginous drinks, &c; eat- ing hastily after fasting too long, missing the wonted meal, or taking it out of season; taking a cold or warm bath immediately before or soon after a meal; medicines, particularly calomel, co- nium, henbane, digitalis, ipecacuanha, especially administered at an improper period of digestion ; venesection when performed soon after a meal, or leeches applied to the epigastrium under the same circumstances. In the delicate and predisposed, we have observed it excited by variable weather, by exposure to a cold and moist atmosphere, by the application of cold to the skin, particularly to the lower extremities, by sitting in a room of low temperature, so low as to cause a sensation of chilliness, by a change of wind, particularly from a north to a south-west gate. b. Chronic form.—In this form of indigestion, which might be termed chronic atonic gastric dyspepsia, the nXTjapovfi of Hippocrates, the dis- order creeps on in a slow insidious manner, and becomes scarcely apparent until it has existed for a considerable time. Some of the following symp- toms, more or less grouped and combined to- gether, afford indications of its approach: drowsi- ness in the day, particularly after a meal; sleep deep, heavy, prolonged beyond the usual hour; the sleep ceases to be refreshing and is disturbed with uncomfortable dreams, sometimes with in- cubus, and the patient awakes in the morning feeling fatigued, and having a disagreeable taste in his mouth;—less aptitude for exercise, frequent stretching and yawning, torpor or sluggishness in movements, which begin to require a greater ef- fort : diminished activity of mind, mental occu- pations becoming laborious; diminished enjoy- ment of the natural appetites, less relish for food, by degrees diminished appetite, especially for breakfast; a sensation of heaviness in the head, of fulness or itchings in the forehead, of fulness or stuffing in the nostrils, particularly after a meal, with a frequent desire to emulge them; a feeling of huskiness in the throat, particularly in the morning, with expectoration of a grey, viscid phlegm, and sometimes an increased flow of saliva. A sensation of fatigue and weariness, sometimes amounting to pain, begins to be felt in the whole or in particular members of the body ; a heavy dull pain in the head with drowsiness, a sensation of weight at the stomach, heartburn, 01 a sensation of internal heat after meals, more especially after breakfast; and the bowels begin to be habitually constipated. These symptoms aro followed by distension after eating, by flatu INDIGESTION. 615 lence when the stomach is empty, at first relieved but afterwards increased by eating; by eructations j of the last meal, sometimes acid, sometimes pu- trescent; by change of complexion, paleness of the face, which is bloated ; by deficient alvine evacuations, altogether disproportionate to the in- gesta, sometimes by diarrhcea of liquid and undi- gested food, which affords temporary relief; or by perspiration on the slightest exertion. The dis- order may continue for a considerable time in the degree manifested by these symptoms without pro- ducing any serious derangement of the health; and, by change of habits, of air, and of exercise, they may be entirely removed. But the long continuance of the disorder brings other derange- ments. The bowels become habitually confined, and there is a constant sense of fulness, disten- sion, and dryness in them. The repasts cease to be pleasant or satisfactory, but are always followed by oppression ; the extremities are generally cold, the power of exercise begins to diminish, the pa- tient begins to lose flesh, and has a constant sen- sation of weakness, faintness, or trembling, or is troubled with vertigo or headach, with noise in the ears, throbbing of the temples, cough or fits of palpitation. The mouth feels clammy; the tongue is more or less furred, or has a whitish sodden appearance ; sometimes the saliva runs from the mouth, and there is a viscid frothy secre- tion from the fauces, or there is frequent spitting. The skin is generally moist and clammy, some- times cold; and perspiration is excited by the least exertion. The urine leaves a coating of lithic acid at the bottom of the utensil. The powers of the intellectual faculties, particularly of attention and memory, are remarkably diminish- ed ; the feelings are obtuse tind little alive; the patient begins to feel flat, dull, and timid without reason, or sinks into a state of apathy or indiffer- ence, whilst the physical sensibility becomes mor- bidly increased, manifested by a remarkable sensi- tiveness of changes of weather, particularly of the approach of moist weather or storms. The further course of the disease is generally very much influenced by the use of remedies, and by the different methods of treatment had recourse to ; for if not properly administered, they are mainly instrumental in determining various forms of dyspepsia hereafter to be described. If the dis- ease be allowed to follow its natural progress, it terminates by inducing a disordered state of the function of the duodenum and liver. More rarely the disease undergoes an entire change, which oc- casionally leads to a natural cure, in consequence of a fixed point of irritation becoming established in the intestines, the activity of the stomach is ex- cited and increased, and the disease is transferred to the intestines in the form of diarrhcea, which, subsiding spontaneously or artificially, leads to a permanent relief of the primary disorder; but which continuing lays the foundation of a form of inflammatory dyspepsia to be treated of in the se- quel of this article. Causes.__This variety of atonic gastric dys- pepsia, is, with some exceptions, the consequence of the same causes as those which give rise to the first variety. It is less the effect of hereditary dis- position, and more the result of the remote causes of dyspepsia operating insidiously upon a healthy constitution. In this way it is induced in people of regular and orderly lives, who seldom commit any offence against temperance or sobriety, and in peopte of sedentary, monotonous, indolent habits. It affects literary (Omnesque paene cupidi litera- rum—Celsus,) and professional people, clerks, shopkeepers, and is met with in all constitutions, but in men rather than in women : it occurs gen- erally late in life, and prevails most in winter. A disproportion between food and exercise is the great cause of this disease ; but indulgence in much warm liquid, as tea, pre-eminently the En- glish breakfast, in relaxing slops, in meals too fre- quently repeated, deluging the stomach with tea whilst digestion is in progress, and the habitual use of malt liquor, are the most fertile sources of this disorder. Pathology. — The morbid condition of the stomach, from which proceed the various symp- toms of atonic dyspepsia, has been recognised by the very earliest physicians ('Arovtri too Tiiipovros 5eppov, Kai -&iv!;i rrjs KOiXir);—Aretxus,) under the term of atony, or some word of corresponding meaning, as asthenia, relaxation, resolution, or debility ; and instead of this morbid condition of the stomach having been overlooked as the proxi- mate cause of indigestion, it has, on the contrary, been too generally admitted, and the species of dyspepsia which is now under our consideration has accordingly been made to represent the whole genus, every symptom indicative of indigestion, every sign of chylopoietic disorder, having been attributed to debility or want of tone of the sto- mach. A state of collapse, of deficient vital power or nervous energy, under various modifications and descriptions, has, as we have already observed, been universally admitted ever since the phenom- ena of life have been an object of observation. By the operation of certain causes, the whole body may he involved in this morbid condition ; by their more partial application, particular parts or indi- vidual organs only may be placed under its influ- ence. But as it is the nature of the body for a part to assume the state of the whole, and for the whole body to partake of the action of a part, whether the disorder be at first induced in the general system, or only in some particular part, in either case they both ultimately arrive at, and ter- minate in, the same condition. The digestive or- gans are not exempt from the operation of causes capable of inducing this morbid condition, and when the stomach, more especially, is placed un- der its influence, the disorder of the digestive function which we have just described is the con- sequence. But by the term atony of the stomach we ex- press a general and complex condition, resolvable into several subordinate or particular ones ; for under it are included—1. a deficient innervation of the stomach, by which some unknown vital action is withdrawn, and the natural affinities of the constituent elements of the alimentary mass, instead of being directed and controlled, obey the laws of inorganic matter, rather than the special influence of organic life ; 2. a depraved or defi- cient secretion of the gastric juice ; 3. a diminu- tion of the absorbing power of the stomach, by which the digestion of liquids is rendered more 616 INDIGESTION. difficult; and 4. a diminution of the contractile power of the muscular fibres of the stomach, by which this organ is prevented from compressing its contents, as in health, that the food and gastric juice being brought into contact may be exposed in successive and appropriate portions to each other's action. It would not be difficult to trace the process by which the causes of dyspepsia induce the fore- going results. If we consider the nature of their operation, we shall find that they admit of a clas- sification corresponding to the several morbid con- ditions just enumerated. Thus by sedentariness and repletion is destroyed the healthy equilibrium of waste and supply; for, as has been well ob- served, as, by virtue of the consent of every part of the living body, all the functions of assimila- tion can only be preserved in health so long as the stomach digests well, so on the other hand the stomach can only digest well so long as the diffe- rent functions which convey and deposit the nu- tritious matter in the various tissues are healthily performed, which, however, cannot be the case when from indolence or similar causes there is both a deficient consumption of this nutritious matter, and a defective elimination of the effete and worn-out particles. The consequence is, that the whole process of nutrition languishes, and the stomach losing the stimulus of demand fails in its activity. This principle, recognised so early as Hippocrates in his famous dictum, ii6n oi> Svvarai loSiu)v avSpunros byiaivuv,T)v pfj xat wovtij, explains the operation of many of the causes of dyspepsia, showing how they may induce a deficient inner- vation of the stomach; and this will be the result whether the equilibrium be destroyed from the consumption being deficient or the supply being excessive. Then we may again observe that some causes induce the same effect by destroying the corresponding and harmonious action of the diffe- rent parts of the alimentary canal; others by di- minishing the natural sensibility of the stomach, either directly, as narcotics, or indirectly, by con- centrating the nervous energy in the head, by in- tense thought and application; whilst others arrive at the same result, diminishing the innervation of the stomach, by withholding or diverting from it a proper and sufficient supply of blood, from which results an unhealthy and insufficient supply of the gastric juice ; very contrary to the opinion of Parry, who attributes idiopathic dyspepsia to a morbid fulness of the vessels of the villous coat of the stomach. Other causes act by diminishing the contractile power of the muscular coat of the stomach, either by producing a relaxed state of its fibres, or by sustaining them in a state of unnatural distension, by which they lose the power of re- suming their natural state : others effect their deleterious influence by withdrawing from the stomach the healthy and accustomed stimulus which calls it into action, so that it not rarely happens that, after having been more or less sti- mulated, withdrawing suddenly every source of excitement, the stomach falls into the opposite state, one of perfect atony ; and this frequently occurs, whether it be the body in general, or the stomach in particular, which is deprived of its wonted stimulus and excitement. This view of the operation of the causes which induce atonic gastric dyspepsia, and of the various morbid conditions which they produce, we shall find very much confirmed by considering the state of the body and of other organs in those cases in which this form of dyspepsia is secondary, whether symptomatic of general disorder, or sympathetic of the disorder of some particular organ ; for we shall find that the dyspepsia of simple general plethora, (anorexia plethorica,) of asthenia or general debility, (Anorexia exhaustorum, cardial- gia lactantium, Sauvages.—Dyspepsia paralytica, Cullen,) whether induced by venereal excess or weakening discharges, of general anaemia, (Dyspepsia menorrhagica, dyspepsia chlorotica,) whether from loss of blood, or disorder of the pro- cess of sanguification, (Halle, v;d. Anemie, Diet. des Sciences Med.,) and the dyspepsia of gout, (Anorexia arthritica, cardialgia arthritica.—Sauva- ges. Dyspepsia arthritica,—Cullen,) all belong to this form. In like manner we shall find that the dyspepsia sympathetic of cerebral irritation, (Vo- mitus cephalalgicus,) of hydrocephalus, of vertigo, (Nausea marina,) and nervous headach, from ac- cidental injuries of the head, from the action of narcotics upon the nervous system, as tobacco, digitalis, hemlock ; the dyspepsia which follows a fit of inebriety, (Dyspepsia inebriorum,) the dys- pepsia of constipation, the dyspepsia of some forms of disordered uterine function, the dyspep- sia of rigid continence, (Nausea a semine corrupto. —Galen,) and the dyspepsia which alternates with an atonic state of various other organs, (Gas- trodynia metastica,—Cullen,) belong also to this form. The dyspepsia which is produced in ani- mals by the division of the eighth pair of nerves, offers a strong analogical proof of the same" posi- tion. • We may also find the view we have taken of the proximate causes of atonic gastric dyspepsia amply confirmed by examining cases of dyspep- sia from organic lesion ; for we shall find that, as the organic changes approach the morbid condi- tions of this form of dyspepsia, the symptoms of atonic gastric dyspepsia are present. Thus, when the stomach has been found unusually large and distended, with or without obstruction of the py- lorus; (Bonet. sep. iii. vi. 1. Lieutuud M. etc. Par. 1756, 223. Cardialgia paralytica.—Sauva- ges. Johnston, Med. Observ. and Inq. ii. 107. Richt. Chir. Bibl. iii. 78. Anderson, Med. Comm. Ed. ii. 294. Douglas, M. Med. Soc. Lond. iv. 395. Abercrombie, case v. p. 32, p. 70;) thus also in induration and thickening of the coats of the sto- mach ; (Abercrombie, xvi. p. 59;) in the early stage of diseases of the pylorus, or where there exists any obstruction to the egress of the chyme from the stomach; (Abercrombie, xvii. p. 61. Bonet. sep. iii. vi. 2;) in atrophy of the mucous and muscu- lar coats of the stomach; or when the stomach has been found lined with a false membrane; in the softening or solution of the mucous membrane of the stomach, (Ramollissement des Vieillardsi) to which we may add anaemia of the alimentary canal, which is always accompanied with more or less attenuation of the coats,—a pathological state not rarely presented to the anatomist, but chiefly observed in the bodies of those exhausted by chronic diseases, or who sink during the conva lescence of a severe fever ; (Andral, Path. Anat.;) INDIGESTION. 6I-1 in all these cases the disorder of the function of digestion approaches the form of atonic gastric dyspepsia. But though approaching and resem- ling each other, the two disorders afford data of distinction; 1. by the absence of sympathetic affections ; in the organic diseases of the stomach, the sympathetic headach and other disorders being never observed; 2. by the stomach being the seat of painful affections; 3. by the greater constancy and invariableness of the symptoms; and, 4. by the attendant emaciation. • Method of cure.—The treatment of atonic gastric dyspepsia is conveniently divided into the means of affording relief when the disorder is ac- tually present, and the means of preventing its return. I. The means of affording relief when the dis- order is present consist in, 1. removing crudities or offensive substances directly from the stomach by vomiting; 2. in endeavouring to remove indi- gestible substances from the stomach, and restore its action by exciting that of the intestines ; 3. by allowing the stomach to repose until its action begins to revive, and by soliciting its action as its sensibility returns; and, 4. by relieving the second- ary affections which arise from the disordered function of the stomach. 1. Emetics afford the proper means of removing offending substances from the stomach. In the beginning of a fit of dyspepsia, in the earlier period of the disease, or in cases of accidental dyspepsia, an emetic frequently at once arrests the progress of the disorder, and we have known some persons subject all their lives to frequent parox- ysms of the acute form of this disease, who have experienced more relief from emetics than from any other remedy. If, however, the paroxysm has continued long, or the disease has become habitual, they cease to bring their former relief, and, when unnecessarily administered, are always pernicious ; (Inutilis est gracilibus et imbecillum stomachum habentibus,— Celsus) ; for vomiting, whether spontaneously occurring or artificially ex- cited, becomes itself a frequent cause of stomach complaints. It was a remedy much used and abused by the Romans, affording them the means of indulging their gluttony ; qui quotidie ejicien- do vorandi facultatem moliuntur.- but it is a short-sighted compromise, granting no impunity ; it changes but does not take away the penalty of the vice. The immediate symptoms which more particu- larly indicate the administration of an emetic are nausea, a sense of weight at the praecordia, bitter eructations, the internal sensation of crudities, the mouth overflowing with saliva, and paleness of the countenance. When vomiting is strongly indicated, it is easily excited. The gentlest means are therefore to be preferred, warm water, simple, or containing a little culinary salt, warm infusion of chamomile flowers, infusion of mustard-seed, and ipecacuanha, are means of different degrees of power which may be occasionally had recourse to ; sometimes simply titillating the fauces answers every pur- pose. After vomiting, cold water is the best remedy for restoring the stomach ; in summer, iced water; sometimes Seltzer water. These should be sipped in small quantities at a time. After a Vol. II. 78 3 B * proper interval, a small quantity of light palatable food may be taken. 2. By virtue of the sympathy which exists between different parts of the alimentary canal, the function of the stomach is frequently restored by exciting that of the bowels, and therefore, when the attack has continued beyond that state in which emetics promise relief, or when they have failed of relief, purgatives are to be had recourse to. They should consist of such as are warm in their nature and speedy in their operation, but neither stimulating nor drastic. Rhubarb is de- cidedly the best. It may be advantageously com- bined with, and modified in its action by, magne- sia, by carbonate of soda, by tartarized potass or soda, in conjunction with some aromatic or car- minative distilled water, with a small quantity of the tincture of rhubarb or compound decoction of aloes, and a little of the compound spirit of lav- ender, or aromatic spirit of ammonia, as the state of the stomach or accompanying circumstances may suggest or indicate. In this form of dyspep- sia senna is not proper, and saline purgatives alone are injurious, as are also the mercurial pur- gatives. It is generally necessary to continue to promote the action of the bowels during the decline of a fit of dyspepsia, and for some days afterwards. For this purpose a few grains of rhubarb, in com- bination with a little soda or carbonate of ammo- nia, taken an hour before the two principal meals, answers very well; or the following formula of Fothergill affords a remedy well suited to this intention : R Aloes gi. Rad. rhei, rad. glycirrh. aa. §ss. Spirit, lavend. comp. gss. Aq. calcis, ^ viii. Infunde per horas xii et cola. Colaturae cochi duo bis terve die sumenda. On some occasions it suffices to relieve the bowels by clysmata, and when this method is found to answer, it is always to be preferred. 3. It would seem unnecessary to insist on the necessity of abstinence during a fit of dyspepsia ; but it is not always superflous, for the morbid sensations of the stomach sometimes imitate, and are readily construed into, that of hunger. They ought not, however, to be listened to, for abstinence is the chief remedy. The patient may drink, from time to time, a small cup of green tea, with- out sugar or milk, or a cup of coffee, moderately strong, with as little as possible of those ingredi- ents ; or he may take a small quantity of light pure broth, sufficiently sapid to be agreeable, with a small quantity of state bread or dry toast. As the natural sensibility of the stomach returns, it may be solicited by a little animal food, such as is palatable and easy of digestion. If the patient is accustomed to the use of wine, but not otherwise, it may be necessary to allow a moderate quantity with the meat: the red wines for this purpose ar generally to be preferred. Farther than this the stomach is not to be excited. All such means of doing so, as brandy, capsicum, or food containing it ; mustard, piquant sauces, curries, or high-fla- voured dishes, arc to be avoided. In this category we would also place bitters, and those medicines improperly termed stomachic. The action of thri 618 INDIGESTION. stomach ought never to be hurried or forced by stimulants; it can only bear them when its func- tion has been already to a certain degree restored. Before this period they only tend to fix the disease. The state of the tongue affords the best guide for the use of food and its quality; as it is moist and disposed to clean they are admissible, and as it is drv they are to be forbidden. 4. Besides the general treatment of a fit of dyspepsia, there are painful symptoms and sym- pathetic affections which ought not to be over- looked, and, indeed, the relief of which is not without its influence upon the primary disease. But in administering means of relief for such affections, it is important to take care that they do not oppose, but are made subservient to, the plan of general treatment. Heartburn. — Dr. Fothergill's formula, men- tioned above, affords a good corrective of this symp- tom ; magnesia, liquor potassae (gut. x. pro re nata), ammonisB subcarbonas (gr. v.), lime-water; sometimes alkalies combined with bitters. We have found Seltzer water a very excellent remedy; and at other times repeated small quantities of very cold or iced water, taken when the stomach is empty. Heartburn which is habitual or of long standing is sometimes more effectually relieved by acids than by alkalies. Pemberton mentions having seen it subdued by the juice of half-a-dozen lemons taken daily, and recurring on the remedy being left off; but we imagine that the heartburn here meant is not that which proceeds from aci- dity, but the burning sensation depending upon a heated state of stomach, a symptom of another form of dyspepsia. In heart-burn, nitric acid is also a useful remedy ; five drops of the diluted acid may be taken every four hours. We have also used successfully the phosphoric acid with the same intention, and have found it more agreeable to the stomach. Flululence.—This symptom is best relieved by combining a carminative with the aperient. Equal parts of the pil. rhei comp. and pil. galbani comp. form a convenient remedy ; carbonate of ammonia in mint-water; very hot water in small quantities after a meal, is sometimes found a very efficient corrective of this symptom. Distension of the stomach from flatulence to an extreme degree, in old people, is often attended with alarming symptoms, sometimes convulsions, sometimes apoplexy. By extreme distension the muscular coat loses its contractility, and the mu- cous membrane its sensibility, and thus the usual remedies lose their power. In such cases mustard poultices applied to the pit of the stomach are of great service, whilst the internal means are put in use. The best of these are ammonia in infu- sion of horse-radish or of mustard-seed, and re- peated draughts of water as hot as it can be taken. In extreme cases the use of the stomach-pump should not be omitted. Nuusea and Vomiting. — When these symp- toms continue after the stomach and bowels have been satisfactorily relieved, effervescing saline draughts, especially those prepared from the sub- carbonate of ammonia, are suitable remedies; to these, if the symptoms are urgent, may be added a little spirit of lavender, camphor julap, and, in rase of necessity, one or two minims of the " black drop." The hydrocyanic acid (gut. i. ad ii.) has been also used with considerable advantage; but we believe it to be more efficacious in the other forms of dyspepsia. Headach___When this symptom does not sub- side with the primary affection, it may be relieved by valerian (tr. valer. amnion, or infus. valer.) either alone, or combined with camphor; if at- tended with sleeplessness, a small dose of pulv. ipecacuanhae comp. may be given in camphor mixture, or a saline draught; or if heartburn be present, may be combined with magnesia or liquor potassae. But a warm pediluvium, containing mustard or culinary salt, or evaporating lotions of vinegar, spirits of lavender and rose-water, ap- plied to the head, are sometimes more efficient than internal remedies. It would be extending this article too far if enter into the treatment of the other various se- condary affections of this disease ; we must con- tent ourselves with referring to the symptomatic form of each of these disorders. II. Having afforded relief to the urgent state of indigestion, it is the duty of the physician to direct his attention to the means of obtaining a perma- nent cure, which consists more in prevention than in positive remedies. The object to be held in view in the prevention of a disease has been clearly and succinctly expressed by Celsus—" quod vel corporis vel loci, vel studii ratio detrahit, cura restituat." Guided by this general view, seeking if possible to avoid or remove, if not to counteract the causes of the disease, we shall endeavour to fulfil this intention by indications derived from the nature of the operation of the causes in which it originates, and from the morbid condition of the stomach in which it consists. These indications serving as principles to direct our prophylaxis, ' and applicable, with some small modification, to every form of dyspepsia, may be stated to be—1, to render the process of digestion as easy as pos- sible by a selection of food of a quality suited to the nature of the disease, and by a proper adjust- ment of the quantity suited to the power of diges- tion ; 2. to excite the function of nutrition by pro- per exercise of body and mind ; 3. to correct the morbid condition of the stomach, the proximate cause of the disease. j 1. This is beyond all comparison the most im- portant point in prevention of this disease; the reducing the quantity of the food to the power of ' digesting and of appropriating it, instead of yield- ing to the cravings of a pampered appetite. The | change ought to be brought about gradually, for [ in that way it is most agreeable to the habits of the body, and most likely to be persevered in; and if the diminution of diet is made with judgment and selection, it ought to be effected by withdraw- ing from it such articles of food as are difficult of digestion, and such as have a tendency to weaken the stomach. The object is best attained by con- fining the patient to a small spare diet of animal [ food, with considerable restriction in the use of fluids. It is in this form of dyspepsia that so much benefit has been obtained by strict adhe- rence to a dry diet, and by avoiding a bulky meal. When the appetite flags, abstinence will be found a better whet than cordials, stomachics, or dainty fare. When the appetite does not fail, the patient INDIGESTION. 619 should finish his meal without waiting for the sensation of satiety, taking care that he be not deceived by a morbid craving, the offspring of dis- ease and bad habit, not of health. When any doubt as to quantity may arise, he may be assured that it is safer to err by taking less than enough than more than enough—« nunquam utilis nimia satietas, saepe inutilis nimia abstinentia." For breakfast coffee is to be preferred to tea, and should be taken with as little milk and sugar as possible, and with a moderate quantity of bread, which, with a little fresh butter, should form the repast. It is necessary that the bread should be limited, for if taken in excess it is a common cause of heartburn after breakfast. The dinner should consist of the lean of animal food, chiefly mutton, poultry, venison, game, with the exception of hare. Roast meat is to be preferred to boiled. Vegetables are to be eaten sparingly, or entirely abstained from ; mealy potatoes mixed with the gravy of the meat, asparagus, soft young summer turnips, cauliflower, or French beans, are the only kinds admissible. Rice mixed with the gravy of the meat will be found a good substitute for vege- tables. Eggs lightly boiled may be occasionally used. The fruits the least offensive are strawber- ries, the morel cherry, and the mulberry ; but they should be eaten in the early part of the day, and never after dinner. Fluids must at all times be taken with the greatest moderation ; the patient should not yield to every slight sensation of thirst; they should be taken slowly, a small quantity at a time, and should follow, never precede the meal. If the weakness of digestion or habit demand a stimulus, port wine and water or sherry and water are the best; malt liquors are to be particularly avoided. Three moderate meals is the best gene- ral rule for the periods of eating, taking care to eat nothing in the intervals, and avoiding suppers. It may be stated also as a general rule, that the food and drink in this form of dyspepsia should be taken decidedly hot or cold, not tepid ; that twice dressed meat should be scrupulously avoided; and that the meat should be eaten slowly, and thoroughly masticated. It may not be easy to say strictly what kinds of food are wholesome and what are unwholesome, but there are some so decidedly so, that there can be no dispute about them. Dr. Mandeville's de- finition of wholesome, " what you like and does one no harm," allows a deceitful latitude to dys- peptics. The admonition of Celsus carries a stronger impress of wisdom and experience; " non quicquid boni succi est, protinus stomacho con- venire, neque quicquid stomacho convenit, proti- nus boni succi est." The kinds of food most decidedly injurious in this form of dyspepsia, and therefore to be avoided, —fluid food, more especially that which is sweet, mucilaginous, or acid, such as contains much milk ; all pultaceous diet, puddings or compound dishes, particularly meat pies or meat puddings; new bread, particularly with butter ; heavy unfer- mented bread ; hard-boiled compact fat dumplings; all preparations of milks, whether custards, creams, curds, or cheeses ; all fat meat, particularly pork or bacon ; all young meat, and all the gelatinous parts of meat; all salted or smoked meat; strong broths, gelatinous soups, or highly concentrated dishes ; fish; melted butter, oil, sauces, spices, condiments, and pickles; all vegetables, more espe- cially roots, with few exceptions,* particularly peas, beans, cabbages, waxy potatoes, cucumbers, and pot-herbs generally ; fruit in general, whether fresh or preserved, jellies of fruits, figs, dried as well as green, currants, gooseberries, pears, apples, plums, apricots, melons, and all kinds of nuts or kernels; mushrooms, truffles, and morels ; treacle and honey; malt liquor, particularly ale; perry, home-made wines, punch, shrub. 2. In the early stage of dyspepsia an increase of exercise admits of greater latitude of diet; when more advanced, it affords no exemption from strict- ness of regimen. But by exercise we do not mean those nominal kinds in which half of the body only is exercised, as a quiet sauntering walk or the passive exercise of a carriage ; —we understand active exercises, in which every part of the body is more or less in motion, sometimes one, some- times the other. In persons of weak digestion the ancient physicians used to insist upon the exercise of the superior extremities, and we fully under- stand the nature of their advice.-j- It is impossible to lay down any precise rule for the extent of exercise, which must be proportioned to the strength and even the habits of the patients; but it should be continued for at least two hours daily, and be sufficient in degree to produce gentle perspiration4 The patient should by degrees overcome his habits of sedentariness, commencing by taking gentle exercise on foot and horseback between breakfast and dinner; he should then extend the period of his exercise, and, if possible, rise in the morning so as to allow of a little before breakfast; but this should always be the least fatiguing. As his strength increases, he may proceed to more active exercises, strong enough to excite perspiration, but not fatigue; such as walking over unequal ground instead of plain, climbing ascents, rowing, dig- ging in a garden, cutting and clearing wood, draw- ing weights over a pulley, turning a heavy wind- lass, as in grinding malt; military exercises, drilling, or the gymnastic exercises; or such amusements as field-sports, as coursing, fox-hunting; swim- ming ; or such active games as cricket, fives, racket, bowling, foot-ball, fencing, the broad-sword, or single-stick, or playing at quoits. Sometimes it is necessary to impart interest to exercise. In such cases gardening, agricultural occupations, the prac- tical study of botany, geology, entomology, have been found of eminent service. On this subject Dr. Cullen says, " as a bodily exercise I can say that walking has good effects. I have always thought it necessary to continue other amusements or business; and there are several instances of persons, who have long laboured under weakness of the stomach, being cured by watching the con- cerns of their farm, which obliges them to be much * The abstinence from vegetable food, which is a pain- ful privation to most persons, might possibly be obviated by using a digester, by which the vegetables might be submitted to a temperature considerably higher than that of boiling water. The ancients considered the cabbage race of vegetables as rendered more wholesome by boiling them in two waters. f Maximeque quas superiores partes moveat, quod ge- nus in omnibus stomachi vitiis ap''1"'"1"™ est.— Celsus. | Exercitationes autem plerumque finis esse debet su- dor, ant certdlassitudoquajcitrafatigationem est .dqua ipsum modo minus, modo majus.— Celsus. 620 INDIGESTION in the open air, and in constant gentle exertion. I have cured weak stomachs by engaging the per- sons in the study of botany, and particularly in the investigation of our native plants, and in other gentle and long-continued amusements, such as our game of golf." (Op. cit.) It was observed during the late war, that many of our tradesmen who joined the volunteer corps, were, by their regular military exercises, entirely cured of their dyspepsia. When the weather does not admit of exercise in the open air, reading aloud, reciting, singing, flute- playing, the dumb-bells, battledoor, dancing, skip- ping, and such-like, afford useful substitutes. Exercise should always precede a meal, and never follow it; neither should the patient sit down to eat in a state of fatigue or exhaustion. A little interval between exercise and eating is on that account desirable ; and this interval would be ad- vantageously employed in gentle friction with a flannel glove, (made best of a piece of coarse blanket,) or the flesh-brush. No active exercise should be used for at least two hours after eating. It is an old rule of philosophy as well as of physic, that the body cannot be properly exercised without the mind, nor the mind without the body. This rule emanates from the twofold function of the nervous system, which not only supplies the vital energy or power by which the entire process of organization is carried on, but also that by which the more distinctive offices of animal life, intelli- gence and voluntary motion, are performed. If the power of the body be occupied exclusively in either of these, the other languishes. Many fa- miliar illustrations of the truth of this position will readily present themselves. Long-continued or intense application of the mind does not derange ' the function of digestion negatively, by interfering with the opportunities of exercise, but positively by withdrawing a portion of the power by which it is carried on. Indolence of mind, on the other hand, does not interfere with the function of di- gestion by withdrawing the power, but by with- drawing the stimulus, the pleasurable enjoyment which well-regulated occupation of the mind im- parts to the whole functions of life. The functions of digestion may be deranged by three different states, obtaining between the exercise of the body and the occupation of the mind : 1st, the most usual, a total inaction and inertion of the body may coincide with a fatigued and exhausted state of mind; 2dly, a state of indolence and sluggish- ness of mind, with inertion of the body ; or, 3dly, a fatigued and exhausted state of body may coin- cide with a wearied and worn state of mind. The two first cases only apply to the present form of dyspepsia, and the indications deducible from them readily suggest themselves. The studious should, therefore, relax from their application, nor urge and overstrain the attention too long and too far; and though entire repose may not be allowed, their studies may be varied, that the different faculties of the mind being exercised* may relieve each other. It was a correct observation of a learned ohysician, that indigestion follows learning as close as the shadow follows the body, " Omnesque piene cupidi literarum" Celsus considers the most * Levet quoque lassitudinem etiam labor is mutatio : rumque quem novum genus cujusdem laboris pressit, id, juod ifi conauetudinem est, rericit.—Celau: constant sufferers from dyspepsia; and Aretaeus has painted with his most vivid colours the painful sufferings which await a devotion to science and letters, Mns uiv ua&no-tos iroSi), when ill regulated and unrestrained. If study cannot be dispensed with, at least all application soon after a meal may be abstained from.f The indolent, on the other hand, should seek occupation, and thus avoid the pains of inertion. But in making these changes, care is to be taken to avoid running into the op- posite extreme. Fatigue of body discomposes the sedentary, vacuity of mind is irksome and oppres- sive to the learned and to the man of business, and much study or business overcomes the indo- lent. Let them seek, then, occupations in which exercise, amusement, and interest may be happily combined, for they may rest assured it is a policy both narrow and short-sighted, which does not allow some hours a day to the care of their health. " Quem interdiu vel domestica vel civilia officia tenuerunt, huic tempus aliquod servandum cura- tioni corporis sui est." ( Celsus.) 3. This indication, correcting the morbid con- dition upon which the disease depends, according to our pathology, subdivides itself into (a) en- deavouring to restore the harmonious action of the different parts of the alimentary canal; (b) restor- ing or increasing the activity of the excretory organs, and (c) restoring the tone, or improving the innervation of the stomach. a. To restore the corresponding and harmonious action of the different parts of the alimentary canal. In health there exists a sympathetic rela- tion and corresponding action between the diffe- rent portions of the alimentary canal. Whilst some are in action, others are in repose, or the action of one part induces that of another. This relation is most remarkable between the stomach and larger bowels; and it is frequently one of the first effects of the operation of the causes producing dyspepsia to destroy or derange this relation ; either by the patient not lending a ready obedience to the calls of nature, by losing the habit of it, or, by the sensibility of the stomach becoming altered, the natural intimation ceases to be transmitted to the bowels, and then the parts lose their corre- spondence. This state is to be corrected by en- deavouring to restore the habit of a daily evacua- tion after the first meal, which is natural to most people in health. For this purpose the water-closet is to be visited even when there is no call from nature. When this does not succeed, the patient may relieve the bowels every second morning by a lavement of warm water. He should only have recourse to aperients when neither of these means succeed, but which will seldom be the case if he has observed those rules of diet, exercise, and oc- cupation pointed out in the first indication ; and whatever artificial means he may have recourse to, he should every now and then afford nature an opportunity of righting herself. Another method in common use, that of resorting to vegetables and fruit and coarse bread, seldom succeeds in this form of dyspepsia, or does so only temporarily; a mild aperient is on the whole more expedient and less pernicious. The best form of aperient with which we are acquainted is the pulv. aloes comp. (gr. v.) ft>in lucubrandum est, non post cibuiu id facerc, ead poet contoutionem. C*l*us. INDIGESTION. 621 or the following:—R. Pulv. aloes spic, pulv. rhei, pulv. g. guaiaci aa Qi. Pulv. ipecacuanha; gr. iv. Ft. pil. xii. Una vel binae pro re nati sumendae. The pil. galban. comp., the pil. scillae comp. may be sometimes advantageously substituted for the guaiacum. From five to ten grains of the inspis- sated residuum of the evaporated decoct, aloes comp. prepared with carbonate of soda instead of potass, or of the baume»de vie, affords a mild and easy aperient. The physician should be economical of his means, and not expend his resources unnecessarily. By this precaution he will both spare the power of the organ and of the remedy. If the habitual use of aperients is established, their power must be increased, and at last even strong remedies fail in their effect. The limitation of Celsus, with regard to aperients, is consistent with his wonted prudence; " dum et modo et non nisi quum opus est adhibeatur;" and his reason in accordance with daily observation, " assuecit enim non ali corpus, et ob hoc infirmum erit." This morbid condition will be also corrected by the means used for invigo- rating the function of the stomach itself. The restoration, however, of the natural relation of the stomach and bowels often suffices to restore the healthy action of the stomach and of the whole function of digestion. b. The equilibrium of supply and waste of the body may become deranged through inactivity of the excretory organs, a common effect of sedentary and indolent habits, and not always removed upon changing them. The bowels, the skin, and the kidneys may become torpid in their action; the effete parts not being carried off, the process of nutrition flags, and the digestion fails; a stagnation takes place in the extreme vessels, the whole re- productive processes go on sluggishly, or are en- tirely at a stand, and the stomach in this way loses its stimulus and impulse. This state is to be cor- rected by giving activity to the excretory organs ; and it is a method of restoring the equilibrium often had recourse to, but ought only to be used when the foregoing methods fail; for it is neither so safe, so salutary, nor so permanent as increased exercise and diminished diet. We have frequent instances of its efficacy in the use of alterative remedies, as is shown in the vigour of nutrition which sometimes follows a course of mercury, or a course of alterative mineral waters. When ex- pedient to be used, a continued source of alterative saline purging affords the best means of effecting it, and most efficiently the mineral waters of Carls- bad or Marienbad. Besides these means of restoring the desired healthy equilibrium of supply and waste, it has been observed that the same may be temporarily obtained by diminishing the volume of the circu- lating fluid ; and on this principle many cases of this form of dyspepsia, originating in a bloated or plethoric state of the system, have received con- siderable relief by letting blood. It is a plan well to know, but seldom to be followed. c. The morbid condition of the stomach which constitutes atonic gastric dyspepsia, may be cor- rected, and the tone of the organ restored, either directly by means applied to the stomach, or in- directly by means acting upon the system at large. 1. Of the direct means which have the power of rousing and invigorating the stomach, in our opinion wine in moderate quantity is not only the most grateful but the most useful. The dry wines are to be preferred, as pale old sherry, diluted with equal parts of water, or old port wine and water, good claret, or white hermitage, sauterne, or hock. Some persons find a little brandy and water agree better than any kind of wine. It is sometimes of advantage to administer these stimulants very cold or very warm, but never of a tepid temperature. The medicines comprehended in the list of bit- ters, tonics, and astringents, have also, in a certain degree, the power of correcting the relaxed state of the stomach. But their power in this respect has been very much overrated, which has led to their abuse, and to the exclusion of more rational and successful means. According to our experience the following are the medicines of this nature best suited to this disease: — lime-water, alone or mixed with some aromatic or carminative water (the distilled water of orange flowers best conceals its taste) ; the infusions of calumba, chamomile, cascarilla, orange-peel, or wormwood, alone, or in combination with carbonate of soda, or ammonia ; camphor julap, mineral acids, the acid, sulphur. aromat., the diluted sulphuric acid combined with tincture of hops, or tincture of cardamoms ; the phosphoric acid in the same way ; the metallic tonics, as the tr. muriatis ferri alone, or in infusion of quassia, the subnitrate of bismuth, or the sul- phate of zinc. Of all the remedies of this description the best are the carbonated chalybeate waters, as those of Spa, Pyrmont, Schwalbach, and Eger, on the con- tinent, or their imitations so accurately and scien- tifically prepared by Dr. Struve at Brighton ; or those of Tunbridge Wells. In administering these remedies, it ought not to be forgotten that they are contra-indicated if any derangement of the biliary secretion be present. The intention of this indication is sometimes more safely and completely fulfilled by combin- ing tonics with aperients, as the powder of ca- lumba with rhubarb and carbonate of soda, sul- phate of iron with extract of aloes, subnitrate of bismuth with rhubarb and aloes, the sulphate ->f quinine with aloes, or extract of colocynth. The stomach may also be acted upon by exter- nal local applications, as by warm stimulating plasters, but more efficiently by the cold douche to the region of the stomach. The ancients held this remedy, to which they gave the name of cataclysmus, in high estimation.* They used chiefly the cold douche, either of sea-water or mineral springs. Those of Cutilla, Simbruinum, and Nepete, were most in repute, now almost un- known ; for the modern Italians prefer the indul- gence of the thermal springs, which they use in precisely the same manner. 2. The indirect means of restoring the tone of the stomach consist in avoiding all the causes which tend to weaken, enervate, or exhaust the body or mind, as over-indulgence in sleep, and hot beds, lustful excesses, hot and ill-ventilated apart- * Hinc perfundi frigida, atque in eadem natare, cu nalibus ejusdem subjicere stomachum ipsum, et magis etiam a scapulis, id quod contra stomachum est.—Celsus. ^Egrotante maritimre natatione exercendi atque cata clysmo, hoc est, aquarum .Jlisione, suppositis partibuo — Cal Jiv-r. 622 INDIGESTION. ments, moist climates, the too frequent use of the warm bath; and correcting or removing those habits or states of body which have the same effect, as leucorrhcea, or other weakening discharges ; habitual venesections, chlorosis, and such-like dis- eases. The hours of steep should be diminished ; the patient should retire to bed early, and should rise in the morning soon after waking ; he should sleep upon a mattress, in a bed without curtains, and should be careful that his chamber is well ventilated and dry. The clothing of the body should be rather cool than warm, but sufficient to prevent the feeling of coldness ; without being oppressive, it should be sufficient to protect the patient from the in- clemencies of the weather. It will be at all times desirable that the lower extremities should be kept in a state agreeably warm. If the patient have the power, he should select for his residence a dry climate, either cold or mild, such as is found in England at Brighton, Tun- bridge Wells, Clifton or Malvern ; in Switzerland, at Berne or Lausanne ; in the south of Europe, at Nice, Genoa, and Naples. He should inhabit airy and well exposed apartments fronting the south-east, so as to have the forenoon sun, and should be cautious not to dwell near rivers and marshes.* Much of the baneful effects of prisons, manu- factories, and places of a like kind, might be cor- rected by proper ventilation, by the use of the cheminee d'appel and similar expedients. The patient should pay particular regard to cleanliness of his person ; he should use freely the ablution of cold water, sometimes to the whole, sometimes to parts of the body ; he should sponge the body every morning for a considerable part of the year with cold vinegar and water, or salt and water, much used by the ancient physicians under the name of ylvxpoXovaia—frigidi consuetudo la- vacri—and should afterwards rub the body well with a coarse towel; at another period he may use the shower-bath, the cold sea plunging-bath, or the cold fresh-water bath, or exercise himself in swimming; and when none of these means can be used, he should not omit dry friction of the body with the flesh-brush or a flannel glove, a salutary exercise for the indolent, and a useful substitute for it in the convalescent, or those who have not the benefit of locomotive exercise. The patient should pass much time in the open air; he should change his air from the town to the country, from the plain to the mountain, from the sea-side to the inland parts; (Adhibita mutatione longS, terrenS et maritima,— Celsus); or he may find a continued change by a well-planned, not hurried, tour, the most effectual. Of exercise as an alterative we have already spoken ; as a tonic it is not less to be regarded ; and to both these means—air and exercise—respiration and perspi- ration—we agree with Aretaeus in granting a peptic power greater than medicine. ("E^« ydp n >/ iia- irvofi Kai rj avairvor) rolovSc t and frequency of pulse, there will be INDIGE then more room to suspect an erythematic inflam- mation of the stomach ; and we have known such symptoms discover their cause more clearly by the appearance of the inflammation of the fauces or mouth." "The erethymatic inflammation," he also observes, »is often disposed to spread from one place to another upon the same surface, and, in doing so, to leave the place it had first occu- pied. Thus such an inflammation has been known to spread superficially along the whole course of the alimentary canal, occasioning in the intestines diarrhoea, and in the stomach vomiting; the diar- rhoea ceasing when the vomitings come on, or the vomitings upon the coming on of the diarrhoea." In the following passage Parry has made a cor- responding observation. " In that state of tongue so common in the West Indies, in which the mu- cous membrane of that and the adjacent parts is affected with chronic inflammation, tending to aph- thae and suppuration, the stomach, apparently by mere extension of disease, suffers all the symp- toms of flatus, acidity, &c. which are common to dyspepsia." Broussais has remarked that a con- tracted state of the stomach and alimentary canal always co-exists with an inflamed state of their mucous surfaces. Inflammatory dyspepsia occurs frequently as a secondary as well as an idiopathic disease. Hence it appears as a symptom of some essential fevers, (In febribus circa ventriculum et fortis aestus et cordis morsus, malum—Hipp.) of variola and ru- beola, (dyspepsia febrilis); it occurs in the last stage of phthisis pulmonalis, and in many organic diseases ; it is frequently symptomatic of inflam- mation of the mucous membrane of the uterus, particularly that which follows retention of a part of the placenta; it is observed in plethora of the uterine system, and in plethora of the abdominal circulation (dyspepsia hemorrhoidalis); and is met with consecutive to extensive burns ; and co- temporary and reciprocally with erysipelas, ery- thema (dyspepsia metastica), and several cutane- ous diseases ; and we have several times found it co-existing with ichthyosis, and that dry impervi- ous state which might be distinguished by the term of constipation of the skin. Method of Cure.—I. Instead of exercise, as in the former species, we must here seek for re- pose of every description, (Omnifaria requies— Cxi. Aur.,) of mind as well as of body; but as some exercise is desirable for the general health, it must be of the easiest kind, such as gentle saun- tering, walking, or the passive exercises of gesta- tion in a carriage, sailing, swinging, rocking, and gentle friction. Instead of a dry diet, consisting chiefly of animal food, we shall find that a liquid diet, bland and farinaceous, small in quantity at a time, from which animal food and all indigestible substances are excluded, is the most to be recom- mended. The different articles of food compre- hended under the saccharine, acidulous, mucila- ginous, farinaceous, and feculent, are most easily digested in this morbid condition of the stomach, and therefore their opposite kinds, milk, eggs, cheese, fish, animal food, animal gelatine, the sub- stantial, solid, or fibrous parts of vegetables, and fruits, are to be abstained from. After repose, or rather diminution of labour and exercise, and a re- frigerant diet, suited in degree and kind to the STION. 627 particular state of the digestive organs, the warm bath may form part of the regimen. It should be used at a temperature from 92° to 96°, from a quarter to half an hour. If the symptoms require, it may be used every day ; and it is of more benefit if used continuously, in a course of ten or twelve daily baths, than if taken interruptedly. Under this mode of administration, the tepid bath forms a direct remedy of great efficacy. But the general cure of this morbid condition of the stomach con- sists in a judicious use of the antiphlogistic regi- men, graduated to the degree of the disease and the strength of the patient. In the lowest degree of this complaint a change of diet, avoiding stimulating and heating food and drink, abstaining from active exercise, the use of a tepid bath, of some cooling acidulated drink, as lemonade, orangeade, imperial, orgeat, preserving the bowels open by a simple warm-water clyster, and, if necessary, any mild cooling aperient, for which purpose none answers better than manna dissolved in infusion of tamarinds, to which a small dose of some neutral salt may be added, afford all that is requisite for the cure. In a higher degree of this complaint it may be necessary to have recourse to a regimen more rigidly abstemious, consisting of gruel, arrow-root, whey, sago, blanc-manges of rice, jelly of bread, of Iceland or Irish moss, solution of gum traga- canth, acidulated with lemon-juice, taken in small quantities at a time, in order to avoid distension ; to prescribe largely acidulated saccharine drinks, as lemonade, cool, cold, or iced, or such bland drinks as orgeat, emulsions, decoction of liquorice, linseed-tea, &c.; to apply leeches or cupping- glasses freely to the epigastrium ; (Cucurbita ad- juncta scarifica tione, sive hirudinum appositio— Cxi. Aur.,) or, which is probably to be preferred, a moderate bleeding from the arm, proportionate to the degree of the disease : if there be signs of plethora or congestion of the abdominal circula- tion, leeches to the anus ; to relieve the bowels by clysters or the mildest aperients, and to solicit the hepatic secretion by small doses of the pil. hydrarg. or pulv. hyd. cum creta given at bed-time, followed in the morning by small doses of castor-oil. The effects of mercurials must be assiduously watched , for in this disease they are apt to act locally on the mucous membrane, and thus affect the mouth, without, however, affecting the system at large. When mercurials are not used, the nitrate of potass may be given in repeated small doses ; for this medicine, antimonials, castor-oil, hydrocyanic acid, the vegetable acids and saline medicines, are the means we are acquainted with which possess most eminently the direct power of lowering the vascular excitement of the stomach ; and we do not hesitate sometimes to rely upon them in cases where venesection might otherwise be necessary. These means will be assisted, and their operation promoted by the use of fomentations, or emollient cataplasms to the abdomen, and by the daily use of the tepid bath. As the excitement subsides, the patient may gradually return to a better diet, beginning with light broths of veal or chicken, and at last, but more cautiously, solid food. We are not unaware that the vascular excite- ment of the mucous membrane of one portion of the alimentary canal may be diminished by can*- 628 INDIGESTION. ing a determination to and a secretion from an- other part of it, and that thus the vascular excite- ment of the stomach may be reduced by a course of purging ; but though this method may be fre- quently successful, it is not rarely prejudicial, some- times dangerous. In the chronic form of the complaint great nicety is required in adjusting the cooling treat- ment to the strength of the patient and the degree of the disease ; for if the disease has been of long continuance, the nervous system is generally affected, and tolerates with difficulty the means suited to the relief of the local complaint; and if the depressing means be disproportionate to the degree of the disease, the stomach sinks into the opposite state, atonic dyspepsia supervenes, and the method of treatment is disparaged. This last consequence is more especially apt to occur if the inflammatory have succeeded to the atonic form of dyspepsia. It is on this account necessary to be cautious in the change of diet, and in the gradual withdrawal of stimulus. It may be ad- visable to continue in moderate quantities, the use of such animal food as is easy of digestion, as light beef-tea or veal-broth, in small quantities at a time, so as to avoid distention, and, by the bye, solid animal food; if not followed by thirst, in- creased heat, or headach, they are always useful. If the patient have been accustomed to stimulants, they must not be all at once, but gradually with- drawn ; for it is an unquestionable fact that a highly morbidly sensitive state of the stomach may be developed, and even a certain degree of inflammation of its mucous membrane may be exasperated, by leaving off an habitual stimulus. The exhibition of medicines and of other directly depressing means must be modified by the same caution. Leeches will be less seldom necessary. Seltzer water, whey, two-milk whey, and goat's whey, may be used as substitutes for the acidu- lated drinks. The nitrate of potass may be made to be more easily tolerated by the stomach by mixing it with infusion of hop, chamomile, or quassia, to which, if no heat be present, a little tinct. cort. aurant. or tinct. card. comp. or spirit. aeth. nitric, may be added. Dr. W. Philip observes that its alterative effect is not impaired by this addition. Or the hydrocyanic acid may be com- bined with these instead of the nitrate of potass, if there be any painful affection of the stomach. The vinum seminum colchici in very sinall doses has also to a certain degree the same effect. We have also observed that a water-ice eaten very slowly in the evening, instead of tea, is attended with very good effects; and in summer we have known great benefit derived from swallowing slowly and at intervals small pieces of solid ice when the stomach is empty, which, if the stomach can bear it, proves both a tonic and refrigerant. With this plan of medical treatment much ad- .antage may be derived from a diet well-timed and tempered, always varying it a little: as, for instance, animal food at first only on alternate days, afterwards on two succeeding days, and so on, but now and then interposing a day of absti- nence. The same observation is also applicable to medicines • a certain change and variation of sev- oral is preferable to a long continuance of any one. The bowls must be preserved open by the mildest and least irritating remedies. For this purpose clysters are to be preferred ; they should consist of simple tepid water, from a pint to a quart, barley-water, gruel, linseed-tea, or such-like, or in smaller quantities with the addition of a little salt, honey, or electuary of senna; some- times cold spring water is found to answer best, When aperients must be had recourse to, they should be bland and unirritating,—castor-oil, man- na, soda with citric acid in effervescence, tartarised soda in infusion of tamarinds, confection of cas- sia or of senna. Ripe fruits eaten in the morning in considerable quantities have been found to have the effect of mild aperients, and to be at the same time refreshing to the stomach, such as ripe grapes, strawberries, and figs, which we believe to he the full meaning of the cure des raisins so much spoken of in Switzerland ; but this method requires considerable caution, for if the fruit be not digested, the object is more than frustrated. In the chronic state of the disease it is gene- rally necessary to promote the secretions of the liver and alimentary canal by very small alterative doses of mild mercurial medicines. They afford valuable assistance to the general principle of treatment; but we must not forget the readiness with which they are apt to affect the mouth. Neither should the morbid condition of the skin which obtains in the chronic form of this disease be allowed to escape the attention of the physician in combining his method of treatment. He should seek not only to relieve its dry, impervious, con- stipated state by tepid bathing, particularly the tepid sea bath, hut he will find it a means of re- lieving the vascular excitement of the stomach to produce a derivation to the surface by small doses of antimonials, either combined with a little liquor. acet. ammoniae, or with the nitrate of potass, or by giving alone a grain of James's powder every night at bed-time, or the tenth of a grain of tartar emetic three times a day. If much irritability be present, the hyoscyamus is usefully combined with the antimonial. The following formula is well adapted to this intention :—R Tr. hyoscyam mxii. tr. opii m ii. vel iii. vini ipecac, m xx. potassae ni- tratis gr. v. aq. flor. aurant. gi. fiat haustus h. s. sumendus. The determination to the skin may also in some cases be usefully promoted by the vapour-bath, and by moistening the skin every morning with a lotion of nitro-muriatic acid. The ancients appear to have had this object in view when they recommended the patient to be envel- oped in woollen cloths impregnated with sulphur, and in directing friction to be made with nitre and oil. But we must confess that in the protracted form of this complaint we have observed every object of this method of treatment fulfilled, and all me- dicinal means far surpassed in efficacy, by a course of mineral waters, such as those of Harrowgate at home, and those of Ems, Vichy, Plombicres, and Cauterets abroad. To any of these, however, we should prefer the Kreutzbrunnen of Marien- bad. Under its use we have often seen the tongue get cool, clean, smooth, and moist; the irritated papillae subside; the uneasy sensations at the stomach give way ; the skin become soft, smooth, and permeable; the bowels regular; and the healthy function of digestion entirely restored. INDIGESTION. 629 It should be taken gradually and in small quanti- ties, in repeated doses of three ounces each. It may be taken warm or cold, as most agreeable to the stomach; if it produce distension, the gas should be allowed to escape; if spasm or diar- rhoea, it may be diluted with the Kesselbrunnen of Ems. The same effect is sometimes obtained from a course of goat's whey, taken in considerable quan- tities in the morning after the manner of a mineral water, a practice which is followed in Wales, and in the highlands of Scotland, but more particularly at Geiss in Switzerland, with the greatest success. Neither in the acute nor the chronic form of this complaint does our experience lead us to place much confidence in counter-irritants, and we think we have not rarely seen the complaint exasperated under their use. But many physicians, whose opinions deserve the highest consideration, place considerable reliance upon them. They consist of blisters, the tartar emetic ointment, and issues. In the chronic form of the complaint we have cer- tainly known great relief to attend the wearing a large warm plaster over the surface of the stomach, and in very protracted cases we consider it a good preservative from a relapse, from spasmodic pains, &c. M. Broussais, having observed the frequency of this complaint in the south of Europe, has mentioned a change to a colder climate amongst his means of cure; but our own experience is in favour of a soft climate, if not too cold. In this complaint we have known one season in Devon- shire of considerable benefit; on the continent, the climates of Pau in the south-west of France, Rome, and Pisa, are chiefly to be preferred. In the harsh, dry, impervious state of the skin, which takes place in the protracted state of this complaint, it is of great service to have an atmosphere and temperature soft, mild, and equable; and this con- sideration should also suggest the propriety of warm clothing, of rooms of equal temperature, and the occasional use of the tepid bath. We think it unnecessary to enter into particu- lar directions for mitigating or relieving the pain- ful and distressing symptoms which are occasion- ally present in this disease, such as vomiting, pyrosis, gastrodynia, flatulence, and the various uneasy sensations felt in the region of the stomach. Their specific treatment is comprehended in the general method of cure; and for the secondary affections which originate in this morbid condition of the stomach, we can safely refer to the separate articles under which each of them will be con- sidered as symptomatic diseases. II. For the means of preventing the returning of this complaint, and correcting the predisposition of body on which it depends, we beg to refer to our plan of prevention in atonic gastric dyspepsia. With some modifications in the degree of the means suitable to the particular nature of this complaint, it will be found also to be of useful application here, after the morbid condition of the mucous membrane of the stomach has completely subsided. III. Irritable Gastric Dyspepsia. Synonyms. — 'H oropaxi^, Aretxus; KapotaKh ittStais, Auct. Grxc; cardialgia sputatoria; py- rosis vulgaris et a conceptione ; gastrodynia atte- 3c* rens, hysterica, periodynia, et a frigore; vomitus nephriticus et hystericus; anorexia melancholica ; flatulentia hypochondrica, Sauvag.; anorexia ex desuetudine veneris, Galen,- gastralgie, French ,- pain of stomach, most felt when it is full, Pem- berton. General Character.—Pain, uneasiness, un- comfortable or unnatural sensations in the stomach, generally increased on taking food, and during the process of digestion, neither the frequency of the pulse, nor the heat of the surface being at the same time sensibly increased; the pain rather relieved than increased by moderate pressure; appetite variable, seldom much impaired ; bowels constipated ; stools little altered ; urine clear and sufficiently copious ; micturition frequent; tongue clean or thinly furred, never thickly coated; tem- per impatient, restless, and changeable; easily dejected, easily excited; the attention constantly and exclusively fixed upon the uneasy sensations; great variableness in the degree and duration of all the symptoms. Form of Disease.—In the slighter degree or earlier stage of this complaint, when the stomach is empty the patient is comparatively free from uneasiness, but on taking food or in the course of digestion various uncomfortable sensations are wont to arise. The patient may feel a sense of choking or constriction in the stomach, as if the progress of the food had been arrested ; the throat feels dry, so that it requires an unusual effort tj swallow each succeeding mouthful, and after the food has passed down he is disposed frequently to repeat the act of swallowing, as if to relieve the uneasy sensation ; without thirst, he continues to sip small quantities of liquid from the same in- stinctive feeling, or the same sensation leads him to be constantly hawking and spitting, as if he had some foreign substance in the throat. This i3 sometimes accompanied with dull, indistinct, but anxious pains in the back, between the scapulae, where the patient rubs or strikes himself, or re- quests some by-stander to hit the seat of the pain, hoping to be relieved thereby. In an aggravated degree the sensation in the stomach amounts to a severe constringing pain, and is attended with nausea, which, extending up the oesophagus, is met by a sensation of very painful constriction and stiffness of the lower jaw, chiefly in the situa- tion of the parotid and submaxillary glands, fol- lowed by a copious discharge of a saltish saliva, which generally affords relief; or all these symp- toms are relieved by vomiting, the food oeing returned very little changed in its appearai.ee, though frequently an hour has expired from the time of taking it : these symptoms together con- stitute pyrosis. Or, instead of constriction, a sensation of heaving or nausea follows the taking of food, which is also occasionally terminated by vomiting. Sometimes it is a sensation of heat or burning, of coldness, sometimes of itching, tickling, or formication; sometimes there is pulsation at the epigastrium, in the hypochondria or abdomen, appearing suddenly, at first violent, and abating gradually, observed by Schmidtman (Summa Ob servationum medicarum ex Praxi clinica triginta annorum depromptarum. Berlin, 1826.) to be synchronous neither with the pulsation of the heart nor arteries, and occasionally changing place 630 INDIGE STION. suddenly, even sometimes transferring itself to the extremities. These symptoms are usually accom- panied by various degrees of general irritation, by a state of fidgetiness, or restlessness, inquietude, or anxiety. Sometimes the uneasiness is not perceived in, or referred to, the stomach, but is felt sympathetically in some other part of the body. Thus, the patient may complain of a sense of tension, of painful anxiety in the head, or of an acute pungent pain limited to one spot; or the heart may be the seat of similar affections accom- panied with palpitation or irregular action, seldom with stronger impulse, with flushing of the face, or quickness of the pulse; or the patient may be seized with fits of loud coughing, with convulsive asthma, or spasmodic affections of the muscles of respiration; with cramp of the limbs, spasmodic pain in the uterus, bladder, or urethra; or neural- gic pain in some part of the body, in the uterus, testicles, or rectum; frequently a fit of hysteria, sometimes even symptoms of hysteria in men. Or the patients may feel restless or unquiet, or be seized with a fit of depression, of ungovernable impatience or anxiety. These symptoms generally terminate with digestion, but may be renewed by taking the mildest food. They are usually ac- companied with coldness of the extremities, and early in the attack a discharge of pale limpid urine takes place. The tongue is seldom furred, more usually clean, or it is covered with a thin mucous fur, interrupted by fine waving transverse lines; under actual irritation it is dry without being accompanied by thirst; more generally there is a deficiency of saliva, but the tongue and lips are covered with a white frothy secretion which the patient is ever endeavouring to get rid of by spit- ting; sometimes it is moist, and the mouth is filled by an unusual flow of saliva ; frequently the tongue is thinly furred, as if a fine white gauze were thrown over it; sometimes it is covered with a i!iin milky white fur, as if the patient had just been drinking milk, and sometimes it is besmeared with a thin frothy mucus. The tongue is generally rather paler than natural, but even when clean is never of a brighter red colour than in health. It is generally of a dull red, sometimes darker than natural. But the surface of the tongue, whether furred or not, presents the appearance of plush or velvet, which arises from the papillae being fine and elongated, never either large, tuberous, and developed, or smooth and obliterated. The bow- els are usually costive. The pulse is generally small, feeble, and soft, or sinall and contracted; it is seldom accelerated, more frequently slower than natural, except under some temporary ex- citement or agitation, when it' is momentarily hurried or irregular. The skin is generally soft, rather glossy, but never dry, harsh, and scaly, as in inflammatory dyspepsia ; it is permeable but seldom moist, except sometimes from a sudden breaking out of perspiration on particular parts of the body; perspiration is rather suppressed than obstructed. In the more protracted forms of this complaint the stomach is rarely free from uneasiness or dis- comfort of one kind or another ; the patient is never unconscious of sensations in the stomach, and to whatever object his attention may be directed, the uneasy feelings of the stomach are mingled in all his perceptions, tinge and darken all his thoughts, thus giving rise to another form of hypochondriasis. These sensations are some- times that of burning heat, sometimes of icy cold, sometimes of gnawing, grinding, or dragging of the stomach, or of some foreign substance in the stomach, sometimes of emptiness or hollowness, of falling or sinking of the stomach, sometimes of nausea; or there is a constant sense of rising in the throat, sometimes of a round ball, sometimes of an insipid liquid. These uneasy feelings com- pletely take away all power both of mind and body ; the spirits become dejected, the body torpid, the limbs powerless,* the mind is prostrate, exclu- sively fixed upon the uneasy bodily sensation, or ever contemplating the gloomy association >r the dark course of thoughts which they call forth ;■(■ and the sensibility of the stomach becomes conse- quently so highly exalted, that patients refer to it all their sensations, as is well expressed in a letter to Pinel from a lady, one of his patients: " Le principe de tous mes maux est dans mon ventre; il est tellement sensible, que peine, douleur, plaisir, en un mot toute espece d'affections morales, ont la leur principe. Un simple regard desobligeant me blesse cette partie si sensiblement, que toute •la machine en est ebranlee. Je pense par le ven- tre, si je puis m'exprimer ainsi." Or there may be a feeling of anxiety, of restlessness, or impa- tience, which can neither be controlled nor over- come, with great nervous susceptibility; the mind is much impaired; the senses become delicate, the head giddy, the eye dazzled by the least effort of attention. Sometimes this morbid irritability is most apparent in the vascular system, the pulse being quickened, the heart made to palpitate, the face to flush with a sound of rushing or ringing in the ears. This peculiarity seems frequently to arise from excessive loss of blood. Urticaria, pru- rigo, stinging or itching of the skin, are not un- usual attendants. These symptoms are occasionally for a time relieved by taking food, and only return as the stomach becomes empty, which acquires a pain- fully irritable state as the period of taking food is delayed, but they are more commonly aggravated during the process of digestion ; and sometimes, in a higher degree of gastric sensibility, severe pain is excited by swallowing the smallest morsel, which is on some occasions instantly rejected. In some cases liquids produce greater uneasiness than solids, and sometimes medicines are the greatest irritants. The symptoms are very much aggra- vated by purgatives; flatulence, violent palpita- tions, with a sensation of approaching syncope, and vertiginous feelings in the head, have been observed to arise upon the action of the mildest purgatives; sometimes violent diarrhoea follows the action of a moderate aperient. The pain and uneasy sensations at the stomach are frequently relieved, but sometimes inordinately increased by touch or pressure upon the epigastrium. In this complaint there is great uncertainty or * "Aan, airopiri, Stilts. dfiavpat, £>tu>v foot, fidpta Kccpa\ris, vdpKrj pe\iuv, Kai rd yvla Xiovrai. rraXuis iv Total inro^ovSpiots.—Aretceus. t 'lexvoi, efaxP°h doStvies, IkKvtoi, Xr.TzoSpavili, aipvxoi, iuXoi, riavxioi, et-a-rrivris r under tne ngnt scapula, or it corresponds with a dull pain felt chiefly at the top of the shoulder, or with numbness or dull pain extending down the right arm to the elbow, wrist, and little finger, more rarely with pain of the right hip, extending down the right leg. Under certain circumstances these symptoms are very much exasperated, and the pain in the right hypochondrium becomes very acute, accompanied with great anxiety or with spasm in the situation of the duodenum, and a sensation of weight in the hypochondrium and loins, amounting to a complete attack of gastro- dynia. If the right hypochondrium be examined, more especially if the examination be made when the patient is in the erect posture, a fulness will be perceptible through the whole hypochondrium, more sensibly apparent when compared with the left; sometimes a circumscribed puffiness is per- ceptible in the site of the duodenum, most particu- larly just before the cartilage of the eighth rib, in which situation it is observed that pressure is dis- agreeable, sometimes occasioning a sense of op- pression or dyspnoea. This puffiness not unfre- quently disappears in a day or two, particularly after free evacuations of the bowels, and then grad- ually returns, but is sometimes quite stationary, and occasionally so obvious as to be observed through the clothes, more especially in females. On some occasions it is so circumscribed and pro- minent as to give almost the appearance of a hernia. Such a case we have met in consultation with our amiable and lamented friend, the late Professor Andrea Vaccu., of Pisa, which appeared to derive considerable relief from the pressure of a bandage. Instead of pain or sense of weight in the right hypochondrium, there is occasionally a feeling which conveys the notion of torpor, of stoppage in or dryness of the bowels, as if their contents made no progress downwards, to which frequently corresponds a sensation of fulness in the lower bowels, leading to ineffectual efforts to relieve them, and not rarely spasmodic stricture of the rectum. Or there is soreness or a sense of fulness below the pit of the stomach in the situa- tion of the arch of the colon, but deeper-seated. These affections are disposed to occur in parox- ysms, seeming to be connected with the state of digestion, for the symptoms are more or less re- lieved as the process of digestion is completed, or they are relieved by satisfactory evacuations of the bowels, and relief is even experienced as soon as the upper portion of the bowels is put in motion, often long before an evacuation. With the above symptoms, distinctly referable to the seat of the disease, or in place of them, the patient may complain of headach, which, generally unaccompanied with nausea, commences with a feeling of uneasiness of the head, with indistinct- ness of ideas, and disinclination or incapacity for mental exertions, chilliness of the body, coldness and dampness of the hands and feet. The head- ach itself consists in a pain or dull aching, some- times of the forehead, but more commonly of the crown or posterior part of the head, which is at- tended with restlessness, with intolerance of noise, with dazzling or mistiness before the eyes, or with the appearance of various colours or luminous forms. The headach is invariably much aggra- vated during the period of digestion ; sometimes it terminates with the process of digestion in a INDIGE S T IO N. 641 few hours, but when it has become habitual, it may continue for one or two days. Instead of headach, there is sometimes a sense of fulness or of distension of the head without any fixed pain. Vertigo is occasionally the most troublesome symp- tom, and we have known it to persist uninter- ruptedly for weeks together; or the patient being seized with temporary loss of consciousness, and of muscular power of the limbs, falls down sud- denly, without syncope or convulsion. Contrac- tions of the countenance, rolling of the eyes, cramps or numbness of the limbs, are very com- mon symptoms, and even hysteria, chorea, a fit of epilepsy or apoplexy, are not rarely connected with it. Rheumatic gout, aching pain in the knees and ankles, particularly of the right side, lumbago, pain of the back, especially- in the direc- tion of the right kidney, commonly aggravated by the recumbent posture, languor, lassitude, and weakness of the limbs, feeling as if the legs would give way, and sometimes actual paraplegia, are amongst the secondary affections of this disease. Fluttering, irregular action, and sense of disten- sion of the heart, irritation of the larynx or tra- chea, causing a constant hawking or effort to ex- pectorate, singultus, dyspnoea, and even asthma, are not unusual symptoms. A degree of spasm, sometimes stricture, with a sense of weight or load about the rectum, spasmodic stricture of the ure- thra, or difficult micturition, are not rarely ob- served in this complaint. The various forms of ephelis, pityriasis versicolor, some species of her- pes, particularly herpes prxputiatis and circinna- tus, the impetigo sparsa, are the diseases of the skin which we have most frequently remarked as connected with this complaint, and their eruption is not rarely attended with relief of the internal disorder. Indolence, sluggishness, listlessness, or indifference of temper, want of the usual distinct- ness of ideas, a feeling of a cloud over the intel- lect, loss of memory, confusion of intellect, or op- pression of spirits, are characteristic symptoms of this disease. With more or less of the foregoing symptoms, either directly referable to a deranged state of the digestion, or secondary consequences of it, the appetite is observed to be seldom impaired, but on the contrary soon returns after eating, and even during the period of suffering is often preternatu- rally increased and voracious, sometimes unusually keen, particularly for food which disagrees, which last proves not seldom a premonitory symptom of an exacerbation of the complaint. The tongue is large, broad, soft, and flaccid, covered with a yel- lowish white mucous fur towards the root, but moist, slimy, and of a dull red colour towards the point and margin, presenting in general a flabby and sodden appearance. The bowels are costive, more rarely alternating with occasional diarrhoea, and the alvjne evacuations when costive are hard, dry, and adust, of a dark brown or dull olive or greenish black colour; if more lax, generally of too light a colour, resembling that of whitish brown paper, of a dull clay or light brownish wlour, and devoid of their natural smell; or sometimes yeasty, tape-like, sometimes of a faint yellow colour floating upon the water, giving out an odour like that of saliva, or frequently contain- ing bits of undigested food, uncombined bite, or Vol. II. —81 3d* occasionally consisting chiefly of bile. The urine is unhealthy, not remarkably deficient in quantity, but dark-coloured, of a deep colour like that of mahogany or stale beer, but always sedimentous, either lateritious, or yellow, or cream-coloured, but more generally white and furfuraceous, and so copious as to be thick throughout like gruel, its surface being generally covered with an oily iri- descent film. The pulse is soft, slower than nat- ural, sometimes preternaturally slow or labouring, frequently intermitting or irregular, faint, and fluttering. The skin is dry, dull, flaccid and ine- lastic, and sallow, and the eye dull and tinged with bile. The feet are habitually cold, the steep is heavy and unrefreshing; the patient either awakes frequently in the night, or is troubled with disagreeable dreams, and, instead of being refreshed, is oppressed with fatigue in the morning. When the preceding signs of deranged function of the organic system present themselves in combination with some of the complaints or sympathetic affec- tions above specified, there can remain little doubt that they are referable to a deranged state of the duodenum, of which distension or irritation of that intestine is the consequence ; and if the preceding signs of derangement of the organic system be present without any complaint, the physician may be sure that a process of disease is in progress which will sooner or later declare itself. Pathology and Causes. — The particular process of the function of digestion, which is more especially deranged by this disorder of the duodenum, is that which, consisting chiefly in the mutual actions and re-actions of the chyme, the bile, and the other intestinal juices, has hence re- ceived the name of encholosis, and of which the result in health is chylification; and the proxi- mate cause of this derangement is no doubt a pathological condition of the duodenum, consist- ing partly in deficiency of tone, partly in defi- ciency of sensibility, from which arises discordant action in relation to the stomach on the one hand, and the intestines on the other. For the duode- num allowing of the accumulation of the chyme, an impediment is opposed to the function of the stomach; the secretion of the bile, depending on the healthy state of the duodenum, is imperfectly solicited, and the peristaltic motion of the intes- tine being impeded, its discharge into the intestine is obstructed; while the other intestines cease to receive, both in kind and quantity, their natural material of operation. This disordered state of the duodenum rarely, however, originates in it- self; from its intermediate position, it is more gen- erally a consequence of an imperfect performance of the function of the stomach or of the large in- testines ; sometimes, but more rarely, it originates in the liver. If the stomach have not sufficiently subdued the food to a healthy and natural chyme, the duodenum becomes the recipient of unnatural ingesta, unsuited to its particular function, irom which disorder must ensue. This state of things appears to us to be more liable to occur to those who, fasting long, are apt to swallow their mea hurriedly, and therefore masticate their food im- perfectly, or to those who, ever intent on the busi- ness of life, eat, as they think, quickly,—a habit very constantly induced in those who have con- tracted the pernicious practice of reading or trans- 642 IN DIG E snoN. acting business at their meals. The same effect which arises from the hurried, imperfect mastica- tion of wholesome victuals, may also be induced by the ingestion of indigestible substances, and therefore the use of such things as the stomach has no power of digesting frequently leads to duo- denal dyspepsia, as for instance, nuts or the ker- nels of fruits, hard indigestible fruits, crude vege- tables, the seeds and skins of fruits and vegeta- bles, cherry-stones and similar substances. The same consequence follows for the same reason in some great feeders, whose pylorus allows imper- fectly digested food to pass; in this respect some persons, and particularly children, seem to have a great facility. But a disproportionate quantity of the healthiest chyme poured into the duodenum quicker than the process of encholosis can be performed, or than its transmission can take place, must lead to pre- cisely the same result as the passage of chyme imperfectly elaborated. This is the reason that children are proportionately more subject to duo- denal dyspepsia than adults; for having in general a good appetite and a powerful gastric digestion, they are wont to eat at all hours and seasons, taking a second meal before the first is digested, so that the duodenum becoming distended with chyme which it cannot transmit, interrupts the discharge of the bile, and accumulation takes place. Of this we have a proof in the crapulous diarrhcea consisting of light-coloured stools, which so often ensues. " Children," says Dr. W. Philip, " are still more inclined to this accumulation than adults, most of their complaints being connected with this state of the digestive organs. Of children who are out of health, with the exception of those labouring under contagious diseases, not one in twenty will be found free from more or less of it; and their restoration to health is never permanent till the due action of the first intestine is restored." Precisely the same effect will, in the same man- ner, be produced by any cause impeding the trans- mission of the chyme from the duodenum on- wards, though it be neither unnatural in quality nor disproportionate in quantity; thus leading to accumulation in the duodenum, to distension, and all the consequences of duodenal dyspepsia. Now this may arise simply from a confined state of the bowels, which, gradually propagated upwards, ends in inducing duodenal dyspepsia ; thence we find that healthy people having vigorous powers of stomach, who, from sedentary habits or con- fining themselves to the passive exercise of a car- riage, have their bowels confined, readily become subject to this form of dyspepsia. The accumulation of faeces in the colon, which in some constitutions, by sympathy, induces atonic gastric dyspepsia, also by its pressure upon the duodenum mechanically interrupts its free action, and prevents it from discharging its contents. And the same consequence results from the pos- tures necessary in certain trades and professions, which have the effect of opposing the proper evacuation of the duodenum. This unhealthy posture is found in the highest degree in shoe- makers, as they stoop to their last; and we have certainly met with more cases of this disease in persons of that trade than in any other. Tailors, engraver*, and many others whose occupation re- quires the same posture, suffer in the same man- ner ; literary people and clerks, from bending to the desk or table, frequently suffer from the same affection of the stomach; the stooping of women in their sedentary occupations of needle-work, and still more the pressure of the stays or tight lacing, tend in no slight degree to the same result. An accumulation of chyme in the duodenum, in whatever way induced, soon lays the founda- tion of its own increase and continuance, for its immediate effect is to impede or interrupt the pro- per supply of the bile, either mechanically, (the pressure of the contents of the bowel closing by compression the oblique valvular orifice of the common gall-duct,) or by preventing the proper peristaltic motion of the duodenum which pro- motes the flow of bile, or lastly by deranging the sympathy of the duodenum and liver, so that the mutual actions and re-actions of the bile and chyme—the process of encholosis—cannot have place, and the intestine is thus deprived of the natural stimulus for promoting the propulsion of its contents. In this way, therefore, a deficient supply of bile, without either an unhealthy state or an accumulation of chyme, may prove a pri- mary cause of duodenal dyspepsia. Hence this form of dyspepsia is that which is induced by idiopathic icterus, and is reciprocally one of the most ordinary proximate causes of icterus. Or it mav be that the sensibility of the duodenum being diminished or otherwise disordered, and the natural sympathetic relation between the liver and duodenum becoming deranged, the bile is not sup- plied in proper season, or a bile of a less active quality is secreted ; for which reason the action of the duodenum begins to languish, and the dis- position to accumulate is increased. Thus dys- peptics have for months, even years, a constant accumulation in this intestine; the duodenum never emptying itself thoroughly, a great portion of aliment is retained there beyond the due time, and is not evacuated before a fresh supply from the stomach has laid the foundations of other ac- cumulations, until at last an enlargement evident to the eye as well as the touch often takes place. This account of the manner in which atonic duodenal dyspepsia is induced, is in perfect ac- cordance with the phenomena, explaining both the origin of the symptoms and the operation of the causes which more especially give rise to it. For we may thus see how the uncomfortable feel- ings in this form of dyspepsia are chiefly expe- rienced a considerable time after taking food ; how the stools present their unnatural appearances, how they are deficient of bile, resembling whitish brown paper, and sometimes as white as pipe-clay —an effect frequently observed to result from the action of opium upon the liver; how the chyme, being prevented from undergoing its proper changes, and accumulating, ferments and gives rise to diarrhcea of light-coloured sour-smelling stools; or how the bile, occasionally suppressed, occasionally accumulated, from time to time is co- piously evacuated, and a bilious diarrhcea is the consequence; how, the secretion of bile being suppressed or impeded, the kidneys assume a vi- carious function, and discharging what ought to pass by the liver, give rise to the unhealthy ap- pearance of the urine; how the duodenum, from 1NDIGE STION. 643 derangement of its function becoming distended by gas or by the accumulation of chyme, or irri- tated by food imperfectly digested, or by substances indigestible, may by its extensive nervous con- nections be the source of all the various sympa- thetic affections above enumerated ; and, finally, how inflammation of its mucous membrane or lesion of its structure may be the result. The peculiar character of disorders of the duo- denum are well illustrated by a case of organic disease of that intestine related by Dr. Irvine, in the Medical Journal of Philadelphia, for August, 1824; several others are also upon record. Treatment. — The morbid condition which constitutes the proximate cause of this disease readily suggests the indications for accomplishing the cure. These are obviously :—1. to afford pre- sent relief by unloading the duodenum; 2. to render the function of the duodenum easy of per- formance, a. by a proper regulation of diet, b. by proper exercise, c. by promoting a healthy secre- tion of bile, and d. by preserving an open state of the bowels; and 3. by seeking to correct the mor- bid condition of the intestine upon which the dis- ease depends. 1. Unless the accumulation in the duodenum be the consequence of pressure from a loaded state of the colon, it is best evacuated by some aperient; otherwise an active enema affords the most imme- diate relief. For emptying the duodenum, senna is the medicine which deserves the preference, being well fitted to promote the action of that in- testine. Dr. Wilson Philip observes that it has appeared more effectually to remove the fulness of the right hypochondrium, when it depends on morbid distension of the duodenum, than any other medicine equally mild in its operation. It is best given in the form of infusion with an equal part of some carminative water or some light bitter infusion, and its action will be rendered more cer- tain and more satisfactory by the addition of a small quantity of tartarized potass or tincture of rhubarb, which has also a tendency to prevent griping; but if this unpleasant effect be much felt, it may be avoided hy the addition of a few drops of liquor potassae, of spiritus ammoniae aro- mat. or a small quantity of tr. cardamom, comp. to each dose of the medicine. When there is any disposition to fever, the infus. sennae comp. of the Edinburgh Pharm. ought to be preferred. It may be combined with manna and tartarized potass. Where senna does not agree, rhubarb is the next best substitute. It may be given in substance in some carminative water combined with sulphate of potass or tartarized soda. For this purpose it is not necessary that the aperient should, accord- ing to the prevailing practice, be preceded by a mercurial purgative. Mercurials are more efficient and more necessary after the duodenum has been already evacuated. The extract of colocynth, com- bined with extract of hyoscyamus, affords also a purgative adapted to this form of disease :— R. Ext. colocynth. comp. Ext. hyoscyam. a.a. 9i. T. fiant pilulae xii. una vel bina hor. som. sum. There can be no doubt that the duodenum is also sometimes spontaneously evacuated upwards by vomiting, and under certain circumstances this method may be imitated by art; but in general, emetics are found to be of little use, and, failing in the object, are liable to do harm. 2. a. In order to lighten the burden of the duo- denum, and render its function easy of perform- ance, a careful selection of such articles of food as are generally held to be easy of digestion, and a scrupulous adjustment of the quantity to the powers of digestion, are of all things the most essential. The reader may refer for ample regu- lations on this head to the regimen of atonic gas- tric dyspepsia. We shall content ourselves with observing in this place that the patient should eat his meals slowly, and that he should masticate his food with the greatest care. In order to avoid infringing these rules he should endeavour to avoid long fasting, which leads to full meals quickly devoured. It is in this sense only that we can understand the reason of that old man's practice recorded by Lord Bacon, in his Essays, who, when asked by what means he had preserved himself to so great an age, answered that he knew no other except that he never waited to eat until he was hungry or to drink until he was thirsty, by which he was able always to make a temperate repast; a rule of great value, provided we do not fall into the opposite extreme of eating too fre- quently. Small meals, then, eaten slowly and at moderate intervals, is the most comprehensive rule of regimen in this complaint. Patients should endeavour as much as possible to keep their minds disengaged at their meals; for they who are ac- customed to read, or have their minds much occu- pied at table, are apt to eat fast and voraciously, and chew their food imperfectly. The food should be of that description which is entirely digested, and which leaves little excrementitial refuse. It should, therefore, consist chiefly of animal food, of stale bread, or moderate quantities of well- boiled rice. Light refreshing broths, which are entirely digested in the stomach, afford occasion- ally a good form of nourishment in this disease ; but they should be taken in moderate quantities, and not every day. Wine in small quantities is useful, but malt liquors are to be renounced. b. The activity of the function of digestion will be excited by proper exercise of the body carried to a certain degree of fatigue ; active walk- ing over uneven ground, coursing, leaping, cricket, fencing, the broad-sword, or dancing, each propor- tioned to the strength and habits of the patient, are the exercises most to be recommended; read- ing aloud, declaiming, and singing are also useful. Horse-exercise is also well adapted to this form of dyspepsia, particularly when the patient's strength is at all impaired. c. In endeavouring to restore the healthy secre- tion of the bile, some form of mercurial cannot easily be dispensed with ; but the employment of this mineral should be so managed as to produce the desired effect upon the liver with as little in- jury as possible to the other parts of the system. All that is here wanted is something that may speedily correct the disordered function of the liver; and it is therefore unnecessary to give it so as to be received into the circulating system. Tc effect this object its local effect on the alimentary canal is all that is necessary; for, whether it act upon the liver by sympathy during its passago through the alimentary cjinal, or whether, ah 644 INDIGESTION. sorbed from the alimentary canal, by the radical branches of the vena portarum, and circulating through the liver, it stimulates that organ, its effect is so direct that it may be considered strictly local. It is best given in moderate doses repeated daily until the quality of the alvine evacuation or the state of the urine is decidedly improved. A few doses generally suffice; and its long-continued use is never necessary. It is more advisable to administer it in sufficiently active than in repeated small doses. The particular action sought for from the mercury is more certainly obtained by combining it with a small quantity of extract coloc. comp. or extract of aloes, to which a minute portion of the powder of ipecacuanha may be added. The pil. hydrargyr. is decidedly the best form of mercurial in this disorder. It may be given in doses of from two to four grains. d. The impediment which is opposed to the healthy function of the duodenum by a torpid state of bowels, is to be corrected by yielding a ready obedience to the calls of nature, and by en- deavouring to establish an habitual evacuation by visiting the water-closet every morning after break- fast ; by the use of the tepid water lavement morning or evening; and, failing these, by the use of the mildest aperients. According to our expe- rience, those of which aloes forms the chief ingre- dient are the best. It may be combined with rhubarb, guaiacum, soap, and a small quantity of ipecacuanha, or James's powder ; and in case of flatulence, with the pil. galban. comp. according to the formula already given. The aperient pill appears sometimes to be more efficacious and less injurious when taken with dinner. A conve- nient formula, given by Dr. Yeats, is the follow- ing:— R Infus. anthem. §i. Vini aloes !ji. Liquor, potass, gr. xv. Fiat haustus mane sumendus. But he prefers a combination of senna and quassia, viz.: R Lign. quassiae 9i. Fol. sennae 9i. ad 9iii. Aquae 8>i. Fiat infusum. R Infusi §iss. Potassae sulphatis 9i. Fiat haustus mane et meridie sumendus. As soon as possible, attempts should be made to discontinue the use of these artificial means, for a constant recurrence to any aperient medicine is sure to establish ultimately a more permanent disease of the intestines. 3. Besides the means for fulfilling the last indi- cations, all directly tending to correct the morbid condition of the duodenum, those which have the power of improving the tone of the alimentary canal in general, or the whole system, possess to a certain degree this power. Amongst the first we have seen the nitric acid in decoction of sar- saparilla or some light bitter infusion most advan- tageously used. Amongst the latter we may spe- cify the cold ablution of the surface, the shower- bath, the nitro-muriatic acid lotion, and assiduous friction with the coarse flannel glove. But in '■bstinate cases we have found the most effectual lemedy in a course of alterative aperient waters »s those of the Muhmrunnen of Carlsbad, either natural or artificial; more especially if (which is not rarely the case) this disordered function of the duodenum be engrafted upon, or be the result of, a general state of excrementitious plethora. II.—Inflammatory Duodenal Dyspepsia. Synonyms.—Phagedxna, Cosl. Aurel.,- hepa- titis obscura; hepatalgia infarctus, intemperie ca- lida; aurigo ah obstructione calida; hypochon- driasis melancholica, Sauvages,- hepatitis chronica, Cullen,- indigestion, second stage of, W. Philip; duodenite chronique, Cazimir Broussais. General Character. — Heavy dull pain; sense of weight or uneasiness in the right hypo- chondrium, confined to one point, or more gene- rally diffused, more or less constant, but varying in degree, being sensibly increased a certain time after taking food, and in some degree subsiding as the process of digestion is finished ; skin dry; extremities cold; but increased heat of surface during sleep, particularly of the palms of the hands and soles of the feet; complexion sallow; countenance dejected ; urine scanty, high-colour- ed, and depositing a lateritious sediment; tongue more or less furred behind, of a glossy red colour at the point and margin, the redness being either bright, equal, or continuous, or brighter red points are dispersed over the general redness, or the pa- pillae unusually red, large, and developed, some- times tuberose. The form of dyspepsia which we are anxious to specify by the foregoing character, has been merged in the description of the diseases of organs considered more important, and whose functions were better known. By Hippocrates it was com- prehended under atrabiiiary affections; by Celsus and Aretaeus it was not distinguished from the diseases of the liver or the disorders of the sto- mach ; by the Methodists its symptoms were dis- tributed amongst several diseases. The moderns have been misled by the same errors. Sometimes confounded with other diseases, we may find it under chronic hepatitis or hepatalgia, or, undue importance being attached to some of its symp- toms, it assumes the name of gastrodynia or icterus, but still more commonly we may detect it under the mask of hypochondriasis or melancholy. Of the pathological condition which constitutes the disease, Cullen had a proper conception, and evidently includes it under enteritis erythematica; but he does not seem to have ascertained the symptoms of the particular disease, for he has no- where described them except under chronic hepa- titis. The disease is well described by Dr. Ferriar, of Manchester, who had himself been the subject of it, and was by him distinguished from diseases of the liver. Dr. G. D. Yeats followed up tne observation of Dr. Ferriar with a spirit of practi- cal and scientific inquiry ; but it is to Dr. Wilson Philip that we are indebted for the full develop- ment of the nature of this disease and the distinct knowledge we possess of it, though we can by no means subscribe to the limitations by which he has defined its origin, or to the latitude which he has allowed to its issue. Form of Disease.—The derangement of the function of digestion which arises from an excited state, from increased vascularity, or from chronic inflammation of the mucous membrane of the INDIGESTION. 64b pylorus and duodenum, is by no means a rare species of dyspepsia, and although manifesting itself by a great variety of symptoms, is in no de- gree difficult of detection. Its symptoms are either direct, indicating the seat of the disorder, or indi- rect, showing the full and various play of sympathy by which the different parts of the body hold com- munication with each other. Of the former kind are the dull heavy pain, the sense of weight, of anxiety, or uneasiness, which, sometimes com- mencing in the epigastrium, is generally seated in the right hypochondrium. This uneasy feeling is either confined to one circumscribed point, or it is diffused over the whole hypochondrium ; sometimes it extends from the epigastrium round the right side to the spine like half a zone, giving the feeling as if the side were begirt and com- pressed by a sickle ; often the course of the pain traces with anatomical accuracy the course of the duodenum downwards, and backwards in the direction of the right kidney, and then again in- wards towards the umbilicus ; very frequently the pain extends directly backwards under the right scapula. The uneasy feeling of the right hypo- chondrium very often corresponds with pain of the right acromion, of the upper part of the right arm, elbow, or wrist, or with a feeling of weak- ness or numbness of the whole arm ; occasionally it extends down to the thigh, to the knee, right leg, or ankle, giving rise to some topical pain in this extremity, or to a more general dull pain or sense of numbness, so that the whole right side of the body feels weaker than the left. When digestion is not in progress, the pain and uneasy feeling of the right hypochondrium is considerably less sensible, seldom amounting to more than a sense of heat, gnawing, or sinking towards the epigastric region, with a frequent desire to take food, which frequently corresponds with a sense of heat, smarting, or blistering of the tip of the tongue, and with watering of the mouth. By com- plying with this craving for food, relief is for a time afforded, but after a considerable interval, from two to four hours, the uneasy feelings are very much aggravated, in severe cases amounting to excruciating pain, bearing all the symptoms of a fit of gastrodynia, which continues for some hours, then gradually subsides; or which is at other times only relieved by vomiting, generally taking place three or four hours after taking food. The uneasy feeling does not usually amount to actual pain, but is described as a rawness and tenderness, and sometimes as a feeling of heat, as if hot water were passing through the intestine, or there is a painful feeling of distension, especially after meals, though no actual appearance of distension can be perceived. But often there is very sensible fulness in the same situation, extending downwards along the edge of the cartilages of the ribs and through the whole hypochondrium. The part of the right hypochondrium which is the seat of pain or uneasiness is also often very tender, the pain being sensibly increased by pressure, but generally it is not increased, on the contrary it is sometimes relieved by it. This tenderness is perceptible in the epigastrium, but most especially at the pyloric extremity of the stomach, and in the course of the duodenum, in the soft parts close to the edge of the cartilages of the false ribs on the right side; the cartilages themselves often become very ten- der, not unfrequently more so than the soft parts, This tenderness on pressure, which becomes much more apparent if the effects of pressure of the right and left hypochondrium be compared, like the pain, is very often circumscribed, being gene- rally situated midway between the point of the sternum and the lowest cartilage of the ribs: in the region of the pylorus it is generally more con- stant, in the region of the duodenum only occa- sional. The patient is in general quite uncon- scious of this tenderness until it is pointed out by the physician. But not unfrequently neither pain, uneasiness, nor tenderness is referred to the bowel; but when food has been taken a consid- erable time, the general uncomfortable feelings of the patient are very much aggravated, the process of digestion being attended with an insupportable languor, lassitude, oppression, dejection of spirits, headach,thirst,fever,or other sympathetic affections. Amongst the sympathetic affections or indirect symptoms of this diseased state of the duodenum, the affections of the head are most frequent; they are either a general painful confused headach, in- creased by stooping or by holding the breath, or a dull pain in the back part of the head, which feels tightly bound, or painful pulsation of the head excited by the least effort of attention : vertigo is also a very common symptom. Not rarely the intellectual functions are very much weakened or disordered ; there is a general confusion of mind, impaired memory, or deficient power of attention. The external senses become sometimes quite dull, the vision indistinct or veiled with dark motes; the hearing, smell, and taste much impaired. The entire function of the mind not unfrequently be- comes disordered, and mania itself we have dis- tinctly traced to local irritation of the duodenum. Irritation of the larynx, producing a short dry cough, or causing frequent efforts to expectorate a grey transparent mucus, (which sometimes be- comes very considerable,) hoarseness and loss of voice, a sensation of constriction of the chest with laborious breathing, and complete paroxysms of spasmodic asthma, are the sympathetic affections of the respiratory organs which frequently origi- nate in this disease. In protracted cases of this disease, it is by no means uncommon for phthisis pulmonalis to supervene, and ultimately terminate the life of the patient. It most frequently assumes the form of laryngeal phthisis, but generally a tu- bercular affection of the lungs lurks behind. Nor does there seem any difficulty in understanding this issue of the disease ; nothing is more compre- hensible than that the irritation of the duodenum should be communicated sympathetically to the mucous membrane of the larynx, trachea, and bronchi, or that the cachectic state induced by the long-continued derangement of the digestive organs, should produce the tubercular disease. This conversion of dyspepsia to phthisis was noticed by D>- ^erriar, but has been only fully explained and insisted upon by Dr. W. Philip (Op. cit.) and Dr. [Sir] James Clark. (Influence of Climate, &c.) Painful affections of the heart are consequences not less common, simulating the character of hy- pertrophy of the ventricles, sometimes of anginn pectoris. 646 INDIGESTION. The urinary and sexual organs frequently feel the effects of duodenal irritation : hence spasmodic stricture of the urethra, painful affections of the testicles, priapism, and venereal dreams; also painful menstruation. Lumbago, painful affection of the hip and knee joints, rheumatism, rheumatic gout, nodosity of the joints, severe and deep-seated neuralgic pains of the legs, we have observed con- nected with this disease. Sometimes the skin is the seat of the secondary effects of this disease. We have noticed, in con- junction with it, herpes zoster, acne induratum, urticaria, lichen, psoriasis,pityriasis, and alopce- cia area. Inflammatory or spasmodic affections of either extremity of the alimentary canal are common attendants of irritation of the duodenum, such as erysipelatous affections of the fauces, generally with a sense of tickling, soreness, or rawness of the throat. The uvula sometimes becomes much elongated, and, losing much of its contractile power, gives the sensation of something resting on the back part of the tongue, and sometimes descending lower, creates a cough, a sense of choking, nausea, and even vomiting, frequently all comprehended under the common term of re- laxation of the throat; not rarely the fauces and neighbouring parts are the seat of troublesome ulcerations, which, united with affections of the skin and osteocopic pains, make up the symptoms of pseudo-syphilis. On the other hand, prurigo podicis, sometimes accompanied with eruptions in various forms, spasmodic stricture of the anus or rectum, inflammation of the mucous membrane of the rectum, hemorrhoidal swellings, painful and irritable excrescences and fissures, are sympathetic consequences of this disease. But whatever be the particular sympathetic affection which may result from the disorder of the duodenum, there is one general and constant which belongs and gives character to them all— hypochondriasis, despondency and dejection of spirits, the mind constantly intent upon and oc- cupied with the bodily feelings. The preceding complaints, whether direct or indirect, are always attended by symptoms suffi- cient to indicate that the natural functions of the body are in a state of disorder. Though the ap- petite may not be deficient, it is seldom natural; it is various and capricious, generally keen, crav- ing, not rarely ravenous; there is a sense of sink- ing, of gnawing, or a constantly recurring desire for food, only temporarily relieved by taking it; or an uneasy sensation, or craving, mistaken for hunger—mendax fames, cibi appetentia, corpore non indigente. Bulimia is sometimes a symptom of duodenal irritation, corresponding to the phage- dxna of Caelius Aurelianus, which we have ac- cordingly not hesitated to place among the syno- nyms of this disease. There is no particular thirst. The bowels are habitually confined; under the use of animal food they are more costive; with a .-egetable diet they are frequently disposed to be celaxed; a fit of bilious diarrhoea from time to time is not however a rare occurrence ; and an habitually loose or irritable state of bowels is sometimes observed, a dejection following soon after a meal; purgatives also occasionally act in small doses, but frequently with aggravation, in- stead of relief, of the symptoms In this statp laxative medicines are generally uncertain in their effects, and frequently apt to act too violently. The evacuations present great variety in their appearance ; they are not always different from those of health; sometimes they are perfectly na- tural, but generally mixed with mucus in a con- crete tenacious state ; more frequently they are scanty, adust, and hard, in small knots of a dark blackish green, frequently of a dark olive green, sometimes of a blackish brown colour; they are frequently smeared with mucus and deficient in smell ; occasionally two or three dark fetid stools are discharged, small in quantity without being figured; or there is a loose stool of a greenish brown colour, in smell resembling the grounds of sour beer, which is often preceded by great depres- sion of spirits ; not rarely they are like tar. Gene- rally they are too dark, and occasionally almost black, but frequently they are of a white clay colour; sometimes there is frequent purging of a substance like the whitest pipemaker's clay, more or less diluted with water; which state has been known to occur when dissection proved the liver to be free from disease, and the gall-bladder con- taining healthy bile. The urine is scanty, high- coloured, sometimes of a dark copper colour, or even opaque, and as dark as mahogany or porter; it always reddens litmus paper, and generally deposits a lateritious sediment. The tongue is smooth, or covered with a thin loose mucous fur towards the root, of a clear red colour, neither a bright nor a pale red; but its anterior part is spotted with small red flat spots of a darker or brighter red colour, not rising above the level of the surface of the tongue, the papillae being very small or very indistinct; or the whole surface of the tip of the tongue and anterior margin is unu- sually red, with some of the papillae more or less enlarged; and in this situation there is frequently a sense of heat, smarting, or of blistering, fre- quently distinctly corresponding with the uneasy sensation in the right hypochondrium. The tongue is always more or less furred towards the root, either with a thin shining coat anteriorly, 01 clean and moist. The lips always correspond with the state of the tongue ; they are of a glossy red colour, or their cuticle is dry and exfoliatory. In protracted cases the lips grow dry, and are divided by fissures; the tongue is covered with a rough yellowish crust, brown towards the root; in some cases there is a peculiar raw appearance of the tongue and throat; at other times the tongue presents a peculiar red, dry, and glazed appearance. The skin is generally dry and scabrous, some- times scaly almost to ichthyosis; the complexion is dull and sallow, and the conjunctiva has inva- riably a tinge more or less of yellow. The pulse is either quicker than natural, or easily accelerated, but seldom ranges habitually above eighty. In the quality of the pulse there is always perceptible a certain degree of hardness or rather tension, which, according to Dr. W. Philip, is in its slighter degree easily detected, in feeling the pulse, by gradually diminishing the pressure of the finger. On some occasions it is very quick and small, but always with a certain degree of tightness, the most certain measure of the general state of the INDIGE secretory surfaces. The temperature of the body™ is very variable and unequally distributed; some- times there is considerable fever or feverish heat • sometimes chilliness independent of any change of temperature of the surrounding medium, at times interrupted by fits of oppressive heat; during the day the hands and feet are often ob- stinately cold, but after eating and during the night the palms of the hands and soles of the feet often become preternaturally dry and hot, and there is a tendency to partial heavy sweats, some- times very profuse during sleep, more especially towards the morning. And not unfrequently there is a feeling of a slight but protracted feverishness when the pulse is not at all affected. Pathology and Etiology.—That the symp- toms we have just described are all referable to different degrees of increased vascularity, some- times to inflammation of the mucous membrane which lines the pylorus and duodenum, there is little room to doubt. It has been directly proved by numerous dissections ; it has been confirmed analogically by cases of organic disease of this part of the alimentary canal, where the patholo- gical condition gave rise to increased sensibility of the mucous surfaces, as in ulceration ; the na- ture of the remedies most usually giving relief afford strong confirmation of this opinion ; and, were more direct proofs wanting, it is the only hypothesis capable of rendering a satisfactory ex- planation of the symptoms. For if we consider the nature of this pathological state of the mucous membranes, the various degrees in which it exists, the particular part of these organs in which it may be seated, whether above or below the ter- mination of the common gall-duct, whether it may affect the whole mucous tissue, or confine itself to the follicles or to the villosities, and, lastly, the ex- tensive sympathetic relation of these organs, by which the irritations of their morbid conditions may be felt and reflected, we shall be furnished with abundant elements from whose combinations it will be easy to explain all the variety of symp- toms, direct and indirect, primary and secondary, constant and accidental, which the disease presents. We shall thus understand how the appetite, if there be no fever, instead of being impaired, is generally increased, sometimes keen and ravenous, though the bowels are habitually confined, know- ing it to be the nature of the alimentary canal to have its peristaltic motion increased towards any point situated below, and diminished from any point of irritation situated above ; how the erythe- matous state of the mucous membrane of the duo- denum, disordering its peristaltic motion, may impede the flow of bile, and may in different ways derange the functions of the liver ; how the secretions of bite, generally diminished, may be sometimes increased when inflammatory irritation exists about or below the orifices of the biliary ducts, thus leading to bilious diarrhcea, to imper- fect encholosis, and all the variety of alvine evac- uation ; how an inflammatory action of the duo- denum, even when existing only in a slight de- gree,—so slight as to elude the closest observation unless the mind be attentively directed to it,—may excite the liver to an unhealthy action, from which a state of erethism and irritability of the whole alimentary canal may ensue; and hence STION. 647 how purgatives act so irregularly ; — or, on the contrary, how the vascular injection of the mucous membrane of the duodenum, being the effect of a sanguineous congestion of the liver, by which its freedom of circulation and its secretion is sup- pressed, may be attended with a diarrhcea in which the alvine evacuations are of a light colour ; and how a particular form of jaundice (icterus a ple- thora) may be produced. The well-known sym- pathies of the different parts of the alimentary canal with each other, supply the means of ac- counting for the appearances presented by the throat, the mouth, and the tongue, and for the uncomfortable and painful symptoms which some- times take possession of the other extremity of the canal; and the universal consent of the state of the alimentary canal with the body in general, or with some organs in particular, explains the multifarious secondary affections which may su- pervene upon this disease. (For a full account of the sympathetic relations of the duodenum with other parts of the body, the reader may consult with advantage Dr. Yeats's excellent paper, Med. Trans, vol. vi.) Nor does it seem more easy to explain the symp- toms of this morbid condition of the mucous mem- brane of the duodenum than to account for its production, if we consider the operation of the causes in which it originates. Thus it is that atonic gastric dyspepsia long-continued, (by which as it were the stomach shifts its function upon the duodenum, the pylorus being irritated by the pas- sage of substances imperfectly digested, and the duodenum, instead of receiving a substance of the bland nature of chyme, becomes the receptacle of the crude residuum of an imperfect digestion,) is observed to prepare the way for this form of dys- pepsia, and frequently to terminate in it—more rarely to be relieved by it. In the same manner, though the function of the stomach may not be imperfectly performed, if persons indulge in the use of substances which no power of digestion can assimilate, (as unripe fruits, crude vegetables, the seeds and skins of fruit, the kernels of nuts and stone fruit,) the operation and the consequence will be the same. And in like manner, when suf- ficient time has not been allowed for the digestion of one meal before another is taken, the duodenum becomes unnaturally distended, from which irrita- tion and an inflammatory state of the mucous membrane may arise,—a circumstance which, oc- curring frequently in children, inducing a saburral state of the mucous membranes amounting to in- flammation, constitutes the preparatory process to the particular remittent fever which afflicts that period of life. But from whatever cause gastric or intestinal fever may arise, chronic inflammation of the mucous membrane is one of their most constant sequelae; and we must confess that our experience knows no cause of this form of dys- pepsia more common than improper diet in the convalescence of those fevers. In persons habit- ually subject to dyspepsia, which naturally pre- disposes to irritation of the mucous membranes. an inflammatory state of the duodenum may arise from suppressed perspiration, from exposure to cold, particularly in dry weather, either hot or cold, as is frequently observed in the spring; and in the same way it. is a common sequel of catarrh, and » 648 INDIGESTION. frequent consequence of the retrocession of erup- tions of the skin. But of all the causes capable of inducing this morbid condition of the duodenum, there is undoubtedly none more sure, and none more general, than the injudicious use of medi- cines in the treatment of other forms of dyspepsia, in which irritating drastics, heating tonics, and stimulants are lavishly and uninterruptedly applied to delicate and sensitive membranes, either already inflamed, or which they seldom fail to make so. There is also another source of this disease which deserves notice, where it presents itself as a secondary affection, the consequence of a state of plethora or congestion of the vena portarum, from which results vascular injection of the mucous surfaces, giving rise, under irritation, to inflamma- tion of a sub-acute or passive form, dyspepsia hemorrhoidal)'s, (Cullen); and also a correspond- ing form of disease which arises from plethora of the uterine system, where the menstrual relief has been insufficient, dyspepsia dysmenorrhceaca and amenorrhceaca. (Id.) Upon this state of disease it is not uncommon for menorrhagia from time to time to supervene. The irritation of teething in children, from some sympathy, direct or indirect, with the liver, the bile being suppressed and he- patic plethora induced, not rarely induces the mor- bid condition of the mucous membrane which constitutes this disease, dyspepsia dysodontiasis. Hence the light-coloured evacuations, and hence the discharges of blood, in short the dysentery of infants in dentition. Treatment. — The method of cure of this species of dyspepsia naturally divides itself into the following indications : 1. to correct the morbid condition which constitutes the disease—to remove the vascular excitement or inflammatory state of the mucous membrane lining the pylorus and duo- denum ; and 2, to render the function of digestion easy of performance, by which the causes of the disease will be avoided. 1. The principle of this indication must neces- sarily be antiphlogistic; but its application requires nice and delicate modifications and adjustments to ensure its success, or the physician may plunge his patient into a state of depression which will frus- trate his intentions. General bloodletting is seldom necessary; but if there be signs of general plethora, if the pulse be hard, tense, and resisting, if the pain of the right hypochondrium be severe, with much heat of surface, and much heat and dryness of the mouth and redness of the tongue, a small general bloodletting will be found to be the means which afford the most speedy and the most per- manent relief. It spares the necessity of topical depletion, and renders a much smaller quantity of medicine necessary, facilitates its action, and en- sures its success. When the symptoms indicate a state of plethora of the abdominal circulation, such as a full or varicose state of the veins of the lower extremities, swelling of the feet, pain in the loins, more especially in the sacrum, indicative of ii hemorrhoidal disposition, dark-coloured or sedi- mcntous urine, a large tongue, seemingly swollen witii blood, and eruptions of the skin, the conges- tion is more speedily subdued, and with less ex- pense to the constitution, by veiy small bloodlet- tings, repeated at intervals of a fortnight, than by fciiy other method • and the result is easy of ex- planation—it seems as if the quantity taken away from the general circulation were supplied from the circulation of the vena portarum, by which the congestion is diminished, and freedom given to the passage of the blood in the hepatic system. Where either of the above-mentioned states is present, the local detraction of blood from the tender part of the epigastrium or hypochondrium by leeches or by cupping, to the amount of from four to twelve ounces of blood, according to the circum- stances, will be found to satisfy the object of this indication ; but if after a few days the symptoms do not indicate improvement, it must be repeated. Except in nervous, irritable, and easily excitable persons, it is often of general service and sometimes very successful to endeavour to induce a deriva- tion of blood upon the hemorrhoidal vessels by the application of leeches to the margin of the anus. The antiphlogistic effect of both general and topical bloodletting may be increased, and rendered more durable by the various methods of counter-irrita- tion and derivation to the skin. For this purpose we think the tartar-emetic ointment or plaster is much to be preferred to blisters; but these also are occasionally useful. In old and protracted cases we have known the greatest comfort derived from the long-continued use of a warm plaster, gently stimulating, sufficiently large to cover the whole hypochondrium. In cases where the obstinacy of the complaint justifies it, either yielding with dif- ficulty or frequently recurring, no method of counter-irritation is to be compared to a seton, from which the most permanent good results are fre- quently obtained : it should be introduced obliquely in the direction of the cartilages of the false ribs. In aid of depletory means, or where the degree of the symptoms have not called for them, considera- ble benefit may be derived from certain medicines which have a direct antiphlogistic effect upon the mucous membranes of the intestines. These, according to our experience, are castor-oil, nitrate of potass, antimonials, and vegetable acids. The castor-oil should be given in doses of a drachm, repeated once in the twenty-four hours; it is best given at bed-time for its soothing and antiphlo- gistic effect upon the mucous membrane; but in the morning, if its aperient action is desired. In inflammatory irritation of the pylorus and duode- num it is a most valuable remedy, often by its soothing effect acting like an opiate, and has the most direct and the most remarkable power in allaying and relieving a heated state of the mucous membranes of the pylorus and duodenum. We must confess that we know no medicine more eminently endowed with this property. In obsti- nate chronic cases of this disease, we have known a small tea-spoonful of castor-oil taken every night at bed-time, as long as the stomach could easily bear it, a remedy attended with the most signal success. The effects of the castor-oil upon the stomach afford a very good test of the nature of the morbid condition of its mucous membranes. In atonic dyspepsia it is borne with the greatest difficulty, producing nausea and vomiting; in purely irritable dyspepsia a small dose of castor- oil acts severely and with much griping ; but if there be any degree of vascular excitement of the mucous membranes, it soothes and quiets, and its effect is often most useful in this way when it INDIGESTION. 649 has no aperient action. Its good effects will not he frustrated by administering it in any mild car- minative water, in emulsion, in coffee, or by com- bining it with a little liquor potassae. The nitrate of potass given in repeated small doses is a useful medicine, and of considerable power in correcting the vascular excitement of the mucous membranes. It may be given in doses of from five to ten grains lliree times a day, in an ounce of water, to which a very small quantity of mucilage of gum arabic has been added. If there be much thirst, the nitrate of potass may be given in a saline draught; and if there be great irritability or restlessness, it may be combined with a small dose of the tinc- ture of hyoscyamus, of lettuce, hop, or conium; if there he much dryness of the skin, it may be combined with a very small dose of vinum ipeca- cuanhae, or Dover's powder. When the cold or atonic state of the stomach tolerates with dif- ficulty the nitrate of potass, or as the symptoms subside, it may be exhibited in some bitters, as infusion of chamomile, quassia, or orange-peel, to which a very small quantity of spiritus etheris nitrici, tincture of cardamom, or orange-peel, has been added : tartarised antimony in very small doses, as small as one-twelfth of a grain, may be given with the same intention as the nitrate of potass, and, by determining to the skin, sometimes more efficiently. It may be given in various vehicles, which, acting as modifying agents, adapt it to the particular circumstances of each case, as in saline draughts, orange-flower water, camphor julap, infusion of quassia, and such like. In a highly irritable state of the alimentary canal, sinall doses of colchicum or hydrocyanic acid are frequently of signal service, and may be combined in the same way as the nitrate of potass and tartarised antimony. The general effect of these antiphlogistic means will be very much promoted by the use of the fresh-water or sea-water tepid bath, daily, or every alternate day. The intention of this indication will also be in- directly fulfilled by those means which, promoting the healthy secretion of bile, give freedom of cir- culation to the liver; and therefore, not before, but after depletion suitable to the case, and in aid of and combined with the means above specified, recourse must be had to hepatic alteratives, chiefly mercurial medicines, which require great care and discretion in their use. The pil. hydrargyri is in general the most suitable form of this medicine; if the bowels are irritable, or if there be a dispo- sition to diarrhcea, the pulv. hydrargyri cum creta is to be preferred; if the bowels are extremely sluggish, calomel. In recent cases it is most ad- visable to give five grains of pil. hydrargyri, or three grains of calomel; in protracted cases, small and repeated doses are to be preferred, one grain, sometimes half a grain of blue pill two or three times a day, the object being to obtain the action of the mercury upon the liver without irritating the mucous membranes. We think it better to give the i„edicine continuously until the secretion of the bile is improved, than interruptedly, thus keeping the body longer under the irritation of the medicine. When the mercury appears to be exciting the mucous membranes without promot- ing the secretions, which will be known by the Vol. II. — 82 3 E increased redness and dryness of the lips and tongue, it may be prudent to interrupt the use of the medicine from time to time. The mercurial may be advantageously combined with other medi- cines, to modify and facilitate its action; as with small doses of the antimonium tartarizatum, or of the pulv. ipecacuanhae, when it is desirable to in- fluence the secretion of the skin ; with nitrate of potass, pil. scillae comp. to favour the action of the kidneys; with extract, aloes to promote the action of the bowels; with extract hyoscytlmi, extract. conii, or extract, papav. if there be pain or rest- lessness ; with pil. galban. comp. if there be fla- tulence or hysterical symptoms; and with any bitter extract or aromatic confection, if it oppresses the stomach. We have seen no advantage in this complaint from the inunction of mercury, and have found it less easy to regulate its action in this way ; besides it thus affects the whole system unnecessarily ; and the advantage of mercury in this complaint being chiefly derived from its local action upon the liver, any thing more is perni- cious, and whenever the least sign of salivation appears its use ought to be discontinued. The use of mercury will be very much assisted by taraxacum, a medicine which has also a very sensible effect in soothing the mucous membranes; and in mild cases this last will alone suffice. When given in an efficient formula, it is a most valuable remedy in this species of dyspepsia. The extract may be given in infusion of hop, chamo- mile, or orange-peel, in the compound decoction of sarsaparilla, and in nervous patients in camphor julap, to which may be added, according to the intention, a small quantity of nitrate of potass, of sulphate of potass, of compound decoction of aloes, or spiritus eth. nitrici. R Ext. taraxaci, :jii. Potassae nitratis, Jss. Spiritus eth. nitrici, ji. Infus. cort. aurant. ^vi. M. Cochleare amplum bis terve die sumendum. The nitric acid, nitro-muriatic acid, and the so- lution of chlorine, are also useful auxiliaries aftei mercury, in some cases substitutes for it. They may be used internally in decoction of liquorice, or compound decoction of sarsaparilla, to either of which a little spiritus aeth. nitrici may be added ; or they may be used externally either in the form of bath or lotion. In case of diarrhcea super- vening, their use should be immediately suspended. 2. This indication will be fulfilled, a. by a pro- per regulation of diet, suited to the degree of the complaint; b. by preserving an open state of bowels; and c. by assisting the function of diges- tion by mild tonics, and by proper air and exercise a. In the slighter degrees of this complaint very low diet is seldom necessary ; a little mutton or chicken may be taken daily, or every second day, and is preferable to a diet consisting exclusively of farinaceous food. In other respects it should be light, bland, and cooling, and in small quanti- ties at a time : light refreshing broths or soups in moderate quantity, light puddings, arrow-root jelly, rice-gruel, blancmange of rice or semolina. In some forms of this disease it is sometimes ne- cessary to restrict the patient wholly to a fluid diet, to jellies of amylaceous and farinaceous food, gruel, asses' milk, and jelly of Iceland moss. In 650 INDIGESTION ordinary cases the stomach requires a certain quantity of animal food, and in this species of dyspepsia the fat of animal food, particularly the fat of bacon, is more easily digested than the lean ; and it appears besides to have a useful effect in allaying the irritation of the mucous membranes, and in assisting the action of the bowels. In severe cases, where there may be a disposi- tion to feverishness, any increase of heat of sur- face, thirst, or night perspirations, it is advisable to abstain from wine. It must at all times be taken in very limited quantity, and its use from time to time interrupted, but it need not be wholly abstained from, and the digestion is very frequently promoted by it. Seltzer water is the best beverage in this complaint; but we have not found any inconvenience from light table-beer in small quan- tities. b. The warm or cold water lavement is the best means of preserving an open state of the bowels. If this does not succeed or cannot be used, castor- oil may be given in small doses night or morning ; its aperient action may be assisted by combining it with manna, or a pill formed of pulv. aloes comp. two parts, and soap one part, may be used instead. c. The process of digestion may in some degree be facilitated and assisted by light bitters, as the infus. quassiae, calumbae, or cort. aurant. to which some neutral salt, as the nitrate or sulphate of potass, may be added in small doses ; by the mine- ral acids, as the phosphoric, the aromatic sulphu- ric acid, or nitric acid in sinall doses; or by the cautious use of wholesome wine in small quanti- ties. But the means which restore the tone and strength of the body in general are far preferable. These are proper exercise, neither heating nor fa- tiguing, as horse exercise, or a sea voyage; dwell- ing much in the open air, in a dry open air; change of air and place ; cold ablution with vine- gar and water; proper clothing, warm but not oppressive; and gentle occupation of the mind; all which remedial measures have been already sufficiently noticed. We must not, however, omit to mention the use of mineral waters in the treatment of the chronic form of this disease, which combine the means of at once fulfilling all the foregoing indi- cations, and render it difficult to know under which head to class them. The most efficient of these according to our experience are the Kreutz- brunnen of Marienbad, and the sulphureous wa- ters of Harrowgate. They may be taken warm or cold, as best may suit the sensibility of the stomach, its power of digesting or absorbing them. Their action should as soon as possible be derived on the bowels, and they ought to be continued until the healthy function of the bowels has been restored, and until the tongue has lost its heated and red aspect, and assumed a healthy appearance. In order to render their good effects more perma- nent, their dose ought to be gradually diminished. A course of goats' milk or whey drunk every morning in considerable quantities, has been known to have a similar effect. In Scotland and in Switzerland it is frequently had recourse to; and we heartily join the late Dr. Ryal in his earnest wishes that an establishment for the sup- ply of goats' whey were formed upon our Brighton Downs, which afford every means of doing so, and where the adjacency of a large town promises a ready consumption. We are inclined to think that the disorders of the liver in which it has been found to be so useful, have been only forms of inflammatory duodenal dyspepsia. Though the treatment of the primary disease has only occupied our attention, we do not think that the secondary or sympathetic affections which originate in it should be wholly left to depend upon it. We think, whenever symptoms can be relieved without interfering with the general plan of treatment, it is always useful, and ought always to be attempted. As has been correctly observed by Dr. W. Philip, the secondary affections un- dergo the same change and partake of the same nature with the disease from which they spring; therefore the secondary affections in this disease are apt to assume an inflammatory character, to become more and more of a permanent nature, in the same proportion more independent of the ori- ginal disease, and, on that account, more de- manding the physician's careful attention. But with this passing observation our limits oblige us to leave them to be each considered under its pro- per head. Strumous Dyspepsia. Under this title we are anxious to draw the at- tention of the profession to the form of dyspepsia which belongs to the scrofulous constitution, for in our opinion it presents a more characteristic feature of this habit of body than any physiogno- mical portrait which has yet been drawn of it. In this respect it is more to be depended on than either the fine skin, the clear delicate complexion, the light hair, large blue eyes, and dull sclerotica of one variety ; or the foul, dull, swarthy-coloured skin, the sallow complexion and swollen counte- nance, the dark hair, and tumid upper lip of the other. It betokens, indeed, little familiarity with scrofula to connect it with any particular tempe- rament, for it belongs to all temperaments, to the sanguine as well as the phlegmatic, to the ner- vous as well as the melancholic, and to all their varieties and combinations. But upon whatever temperament the disordered habit which we call scrofula may engraft itself, we venture to say that this form of dyspepsia will also there be found ; and, therefore, being constantly present with it, preceding and accompanying the various symp- toms which issue from it, it would be contrary to all reason to refuse to it an important share in the development of this disordered habit, and in the production of the local affections which have hitherto too much engrossed the attention, to the exclusion of a proper consideration of the consti- tutional disease. Of late years, however, the constitutional affec- tion has received more of the notice of physicians. It has been described by Malfatti of Vienna under the name of latent scrofula, by Dr. Ayre under that of chronic marasmus, and most faithfully by Dr. [Sir] James Clark under the term tubercular cachexy ; it has also been sketched by Dr. Mar- shall Ha'I under the title of disorder of the gene- ral health in tuberculous affections ,- but we are not aware that any of these physicians have con- nected it with a special disorder of the chylopoietic function. INDIGESTION. 651 Form of the Disease. — In the offspring of I scrofulous and also of dyspeptic, hypochondriacal, ' or cachetic parents, in the children of old men, in children who have been badly nursed, or who, brought up by hand, have been improperly fed, or reared in the impure air of crowded towns, symp- toms of disorder of the function of digestion early manifest themselves, generally between the first and tenth year, often commencing with the first dentition, which is commonly painful and difficult. Though the child from time to time loses its ap- petite, it is generally morbidly craving or ravenous, even soon after a plentiful meal requiring fresh food, so that the nurse remarks there is no satis- fying such children. The complexion loses its colour, the skin its tone, ceasing to compress the flesh ; the flesh becomes soft and flabby, the ap- pearance is languid, the belly generally tumid, and there is a want of the usual disposition to play, or to use the exercise common to that period of life. The little patient is soon tired, complains of aching of the legs and knees, desires frequently to be taken up; his temper is fretful, he is easily set a-cry, and his intellect is either precocious or unusually dull. His sleep is seldom calm and composed; he moans, talks, or grinds his teeth, sometimes screams and raves. His bowels are generally confined, and his evacuations are of a light grey colour, like pale brown paper, some- times curdled with streaks of mucus; or they are of a greenish colour, frequently yeasty, of a sour and highly offensive smell, and very often the food is passed unchanged. Diarrhcea occasionally oc- curs, consisting usually of light-coloured or slimy stools, and the patient frequently complains of pain in the bowels or uneasiness of the stomach. The urine often deposits a whitish sediment; the breath is fetid or heated; there is some slight thirst, slight heat of skin, except on the extremi- ties, which are colder than natural; the skin is harsh and dry, except during sleep, when there are frequently heavy but partial sweats. The tongue is redder than natural, and on its anterior part spotted with small points of a darker and brighter red colour than the general surface ; it is seldom much furred, being either covered with a thin mucous fur, through which the red spots ap- pear, or with a slimy brownish coat, or the fur is distributed in small circular white spots, more or less confluent, presenting altogether a dappled ap- pearance. When irritation of the stomach super- venes, the tongue is dry and of a brownish red colour. These symptoms, seldom entirely absent, continue from time to time to recur, more or less severe in degree, as the causes of derangement, irregularities in diet, an indulged and pampered appetite, may present themselves, being always most remarkably manifest after any of the ordinary diseases of childhood. As the child grows, unless the most judicious management has interfered with the natural progress of the complaint, other symp- toms begin to appear. The patient becomes sub- ject to sore throat, the fauces are redder than nat- ural, and the tonsillary glands are observed to en- large ; there is a frequent tickling cough, and itching and picking of the nose and lips. The hands and feet are usually very cold and damp, or on the least cold turn of a dark livid purple colour, and the child is extremely subject to chil- blains, even sometimes in summer. The patient is liable to be troubled with various affections of the skin, very early with porrigo furfurans, pso- riasis guttata, achorous pustules, on the hairy scalp, (the tinea mucosa of Alibert,) with pity- riasis, herpes circinnafus, with lichen and pur- pura, frequently the lichen urticans and purpura urticans, at a later age ichthyosis, pityriasis ver- sicolor, porrigo decalvans, erythema nodosum, and porrigo favosa, sometimes spreading over the whole body, and at a still later period of life, acne indurata, one of the most characteristic 6igns of this habit of body. All these diseases of the skin, in their external appearances so dissimilar, have yet in their nature a close affinity to each other, and, frequently convertible into and succeeding each other, seem only different external manifes- tations of the various degrees and modifications of the irritations of the internal organs. The eye is frequently the seat of various troublesome affec- tions ; hordeola constantly recurring, inflamma- tion or purulent discharges from the ciliary glands, falling off of the eye-lashes, &c. Occasional dis- charges of blood from the bowels, epistaxis at a much earlier age than usual; copious mucous discharges from the bowels, sometimes from the vagina, are not rarely observed in this disease. Sometimes the cellular system feels exclusively the effects of the internal disease, a succession of cold indolent abscesses occupying every limb of the body. Frequently the nervous system is the seat of the secondary irritation, sometimes in its membranes and vascular structure, giving rise to inflammation and hydrocephalus ; sometimes in its functions, inducing chorea, epilepsy, idiocy. The bones very commonly manifest symptoms of disorder, but the ordinary termination of the dis- ease is the formation of that morbid growth or deposit well known under the name of tubercle, which, most usually seated in the lymphatic glands, has almost exclusively received the name of scrofula. In young females about the age of puberty this disease frequently undergoes a remarkable change; for habitual constipation becoming established, another form of dyspepsia is induced, which in this constitution very frequently leads to spinal affections. In the adult age the symptoms present consi- derable modification. The patient's complexion becomes pate, of a slightly blueish or leaden co- lour, particularly under the eyes; in dark com- plexions it becomes of a pale sallow or yellowish colour; the body is more or less emaciated, the skin flaccid, the muscles flabby ; there is an unu- sual sensibility to cold, the patient is very apt to shiver, and there is a constant tendency to cold- ness and lividity of the extremities. The appe- tite continues good; frequently it is craving, and the food does not appear to satisfy; sometimes there is a constant empty and sinking feeling at the stomach, only temporarily relieved by eating, the patient feeling after a meal as if he had long fasted, and is again desirous of taking food. The bowels are confined ; more rarely they are loose, discharging copious light or drab-coloured stools, which are frequently more than usually fetid. The urine generally deposits a whitish sediment, sometimes mucus. The tongue is red at the 652 INDIGESTION. point, generally studded with enlarged papillae, of a brownish red colour behind, but seldom coated. The pulse, always weak, is small and drawn, sometimes it is slow and weak. The steep is seldom natural, the patient is restless during the first part of the night, and towards morning falls into a heavy unrefreshing sleep, during which he sometimes perspires profusely. He is listless and drowsy by day, and though the spirits are some- times sufficiently cheerful, more commonly the patient is timid, nervous, torpid, or hypochondria- cal. Frequently there is a great tendency to per- spiration on the least exertion or the least excite- ment, and the palms of the hands and soles of the feet feel damp and clammy, frequently cold. The thyroid gland, the lymphatic glands of the neck and groin, are observed to be large and swollen, but not painful. In women, leucorrhcea, painful or deficient menstruation, in men, a disposition to hemorrhoids, is observed; but the usual progress of the disease is to tabes mesenterica or phthisis pulmonalis. Pathology.—The phenomena of this disease, its whole complexion and character, sufficiently indicate a congestive state of the hepatic system ; and were we to assume as the proximate cause of the disease a plethora of the vena portarum, both in its roots and branches, we should be furnished with the means of explaining all the symptoms of the disease ; for we should readily understand how, in this state of the circulation of the abdo- men, the mucous surfaces of the intestines should be full of blood, consequently subject to inflam- matory irritations and disordered functions, whilst the peculiar office of the duodenum renders it es- pecially liable to be the seat of them : how the function of the liver being deranged, all the other consequences of this disease may follow; for though we may not know precisely what share the function of the liver may have in the process of sanguification, we may easily understand how it may interrupt and interfere with this process, leading to a cachectic state of the fluids, from which result tubercles and other semi-vital and semi-organic productions. (For a further explana- tion of this opinion, we refer the reader to our account of the formation of tubercles in Dr. [Sir James] Clark's work on Climate.) Nor does it seem an improbable supposition that a disposition to abdominal plethora, or an organization which favours it, may be transmitted by parents to their offspring, more especially in dyspeptic and hypo- chondriacal persons, in whom the chylopoietic viscera, under constant irritation, are necessarily also in a state of congestion: we might thus ex- plain how the strumous cachexy is continued, and how it is generated. The foregoing view of the nature of this dis- ease is also in conformity with the observation and opinions of other physicians. " In children," ooserves Dr. Wilson Philip, "the symptoms of inflammatory dyspepsia supervene early, and the disease in them commences in the liver rather than in the stomach." And Dr. Ayre has, in the following passage, confirmed our statement, though we have offered another explanation of it: " Dis- eased mesenteric glands occur in children from acrid condition of the duodenal contents; the liver, pancreas, and duodenal glands become dis- eased from congestion, and irritation will be pro pagated to the brain, giving rise to hydrocephalus, spasms, convulsions, vomiting, contortions of the countenance, affections of the sight, violent head- achs, faltering voice, chorea, palsy." Treatment.—The plan of cure of this dis- ease consists in the following indications: 1, to correct the morbid condition of body which we have stated to constitute the essential foundation of the disease; 2, to render the function of diges- tion easy of performance by a regulation of diet suited to the nature of the disease; and 3, to improve the general tone and strength of the body. I. In the ordinary degree of this disease, it is seldom necessary to relieve the congestive state of the liver by the detraction of blood ; but when there is much febrile excitement, with a red and dry tongue, with fulness or tenderness of the right hypochondrium, the application of a few leeches brings more immediate relief, and spares the ne- cessity of much physic. In general, lie direct antiphlogistic part of the treatment is accomplished by a light diet, by the nitrate of potass given in repeated small doses, either in saline mixture or in some carminative or bitter infusion, as the case may admit, whilst the intention of this indi- cation is also obtained indirectly by increasing the secretion from the liver. We entirely agree with Dr. W. Philip in his high estimation of this remedy, the nitrate of potass. Of itself partly a substitute for mercury, when combined with it, it renders less mercury necessary ; with purgatives, it renders their action more free, and with antimo- nium tartarizatum it is invaluable in case of de- termination to the head. For promoting the secretion of the liver, mercury is the medicine most usually resorted to ; as an occasional remedy for regulating the secretion of the liver, it is also probably the most safe and the most convenient. It should, however, be given only in interrupted doses, and should on no account be allowed to affect the system. The hydrargyrum cum creta' combined with a few grains of subcarbonate of soda, and a minute quantity of pulvis ipecacuan- hae, or pulvis Jacobi, we consider the best general formula. If the bowels are too open, the mercury may be combined with the pulvis ipecac, comp.; if confined, with a little magnesia, nitrate of potass, or extract of aloes ; but in either case this alterative should be followed every morning, or every second morning, by a tea-spoonful of castor- oil, hy a little electuary of cassia or senna, i>r by a small dose of sal polychrest. The effects of the mercurial medicine will be also very much pro- moted by following it up w ith a course of taraxa- cum or sarsaparilla, or both united. The action sought to be induced upon the liver, and through that organ upon the abdominal cir- culation, by means of mercury, may also be ob- tained by means of iodine, in our opinion more efficiently and more permanently; and where the inflammatory state of the mucous membrane of the duodenum exists in a slight degree, we think that it merits the preference. We have been in the habit of using the tinct. iodin., and have had much satisfaction in its use in strumous affections, but we have always observed that its value has been invariably in the degree in which it acted on INDIGESTION. 653 the liver. We have made it a rule to commence I in small doses, gradually increasing them; and though we have never seen any untoward conse- quences from its use, we have invariably observed the precaution of from time to time interrupting its exhibition for a few days. Where there is any hemorrhagic or scorbutic tendency, shown by eruptions of the nature of purpura, iodine is de- cidedly contra-indicated. It is probable that the muriate of lime has a similar action upon the liver, and may be advantageously used for this purpose. In chronic cases we have seen the greatest advantage derived from a course of the Kessel- brunnen of Ems; and when there is any ten- dency to diarrhcea, we believe it to be preferable to every other form of medicine. The Obersalt- brunnen may be also used in similar circumstances. When the state of the mucous surfaces admits of the exhibition of chalybeates they prove an alterative of very great value, and possess consid- erable power of correcting the congestive state of the abdominal circulation. This property of chaly- beates has in our opinion been very much over- looked ; for though they are usually administered in this disease, they are never exhibited with this intention. The chief obstacle to their use is the state of the mucous surfaces; for if they be not in a cool and secreting state, chalybeates are re- pugned by them as irritants. On this account it is most advisable to select the salts of steel the least exciting, as the ferrum tartarizatum, or to qualify the chalybeates by saline refrigerants, as by uniting the carbonate of iron with small doses of the nitrate or the sulphate of potass ; or, best of all, by giving the remedy in the form of some saline chalybeate water, as the Eger. We have lately been in the habit of combining the iodine with chalybeates, and we think with very consid- erable benefit. They appear to correct and pro- mote each other's action. This is our formula:— R. Tr. muriat. ferri, tr. iodinii aa gii. aq. purae gss, Guttae x. ad xxx. ter die sumendae. The congestion of the hepatic system may also be relieved by increasing the action of the kidneys and skin; that of the former will be promoted by the alteratives already mentioned; and that of the skin will be excited by the tepid sea-water bath, by sponging the body with vinegar and water, or salt and water, by the use of the nitro-muriatic acid lotion, by warm clothing, and by exercise; and, failing this, by gentle friction of the whole surface of the body for at least half an hour daily. Unless a free and open state of the bowels be made to concur with the preceding remedies, they will prove abortive; but violent purging by irri- tating medicines is equally to he avoided. A soluble state of the bowels, procured by such mild remedies as have been already mentioned, is all that is to be desired. Sometimes a course of purg- ing by the sal polychrest or the Harrowgate salts is of service, and when a sluggish state of the colon coincides with this disease, it is absolutely necessary that this intestine should be unloaded and preserved so. 2. Except under occasional febrile symptoms from an aggravated degree of the disease, the anti- phlogistic regimen is unnecessary, and it ought never to be long-continued. According to our 3e* experience a limited diet of animal food, nutritious and easy of digestion, answers best. The meals should be small, consisting chiefly of animal and farinaceous food; all vegetables and fruits ought to be avoided, or used very sparingly. Cows' milk seldom agrees well, and ought therefore to be considerably diluted ; occasionally a little beef- tea or plain bouillon answers very well as a sub- stitute for breakfast when milk is found to disagree. Wine, porter, ale, and beer are unnecessary, and therefore better avoided. In this disease fish is a very unwholesome food. 3. In ordinary cases, when the organs of nutri- tion are restored to a healthy state, the natural resiliency of the constitution can generally dis- pense with artificial assistance; but with feeble powers of body—a marked feature of the disease of which we are treating—some further help is necessary. We cannot, however, speak much in favour of internal tonics, excepting chalybeates, (which we do not view simply in the light of tonics,) and of them we have already said enough. More benefit is derived from tonics externally ap- plied. Of these, unquestionably the most power- ful is the cold sea-bath, and the most beneficial, unless it produces languor and chilliness. The shower-bath, cold ablution, exercise in the open air, in a dry free atmosphere, either by the sea- shore or in an elevated situation. The exercise should be moderate, chiefly on horseback, or for children, on donkeys. Amusing plays, moderate and agreeable occupation of mind ; gentle friction over the whole surface for half an hour every evening ; and lastly, occasional change of air and change of habits. III.—Follicular Duodenal Dyspepsia. Synonyms.—Hypochondriasis pituitosa ; ( Fra- cassini, cap. 4. p. 388;) Auct. Var.,- aurigo fri- gida ab obstructione, Sauvages ; infarctus, Ktimpfi; painful affections of the intestinal canal, Powell. (Med. Transact, vol. vi.) General Character.—Symptoms of painful or difficult digestion, felt chiefly a considerable time after taking food, most frequently observed in phlegmatic habits ; occasional alvine discharges of mucus in various morbid states; acute attacks of gastrodynia or jaundice sometimes intervening. Form of Disease.—In persons of a cold tem- perament and relaxed habit, characterized by soft- ness and want of elasticity of fibre, dark carbonized blood, a slow circulation, a soft pulse, low animal temperature, yellowish or chlorotic, and sometimes swarthy paleness of the skin, who are also much disposed to steep, showing great languor, sluggish- ness, and apathy in their feelings, and betraying a want of decision and energy in their moral and intellectual character,—disorder of the duodenum assumes a particular form, depends upon a pecu- liar morbid condition, and manifests itself by cer- tain characteristic symptoms. The general progress of this species of dyspep- sia is insidious, and can hardly be distinguished from the other forms of duodenal disease, except that the appetite is commonly much impaired. sometimes to loathing. There is great languor, lassitude, and incapacity for every exertion. The patient complains of a sense of load, distension, or pain, some hours after taking food, and the diges 654 INDIGESTION. lion is accompanied with flatulence, oppression, anxiety, sometimes amounting ti a feeling of suf- focation. There is no remarkable loss of flesh, but the appearance of the skin U much altered; the complexion becomes bloated, loses its colour, is dull and cloudy, sometimes swarthy, frequently clammy, greasy, or waxy, as if covered with a thin film of melted wax ; or the skin is sallow and somewhat jaundiced ; it feels generally cold, moist, and clammy, the hands and feet particularly so. The lips and gums are generally pale ; the tongue is moist, pale, and flabby, covered with a pearly white mucous coating, but seldom much loaded ; sometimes there is a thick, shaggy, cottony fur. The mucous coating of the tongue often has the appearance of a false membrane, which, falling off' in pieces, leaves patches quite clean, sometimes red, and morbidly tender. The bowels are almost always constipated, but diarrhcea is sometimes, though rarely, observed ; the stools are light- coloured, porraceous and abundant, out of all pro- portion to the ingesta, and having often a faint mawkish smell; occasionally they are dry and dark-coloured, more frequently fluid and dark, of a greenish or brownish black colour, and not un- , commonly dark, viscid, and pitch-like. But the characteristic features of the evacuation are con- siderable quantities of mucus, which are discharged in various morbid states and forms: sometimes it resembles transparent jelly, or is glairy like the white of an egg; frequently yellow and viscid like the yolk of an egg; sometimes it assumes the solid form, appearing in concrete masses varying in size and figure, frequently resembling small bits of tallow, wax, suet, or bits of the blanched kernel of walnuts ; in other cases it appears in large shreds of a semi-transparent membrane of considerable tenacity ; or large quantities of flakes mostly torn into irregular shapes, and appearing to have formed parts of an extensive adventitious membrane of no great tenacity or firmness ; some- times the membrane is passed in perfect tubes of considerable extent. Frequently it is passed in solid cylindrical forms like shreds of boiled mac- caroni or vermicelli, not rarely mistaken for the detritus of worms; and on some occasions con- siderable quantities of mucus of a purulent appear- ance are discharged at once, leading to the sup- position that an abscess has burst internally. These discharges of mucus appear to take place periodically, and as it were critically, being in general preceded by considerable aggravation of the symptoms, whilst the recovery is attended I with evacuations of quantities of mucous or gluti- I nous substances. In these attacks the patient is sometimes sud- denly seized with acute spasmodic pain in the right tiypochondrium, darting through to the back, fre- quently accompanied with vomiting or a hard dry cough, by either of which the pain is greatly ex- asperated. Often there is sudden and excessive pain towards the epigastrium, returning with vo- miting, in violent paroxysms. These pains are occasionally rather relieved by pressure; but the parts are frequently so sensitive that the slight- est touch cannot be borne, and even during the intervals of the pain the patient complains of great tenderness and soreness in these parts. The tongue, already coated with a white fur, becomes dry. the pulse accelerated, the stools white, the urine turbid and of a dark red colour, like blood. As the pain remits, the patient is bathed in a profuse pcrspi- ration. After a day, sometimes longer, the skin becomes jaundiced, and on examining the evacua- tions, instead of gall-stones, as he expected, the physician finds copious flakes of mucus in various forms, which are passed with considerable relief to the patient. This mucus, sometimes fluid and approaching to pus in appearance, has, in connec- tion with the foregoing symptoms, frequently im- posed the disease upon the attendants for the rup- ture of an abscess of the liver ; but the same symp- toms and the same discharge occasionally occur without jaundice or any symptom of hepatic ob- struction. The urine, in the ordinary progress of the dis- ease, is extremely variable; in the early stage it is rather pale and abundant, occasionally crude and transparent like water, and voided in considerable quantities; but during the severity of the symp- toms this secretion becomes very deficient, high- coloured, and extremely loaded, sometimes of a deep orange colour, unless there be some obstruc- tion of the biliary secretion, when, as has been already observed, it is of a dark blackish brown colour, like porter, or, mixed with a copious late- ritious sediment, it almost resembles blood. The pulse, except during what may be called the acute attack, is always weaker than natural, generally slow and small, more rarely frequent and small, or wiry and fluttering. The seat of the disorder may entirely escape the notice of the patient and even the observation of the physician ; the chief complaint, frequently the only object of the treatment, instead of indi- cating any derangement of the function of diges- tion, may be an affection of another part of the body, some of the multifarious symptomatic dis- eases which originate in this disorder. Among the secondary affections which occasionally accom- pany this morbid state of the small intestines, (for we do not pretend to cm fine it strictly to the duo- denum,) are, a remarkably altered state of the temper and feelings, languor, indifference to every thing, complete apathy, sometimes stupor or fatuity, sadness, great depression of spirits, obstinate me- lancholy, great irritability of temper, moroseness, obstinate silence and reserve. Sometimes the patient is oppressed with irresistible drowsiness during the day, and troubled with want of sleep at night, or the sleep is disturbed by dreams and incubus. The uterine functions seldom escape the influence of this disorder; menstruation is gene- rally deranged, being either painful, irregular, or deficient, and the secretion pale-coloured ; leucor- rhcea is a very common attendant of the complaint in early as well as in protracted cases. Frequently the patient complains of uneasy sensations about the heart, of a sense of fluttering, of violent palpi- tation or syncope. The organs of respiration often suffer in consequence of this disorder; hence dys- pnoea, short dry cough, frequently moist humoral cough with a grey viscid expectoration, or pain and sense of weakness of some part of trie chest; in children a spurious form of croup is one of the most common symptomatic affections. The nerv- ous system is often the chief scat of disorder, and chorea one of its most common firms; sometimes INDIGESTION. 655 it affects the whole body, less often only one half the body, generally the right, and on some occa- sions only one of the extremities, very commonly the right arm. Paralysis, generally partial, affect- ing one, seldom more, of the limbs, is another form of secondary affection. Painful local affections are often the chief subject of complaint, rheumatic paralysis, rheumatic gout. Erysipelas, erythema, acne, and impetigo, are the most common affec- tions of the skin which originate in this disorder. The unfavourable progress of the disease leads to a state of general cachexy, cachexia pituitosa, which sometimes terminates in anasarca. Pathology.—This species of dyspepsia, no- ticed by some of the ancient physicians, has been more frequently concealed under the name and description of other disorders. Overshadowed by the secondary affections which originate in it, it is only to be found masked under the symptomatic forms of other diseases. But the morbid products of the mucous secretion have scarcely escaped the observation of any practical physician. Marcard (Description de Pyrmont, vol. iii. pp. 45, 90,) and Stoll (Ratio medendi, p. ii. pp. 319, 346,) have particularly described them ; Theden (Remarques et Experiences, vol. ii.,) and Hoffmann (Med. Ra- tion, vol. v. de morb. infant. Obs. ix.,) have con- sidered them as not an unfrequent cause of sudden death; Bonnet, Morgagni, Vesalius, Brunner, and other pathologists worthy of every confidence, have discovered them in the dead subject; and the minuter researches of modern anatomy have traced them to their proper origin. But this morbid con- dition of body never received its due share of im- portance until the work of Kiimpf, (Abhandlung von einer nu'en Methode die hartnilckigsten Krank- heiten, die ihren Sitz im Unterleibe haben, zu heilen, 1784,) a Dutch physician, by whom it was first professedly described under the name of in- farclus, and who must be considered to have es- tablished it as a particular disease. Though this author was in some degree guilty of the common error of most original thinkers, of overstepping and overcharging his premises,—for he said he recol- lected few diseases which were not originally re- ferable to infarctus,—it was not so much this fault as his singular method of cure, which failed to lead to a more general reception of his opinions, which, except in Germany and Holland, have been too little attended to. In our own country, as far as we are aware, the pathological condition of this disorder has never been accurately specified, though the secondary forms of diseases under which it masks itself have been frequently described. A few interesting cases of the primary disorder have been given by Dr. G. D. Yeats, (Op. citat.,) but more particularly by Dr. Powell. (On certain Painful Affections of the Intestinal Canal, Med. Transact, vol. vi.) It has been observed by those who have devoted much attention to morbid anatomy, (Andral, Anat. Path.) that the mucous glands of Peyer and the follicles of Brunner do occasionally pre- sent appearances very different from that of the healthy state. Sometimes they are found unusu- ally developed; as large as mustard seeds ; fre- quently they contain a whitish concrete matter, more or less friable, bearing a close resemblance to the caseous or lardaceous matter of tubercles ; at other times a great number of small white bodies are found disseminated over the surface of the intestines, corresponding to the grub or em- phragma sebaceum of the skin; for they are nothing more than the follicles filled with concrete mucus. These bodies occasionally acquire con- siderable size, but seldom exceed that of a pea; sometimes they are elongated, projecting in the form of little excrescences or fungous papillae; or on the contrary, the follicles are flattened and de- pressed, with their orifice more or less apparent, from which is thrown out a thin greyish mucus, which sometimes collects in astonishing quantities in particular parts of the intestinal canal, or, spreading itself in every direction, forms a thick mucous coat over a considerable part of the sur- face of the intestine, which on the first view might easily be mistaken for the mucous membrane it- self, in a white and healthy state; sometimes it is a tenacious mucus of a dark brown colour; or instead of this greyish semi-transparent semi-fluid mucus, a concrete matter, equally secreted by the follicles, may spread itself in the form of a mem- brane, more or less dense, over the surface of the intestinal canal; or instead of being spread on the surface, this concrete matter may form solid masses, as occurred to the celebrated Justin Lip- sius, who, though treated by his friend and col- league Heurnius, suffered for a long time from this complaint, and was not relieved till he had voided a viscid muss of the colour and form of the intestines. It was the doctrine of the school of pathology just disappearing, to consider all these morbid appearances as the result of inflammation of the mucous surfaces. Dr. Parry observes that the appearance of the fibrous and curdled stools of children, and the consistent concrete membranes taking on the tubular form of the intestines in adults, which are often evacuated from the bowels in slight inflammatory affections of the mucous membrane of the colon and rectum, so often mis- taken for worms, consist rather of coagulated al- bumen than of concrete mucus ; but there does not appear any just reason for this opinion. We have observed these without the remotest sign of inflammation ; nor did Dr. Powell observe any, but on the contrary, states that the most remark- able circumstance in the history of his cases was, the production of an effect usually ascribed to in- flammatory action without its previous existence. There will be little difficulty in understanding how all the various symptoms and sufferings de- scribed as originating in this morbid condition of the mucous follicles may be consequences of it, if we allow a due importance to these organs in pre- serving a healthy action of the membrane of which they constitute so essential a part. On comparing the various morbid appearances presented by a disordered state of the follicles, we may remark that they divide themselves into two classes; one in which the secretion is suppressed or retained, and another in which it is excessive or overflows, to each of which opposite states a more precise observation will in all probability ascribe its appro- priate symptoms. In the mean time it may be easy to conjecture how the mucous membrane, not defended by its appropriate secretion, may ac quire a preternatural sensibility and irrita!:I':v 656 INDIGE STIOX. which, not only disturbing the function of diges- tion, and giving rise to most painful affections of the intestinal canal, but rousing the actions of its sympathetic organs, may induce any of the dis- orders which we have noticed; and how, on the other hand, the membranes, sheathed and muffled by the morbid envelope, and thus deprived of their sensibility, will induce disorder and excite sympa- thies of another character, and will also sometimes become mechanical causes of irritation and ob- struction. The inconvenience of a dirty skin, as a writer on this subject observes, is felt, because its obstructed pores prevent the transmission of that insensible perspiration which is essential to health; languor, sickness, headach, and other in- conveniences originate precisely in the same man- ner, from filthy intestines. And we know that the mucous membrane, either by sympathy or as- sociation, sometimes degenerates into a state rela- tively similar to that of the teguments of the sur- face of the body, which sometimes become hard, harsh, and rough ; or glossy, smooth, and shining, like parchment; pale, weak, and withered, or co- vered with large thick scales of cuticle adhering to its surface, thus losing all its permeability ; or, on the other hand, besmeared with an excess of sebaceous secretion, covering the skin with an oily, greasy, or waxy coating. When both these secreting surfaces, the skin and the mucous mem- branes, cease at the same time to perform their offices, it is not difficult to understand how the fluids become disordered, how nutrition becomes impeded, and how the most inveterate forms of cachectic complaints ensue. Our pathology of this complaint receives con- siderable illustration and confirmation from consi- dering its causes. It has been observed most frequently in females and children, in whom the mucous follicles are most developed ; it prevails most in cold humid seasons, in cold humid cli- mates, and therefore, prepared by the influence of winter, it often declares itself in early spring, and on the return of cold in autumn. Sedentary em- ployment in confined and impure air, with neglect of personal cleanliness, are the circumstances most powerful in producing it; to which may be added unwholesome food. When the predisposing causes have been in operation, it is generally immediately excited by colds, errors of diet, drastic purgatives, fatigue, watching, anxiety, alarm, and bodily acci- dents. Constipation of the bowels, while it is a consequence, is also one of the exciting causes of this disease. Method of Treatment.—The indications for directing us in the cure of this disease, are, 1, to render the function of digestion easy of perform- ance by a proper selection of food, by preserving an open state of the bowels, and by proper exer- cise ; and, 2, by endeavouring to correct the mor- bid condition of the follicles, which constitutes the proximate cause of the disease. 1. Having already so fully and so frequently considered the means of fulfilling the first indica- tion, it will be unnecessary again to recur to that subject; we shall, therefore, content ourselves ■vith referring to the treatment of follicular gas- tric dyspepsia, and shall for the present confine *ur observations to the means of fulfilling the second indication. 2. Some medicines appear to exert a particular influence upon the functions of the mucous folli- cles. According to our experience they consist of purgatives, especially rhubarb, senna, scammo- ny, and aloes, of sulphurous and some neutral salts, as sal polychrest, muriate of soda, of alka- lies, mercurials, chalybeates, of iodine, colchicum, gum ammoniacum, and ipecacuanha. Amongst several means capable of effecting the same ob- ject, it is a received principle of physic to select those whose operations are best known and most under control, having recourse to others only when their use cannot be dispensed with. Ac- cordingly, some of the purgatives above enume- rated, either alone or in combination, form the proper remedy of this complaint in milder cases; and where no signs are present indicating an in- flammatory or excited state of the mucous mem- branes, rhubarb, with sal polychrest and a small proportion of ginger, the pulvis scammoniae com- pos., the infusion of senna ; in cold habits, the vinum aloes, the decoct, aloes comp., and the baume de vie, are convenient combinations. Dr. Powell found, in his cases, that the infus. sennae with the infus. gentian, comp., and from x to xx minims of liquor potassae, repeated so as to pro- duce four or more stools in the twenty-four hours, discharged the flakes of mucus better than saline aperients, and more efficaciously than mercurials. Where there were general torpor or coldness of the system with much pale urine, and dark stools with much mucus, Dr. Yeats observed very ex- cellent effects from taking one drachm of the vinum aloes with xv minims of liquor potassae in a little infusion of chamomile every morning. It is not enough that these medicines be taken in isolated doses. To give them effect, they must be steadily persevered in for some time. But their effects must be watched. If they cause irritation, heat, thirst, or much griping, they are not indi- cated, and may induce the very state we are seek- ing to remove. The largest fistulous membranes that we ever recollect to have seen discharged by stool, we observed in two ladies who were in the habit of using the electuary of senna every day as an aperient. The operation of purgatives is rendered much more efficient when the bowels are prepared for their action by one or two small doses of altera- tives. Of these the most certain and most man- ageable are mercurials, and we believe calomel to be the best form of this medicine. One, two, or three grain doses are generally sufficient, and, ac- cording to the state of the patient's stomach, it may be combined with the pil. galban. comp., the pil. scillae comp., with a little prepared chalk if there be a disposition to diarrhcea, or with a minute quantity of opium or opiate confection. Chalybeates, though in a less degree, possess the same alterative power over the follicles as mercurials, and united with their tonic properties, afford a means of cure applicable to another com- bination of circumstances ; as for instance, when there exists a general torpor and coldness of the system, with much pale urine; when the patient is thin, pale, and weak, with a withered look, a peculiar dry state of the skin, and a small weak pulse, the appetite variable and capricious, the bowels slow, though easily regulated, and the IN DIG E STION. 657 evacuations always of a remarkably dark colour, like mahogany, or almost black; or when the pa- tient is pale, bloated, and chlorotic; in all such cases chalybeates are very useful remedies. The most suitable preparations are the sulph. ferri combined with pulv. aloes; the ferrum tartariza- tum or ammoniatum with rhubarb, or the car- bonas ferri with rhubarb and soda. It has been observed in these cases, contrary to what happens in general, that chalybeates, instead of rendering the faeces darker, restore them to their natural co- lour, an observation which is in accordance with the experience of Nehr and Heidler, of the action of the mineral water of Marienbad. Karnpf's method consisted in injecting frequent small enemata of strong decoctions of plants which he supposed to be endowed with resolving powers, as taraxacum, saponaria, melitotus, and such like; these he allowed to be absorbed from the intestines. It is always desirable, as far as the case admits, to combine some tonic with the corrective treat- ment, and, as soon as the evacuations have as- sumed a healthy appearance, it may always be at- tempted. Chalybeates, as already observed, answer this purpose best; but when they are not admis- sible, or after their use, tar-water, lime-water, in- fusion of cascarilla, nitric or nitro-muriatic, or muriatic acids, are very useful remedies. It is unnecessary to observe that this direct method of cure must be assisted by all those means which tend to the improvement of the general health, and which at the same time correct and avoid those habits which form the predisposing causes of the disease. Amongst these the state of the skin deserves particular attention. The warm sea-water bath, the cold sea-bath, the cold' shower-bath, cold sponging with vinegar and water, or salt and water, friction with a flannel glove, warm clothing, preserving the feet dry and warm, will be found most useful auxiliaries. But a remedy superior to any or even all of these, we have found in mineral waters, by which every intention of the medical treatment, corrective as well as tonic, we have seen more efficiently, more fully, and more surely accomplished than by any other combination of remedies. Some of the most surprising cures effected by mineral waters have been chiefly in affections of this nature, as has been observed at Carlsbad by Becher, at Marienbad by Heidler, in the waters of the Pyre- nees by Bordeu, at Pyrmont by Marcard, and also at Eger and Harrowgate. III. COLONIC DYSPEPSIA. The functions of the large intestines being chiefly disordered. Alvine excretion forms so important a part of the function of digestion, that, in common lan- guage, the term indigestion is exclusively appro- priated to the disorder of that function; and if it be impeded, interrupted, or otherwise deranged, it is rare that its other processes continue to be healthily performed. There may be some excep- tions to this, as in the extreme cases mentioned by Heberden, where one person was in the habit of having his bowels relieved only once every month, and another person twelve times every day, yet both with the enjoyment of perfect health; and in all persons, what is called the regularity of the Vol. II. — 83 bowels admits a certain latitude; but in ordinary circumstances the right performance of excretion is so essential to the health of the whole function of digestion, that any serious or long-continued irregularity of the bowels invariably leads to its disorder. We cannot, therefore, be said to have exceeded the limits of our definition in consider- ing disorders of the functions of the large intes- tines as constituting species of dyspepsia. The large intestines are very frequently, indeed most frequently, the part of the apparatus of di- gestion of which the functions are the first disor- dered ; and the symptoms of their disorder often present the first perceptible link of the chain of the disorder of the whole apparatus; and though ultimately their disorder necessarily involves the whole apparatus, their derangement may so en- tirely predominate, that the healthy or unhealthy state of the other processes follows as a mere con- sequence of the state of the large intestines. The disordered functions of the large intestines, considered only in reference to the part which they perform in digestion, without regard to the more positive diseases of which they may be the seat, are of themselves a source of great discomfort to the patient; but they deserve most consideration as being the medium through which the greater number of the disorders of the function of digestion become established, not only directly, by the im- pediment which they present to the function of the stomach and small intestines, but indirectly, by the stomach being made the recipient of the medi- cines which are necessary for their relief. The disordered function of the large intestines may, therefore, be considered as the means by which most of the noxious causes which disturb the healthy function of digestion produce their effect, and the principal secondary cause by which they extend their mischievous consequences. The disordered functions of the large intestines afford almost the first symptoms of the derange- ments of the stomach and small intestines, which attract the attention of the patient, and have not seldom been improperly treated as a dyspeptic state of the stomach itself. This, as Dr. G. D. Yeats very justly observes, is not remarkable, it being recollected that the great arch of the colon lies close upon the stomach, whence a swelling or puffiness in the one may easily, without due care, be attributed to the other. As long as the disorders of the large intestines continue to predominate over the disorders of the other parts concerned in the function of digestion, they have their own symptoms, and demand their own method of cure. When they have induced the disorder of the whole function, it is always important to know where the error originated; and as their disorders may be mistaken for those of other organs, it is necessary that a distincti m should be made between them. Under every con- sideration, as the disorders of the functions of the large intestines admit of being ascertained, so they deserve being made a subject of special at tention. Like the other organs of the apparatus of diges- tion, the large intestines may be deranged in dif ferent ways ; they may be disordered from atony, from morbid irritability, from inflammation of their mucous membrane, from disorder of its follicles; 658 INDIGESTION. all which morbid conditions afford the means of dividing colonic dyspepsia into a corresponding number of species. I.—Atonic Colonic Dyspepsia. Synonyms. — Obstipatio debilium, Cullen ,- mimoses; acute disorder'of the general health; Marshall Hall; cceliacus affectus, Celsus,- colica stercorea, Etmuller,- colica flatulenta, Sennertus ,- lien verberans, Bonetus,- stridulous affection of the bowels, Bradlye,- (Observations on a Stridu- lous affection of the bowels, London, 1818,) tenes- mus a scybalis ; dysodia stomachalis, Sauvages ,- excrementitious plethora, Barlow. General Character.—Bowels habitually con- fined, but alvine evacuations not remarkably altered; pain or uneasiness in some part of the colon, variable in degree, situation, and constancy ; often stridulous noise in the abdomen. [See Colon, Torpor or the.] Though costiveness is the leading symptom of this disease, it would be a mistake to suppose that it consisted in costiveness alone, or that constipa- tion of the bowels was the only symptom which an atonic state of the colon gave rise to. Form of Disease.—This disease is not con- fined exclusively to either sex ; it is most common in young females, and in delicate boys or young men. After there has existed for some time an habitually confined state of bowels, or a morbid state of them, in which, though evacuations occur daily, they are scanty and insufficient, the patient appears slowly and imperceptibly to fall out of health; but it is some time—several months, even years—before his ailments attract serious atten- tion. The patient has no marked or distinct com- plaint, but the appetite is impaired, there is lassi- tude, loss of strength, weariness after any bodily exertion, a general, sometimes painful feeling of weakness, an aching over the whole body, or very distressing pains in the loins and lower extremi- ties, attended with some degree of torpor, espe- cially on walking or long standing; and hence the patient is constantly constrained to sit down or to rest on a sofa. There is frequent headach, great nervousness or susceptibility of impression, a ten- dency to perspiration on the least surprise or exer- tion, fluttering, faintishness, timidity, discompo- sure by the least hurry or agitation, sometimes tremor and vertigo. At first there is no loss of flesh, but the skin grows coarse, the countenance puffed and bloated, the complexion dull, foul, and greasy, and the lower eyelid becomes dark, sallow, or otherwise discoloured. But as the disease con- tinues, there is considerable loss of flesh, the com- plexion loses its colour and turns pale, sometimes dead-pale, sometimes swarthy pale, sometimes rather chlorotic; the countenance becomes thin, the features sharp, and the lips, more especially the upper lip, are sensibly paler than any other part of the face; the surface of the face is some- what shining and glossy, or is frequently affected with a slight degree of clammy or oily perspira- tion, especially about the nose; and the orifices of the sebaceous follicles appear as small black points disseminated over the surface ; and the discolora- tion under the eye increases to sallowness or a greenish black colour. I'ain is frequently complained of in some part of the colon, which, when it exists in an aggra- vated form, is various and irregular in its situa- tion, course, degree, and duration ; its approach is sometimes sudden, often slow and progressive ; at first it is apt to change its situation from one side to the other, or from one part of the colon to another, and frequently appears to move up the chest or to the back, but by degrees it becomes more permanent in its situation ; it is commonly observed in one of the iliac regions, frequently in the right iliac region in the course of the ascend- ing colon, in which situation the pain on some occasions becomes very acute, aggravated by vio- lent spasms returning in paroxysms, and not rarely attended by vomiting and great irritability of stomach, (the colica stercorea of some authors,) often the forerunner of stercoraceous tumours, and ultimately of that disease which has been described by Dupuytren under the name of phlegmonous tumours of the right iliac region, and which has been recently well described by Mr. Ferral. (Edin. Med. and Surg. Journal, 1831.) A common situation of the pain is in the left side just under the false ribs, and very often in the left iliac region in the course of the sigmoid flexure of the colon; in this last situation it is occasionally attended with a frequent desire to go to stool, accompanied with distressing tenesmus. Frequent though in- effectual efforts are made to obtain a stool for seve- ral days, and at length a number of small hard- ened and slimy lumps, or scybala, either sepa- rately or connected together, similar to sheep's dung, more rarely of a flattened or tape-like form, will be voided, sometimes preceded and sometimes succeeded by liquid and sanious stools of various colours and of a frothy consistence, always ex- tremely offensive. This is the tenesmus a scyba- lis of some authors, and the dysentery of others, of which inflammation and ultimately ulceration of the mucous membrane, and occasionally stricture of the lower part of the colon, are the remote con- sequences. On some occasions the pain and soreness is felt about the middle and lower part of the hypogastrium ; and a slight pain is also expe- rienced on micturition. Sometimes there may be perceived in the course of the colon a distinct hardness or tumour, which appears to arise from a loaded state of the intestine, an occurrence par- ticularly apt to take place in females, and more especially in the left iliac region. When the dis- ease has made some progress, the hypogastrium is generally swollen, especially in the evening and fore part of the night, but in the morning the en- largement has nearly or altogether vanished, in some cases leaving a degree of soreness in that region. One of the most common and most distressing, as well as unpleasant attendants of this complaint is a disagreeable noise, not unlike the croaking of a frog, heard in the bowels, proceeding more espe- cially from the left side. The noise is very much under the influence of respiration, and also any state of excitement. For the most part, especially on inspiration, it is similar to the croaking of a frog ; but on expiration it is somewhat less so, conveying the idea of the sound issuing, as it were, from water; often before it ceases, it is like the plaintive sound of a dying animal. Dicilur gemere de turture, rplfav rpii^tit'. At every act of INDIGESTION. 659 inspiration, on laying the hand on the left umbili- cal region, about two inches or two inches and a half from the navel, in a transverse direction to- wards the spine of the ilium, a sensation is felt as if some liquid were forcibly spirted or dashed against the peritoneum ; on expiration this is less perceptible. This curious verberation is not al- ways confined to the same part of the abdomen, as it will often be found two and a half or three inches from the navel in the direction of the spleen. During its presence the patient seldom complains either of pain in the part or on any moderate pressure, or even from change of pos- ture ; but if the part be suddenly pushed by a moderate force, great pain is often felt in the region of the stomach, so much as to cause fainting, a circumstance which more particularly happens when the pulsation approaches the epigastrium. At first this stridulous noise returns at uncertain intervals in the course of the day, and is of no limited duration. The period of its continuance, however, seldom exceeds twenty minutes or half an hour; it is particularly marked whilst the patient is in an erect posture; on lying down it will almost instantly cease, and be no more heard as long as the body continues in an horizontal posture. Whatever is taken into the stomach, whilst the body is erect, has no inconsiderable in- fluence in exciting or abating this stridulous sound. For instance, after the patient has sat down to a meal and taken a few mouthfuls, it will almost invariably ensue, and continue for some time, after which it becomes weaker, and intermits more and more until it ceases. In other cases, however, instead of food producing this effect, it oftener abates this noise, especially when the stomach is empty, and there is faintness and a sense of craving for food. In the advanced stage of the complaint, the noise frequently re- turns, even while the patient remains in the hori- zontal position. The varied state of the bowels seems to have little influence either in augment- ing or diminishing the noise in the abdomen. If the state of the organic functions be in- quired into, they will be found to betray a consi- derable deviation from the state of health. The appetite is generally impaired, sometimes to loath- ing, but frequently without any symptom of gas- tric or duodenal dyspepsia; sometimes there is remarkable irritability of the stomach, the patient throwing up part of the little nourishment taken immediately on swallowing it; and this vomiting is often attended with pain or uneasiness in, or tightness across, the stomach ; sometimes there is faintness with a sense of craving for food. The tongue always presents an unhealthy appearance, almost invariably it is loaded or covered with a white slimy fur; sometimes it will be found coated with a whitish fur, inclining to a yellowish tinge, and often dappled towards the root, especially of a morning; occasionally for a few days this incrus- tation is diminished, and the patient is more dis- posed for food, but this change is of short dura- tion. Frequently the tongue is loaded, swollen, and cedematous, and marked by pressure against the contiguous teeth ; it is frequently so large in proportion to the mouth, that from compression it is found more or less divided with sulci or folded into plaits. The teeth and mouth are foul; the gums also are frequently coated and palish; the inside of the cheeks, like the tongue, is often impressed by pressure against the teeth; a vitiated taste is sometimes perceived, particularly in the morning; the saliva is viscid, the breath tainted and fetid, sometimes emitting a heavy strong smell, not un- like roasted meat, sometimes a putrid, even ster- coraceous odour. The bowels are at first always constipated, afterwards constipation and diarrhoea occasionally alternate; in advanced cases the latter state becomes permanent. The faeces at first exhibit in general no unnatural appearance, except that they are scanty and indurated; after- wards they are occasionally fluid, scanty, dark- coloured, and extremely fetid, often accompanied with mucous and even blood ; sometimes, as al- ready observed, they are attended with tenesmus, bloody stools, and pain in the right iliac region, an occurrence very common in young females. In the commencement the urine is high-coloured and apt to be loaded, depositing a whitish sedi- ment, and presenting a supernatant iridescent pel- licle ; afterwards it lets fall a mucous deposit, sometimes of a lateritious tinge ; during the con- tinuance of the disease the urine frequently be- comes limpid, but slight exasperations of the com- plaint restore the deposit. The pulse is frequently nearly natural; sometimes it is quick or easily accelerated, or variable, and apt to become irregu- lar and intermitting; it is usually soft and weak, sometimes small; it varies in point of fulness, and continues to increase slowly in frequency as the complaint advances. The skin is in general cool, rather moist and clammy, particularly the hands and feet, which are apt to be obstinately cold ; the fingers are rather livid, and the nails assume a lilac hue. It is remarked by Dr. M. Hall, from whose exact portrait of this complaint we have drawn a considerable part of our description of it, that the condition of the countenance, the tongue, internal mouth, and general surface, is peculiarly constant and uniform in almost every case and every period of the disease, but that the other symptoms are characteristically inconstant and variable. These symptoms are—an unaccountable sensa- tion of weakness and weariness, the patient suf- fering from a sense of aching after slight exertion ; a considerable loss of strength, sometimes amount- ing to faintishness in the upright posture, with a peculiar sense of fluttering at the heart and pit of the stomach ; but the most frequent subjects of complaint are headach, vertigo, and nervousness. The headach, which is severe on rising from bed in the morning, insomuch so as sometimes to ex- cite vomiting, will continue unabated for an hour or two, and is often proportionate to the degree and length of time which the patient has slept. The patient is flurried by the least hurry, agitation, or excitement, is very frequently affected with nervous tremour on the least surprise or least exer- tion, frequently manifested in a quivering of the lip or dimpling of the chin on speaking, or, when at all agitated, by tremour on holding out tne nand, or carrying a cup of tea to the mouth, on attempt- ing to stand or walk, or on being fatigued or hur. ried. Sometimes there is oppression, heavy sleep, or considerable stupor or obtusencss of intellect during the day, and during the night great wake- d60 INDIGE STION. fulness and restlessness, disturbed sleep, dreams, a/*d incubus. The patient is liable to violent and sudden at- tacks, generally induced by some improper article of diet, or a more than usually loaded state of the large intestines, such as sickness, vertigo, faintish- ness with cold perspirations, paleness of the coun- tenance, and coldness of the extremities. These attacks are sometimes accompanied with spasmodic or convulsive paroxysms, frequently assuming the form of hysteria, more rarely of epilepsy, and oc- casional temporary delirium, loss of memory, or absence of mind. Sometimes the attacks consist of spasmodic or anomalous pains about the heart or side, or in various parts of the abdomen; in fluttering, irregular action, violent palpitation of the heart, with syncope; in local pains more or less severe, occasionally so severe as to resemble tic douloureux, of longer or shorter duration, arid in various forms and situations ; in some cases resembling the passage of gall-stones, in others inflammation of the pleura, of the liver, spleen, kidneys, and intestines or peritoneum, and affec- tions of the bladder. Sometimes there is an ex- traordinary loss of muscular power, especially of the lower extremities, which are so enfeebled as to appear affected with paralysis. Curvature of the spine is not a rare complica- tion and consequence of this disease, more espe- cially in scrofulous constitutions. Its approach is very gradual, and long before any deformity can be observed, on forcibly pressing with the fingers on each side of the spinous processes of the third or fourth lumbar vertebra, considerable pain will generally be excited, insomuch as occasionally to produce a degree of sickness. The seat of this pain is, however, confined to no exact point. After a considerable time the patient experiences a fur- ther increase of weakness and derangement of the general health, and the spine, at the place above mentioned, will now be found giving way, either slightly projecting anteriorly or to the left side. In consequence of the curvature of the spine to the left side, the right hip has the appearance of being enlarged, by reason of the hollowness be- tween the iliac and vertebral column being in- creased, whilst the left hypogastric region is more swollen than the right. Dr. Bradley conceives that the disease of the spine is the primary affection, of which the strid- ulous sound and other derangements are only the consequences. We confess that to us his reason- ing presents a very remarkable instance of a false induction ; for on his own admission there is no constancy of conjunction between the affection of the spine and the stridulous noise, as every prac- titioner must be able to confirm. They are both accidents of a more general disorder, only con- nected together through their common cause. Causes.—A certain period of life, from the age of ten to thirty, seems very much to favour the formation of this disease. It may be partly con- nected with the natural conformation of the body and tne development of the constitution at this particular time of life; but perhaps it is more strictly dependent upon the change of habits coin- cident with it in the children of the rich, who are either unremittingly occupied with their omnifa- rious education, or, to obtain a graceful carriage, steadfastly confined to one posture, the undeviat- ing sedentariness of the body presenting a re- markable contrast to the desultory activity of the mind ; and in the children of the poor, who are of necessity obliged to seek their bread in the se- dentary occupations of needle-work, in the tedium and wearisomeness of manufactories, at the tam- bour, the stocking or the lace-frame. Hence females, who are under boarding-school discipline, and rigidly subject to it, being compelled to sit many hours of the day with the head erect and the shoulders thrown forward, are liable to this disease; hence governesses, sempstresses, milliners, mantua-makers, students, and all persons of se- dentary and inactive occupations, are the chief sufferers from it. The effect of sedentariness is increased by any causes which have a relaxing influence upon the body ; and hence the confined or impure air of apartments, the warm relaxing vapoury air of some occupations, as that which arises from working over ironing-stoves, or from the steam-engines of manufactories. But every circumstance which tends in any way directly or indirectly to impede the evacuation of the bowels is the most influential cause of this complaint. Hence not lending a ready obedience to the calls of nature, which often arises in children from in- dolence of habit, but more frequently from being placed in situations where their modesty checks them in doing so, and, at a later period of life, from the unbending restraint and thraldom of so- ciety ; or amid the fatigue, care, and anxiety of life, from neglecting a due attention to the state of the body. Pathology.—The explanation of the nature of this disease presents no difficulty. That it con- sists in a state of atony and insensibility of the colon, the most probable consequence of habitual over-distension of its muscular fibres, there seems to be little reason to doubt. The symptoms may be clearly and distinctly traced to this morbid con- dition of the colon, with which also it seems easy to connect the disorder of the general health which ensues. For, sometimes by continuity, sometimes by sympathy, deranging the function of gastric and duodenal digestion, sometimes by defective excretion changing the state of the circulating fluid and interfering with the process of nutrition sometimes by the sympathetic irritation of disten- sion disturbing the functions of the nervous sys- tem, and by pressure impeding the circulation in the abdomen, (from which cause and continuity, the functions of the womb and pelvic viscera be- come disordered, and the spine loses the support of the antagonist muscles,) it seems all-sufficient for the effects which we attribute to it. When the disorder of the colon is secondary, supervening upon gastric or duodenal dyspepsia, it appears to be merely a degree of languor or sluggishness in the bowel, causing delay in the passage of its contents, the consequence of the bile and other secretions being less adapted to support its action; but when its contents are longer de- layed than usual, they become hardened, and irri- tate the surface of the intestine, causing tender- ness on pressure, a feeling of hardness in the part, and all the symptoms of colonic disorder already described. Treatment. — The indications for direcing INDIGESTION. 661 the method of cure are, a. to remove any accu- mulation of faeces by having the bowels fully and satisfactorily evacuated ; b. to facilitate and pro- mote the regular performance of the function of the colon ; and, c. to correct the morbid condition of the colon, the proximate cause of the disease. a. For fulfilling this indication, purgatives can- not be dispensed with ; but though constipation is a constant attendant of this disease, they are not to be given with an unsparing hand. Rhu- barb, combined with sal polychrest and a little ginger, the pulvis scammoniae comp. followed at a proper interval, if necessary, by a little infusion of senna, are the best description of purgatives. If the bowels are not easily acted upon, it is a bad practice to continue throwing in without dis- crimination any description of purgatives without allowing sufficient time for moderate doses to act. Mercurials are unnecessary unless the alvine eva- cuation does not resume its proper colour by means of the other class of aperients. b. This indication may be fulfilled by the daily use of the warm water lavement, and, if necessary, by some mild aperient medicines, just sufficient to solicit the bowels without irritating them. The object should be to induce a full and consistent evacuation daily, avoiding as much as possible the fretting and painful operation of medicines, by which the bowels are irritated. On the other hand, the power of the aperient must not be less than equal to obtaining a complete evacuation of the bowels ; scanty evacuations will not suffice. Whilst, therefore, too considerable and too often repeated doses of medicines are to be guarded against, ineffectual medicines are equally to be avoided. Good forms of aperients are the pulv. aloes comp., decoct, aloes comp., or baume de vie in pimento water; a pill composed of equal parts of ext. colocynth. comp. and extract, hyoscyami: three, four, or five grains of this composition may be occasionally taken. The following formula affords a useful pill:—R. pulv. aloes, pulv. gam- bog, saponis, ext. hyoscyami aa^i. fiant pilulae xx. Una vel duae hora somni sum. Though the use of the warm water injections in the loaded state of the bowels is frequently at- tended with pain in the course of the colon, or though they may not be at first successful, yet a perseverance in their use generally overcomes these obstacles, and occasionally restores the natu- ral and spontaneous action of the bowels: by pre- venting the constant distension by accumulated faeces, the opportunity is afforded the intestine of resuming its tone and sensibility. But whether clysmata or aperients are used for relieving the bowels, opportunity should be from time to time afforded for their natural action, by leaving off, or gradually diminishing, the medicines. The diet should be mild, light, and nutritious, taken in moderate quantities, and frequently not less than three or four small meals daily, for the frequency of the meal appears to have a conside- able effect in promoting the action of the bowels. It should consist of mild animal food, boiled or loasted, and should be well masticated ; mutton, chicken, beef less frequently ; stale pure bread, untoasted, mealy potatoes mashed, tea or coffee in moderate quantities. We have not known much advantage from using more aperient kinds of food, as fruits, figs, medlars, stewed plums, stewed apples, brown bread, oatmeal porridge, and such-like. They generally disorder the first processes of digestion. The function of the bowels will be also pro- moted by a system of regular walking exercise, apportioned to the strength; but violent efforts and fatigue are injurious. Sometimes easy, loung- ing exercise, with complete relaxation of mind, has considerable effect in promoting the evacua- tion of the bowels. c. The means of fulfilling this indication are partly direct, partly indirect. 1. When the bowels have been preserved in a soluble state, the use of tonics or chalybeates may be advisable for correcting the morbid condition of the bowels. When chalybeates have a tendency to keep the bowels open without causing griping, they are often of great service, and we have had frequent opportunities of observing the superiority of the chalybeate mineral waters in this respect over the officinal chalybeates. But the state of the tongue must always be the guide for administering tonics, for as long as this is considerably furred, the most effectual means for removing such fur will prove the best tonic, and the utility of any tonic may be estimated by the return of appetite ; there- fore any stomachic tonic which does not effect its purpose by removing the fur is injurious. Friction over the bowels with the flannel glove or flesh-brush, the galvanic circuit passed through the bowels and daily repeated, and in obstinate cases an occasional blister, are also direct means having the same effect in different degrees. But of all external means we have known the greatest service from the warm or cold douche upon the abdomen, continued for a month or six weeks, as so commonly practised in Italy. 2. The indirect means are sea-bathing, sponging the body with salt water or vinegar and water cold; change of air ; country air; travelling ; warm clothing; preserving the feet dry; relaxation from study, occupation, and business. II.—Inflammatory Colonic Dyspepsia. Synonyms.—KoiKiaKfi, Grxcorum; ventriculosa passio, Cxi, Aurel.; enteritis colica, colica phlo- gistica, Sauvages. General Character.—Pain in some part of the colon, prevailing most in one particular point, felt always more before an evacuation of the bowels, seldom increased on pressure; stools gen- erally liquid, rarely formed, not alwayj more fre- quent than natural. Form of Disease.— We wish, without en- croaching upon the subject of diarrhoea or dysen- tery, to characterize by this term a disorder of the function of excretion, arising from chronic or sub- acute inflammation of the colon. This complaint is manifested by pain in some part of the colon, and by sense of extreme weakness or of fainting after an evacuation of the bowels. The patient is always remarkably lowered, irritated, or made otherwise uncomfortable by the action of purgative medicine, and even by the spontaneous action of the bowels, which is always followed by more ot less feeling of exhaustion; he feels always most strong and most comfortable when his bowels aro confined. Sometimes the pain or uneasiness ex- tends over the whole abdomen, and there is also a 662 INDIGESTION. certain degree of tenderness and an increased heat of the part; but more commonly the pain is re- ferred to particular points of the colon, to which it is more or less confined—frequently to the caput ccecum coli and the ascending colon; sometimes to the arch of the colon; in young women to the sigmoid flexure. The pains of the colon are ac- companied with a pulse somewhat accelerated and rather tense ; there is some degree of thirst, but seldom much heat of surface. The motions pre- sent an unhealthy appearance; they are seldom formed, more commonly liquid or pultaceous; sometimes they are light-coloured, almost white, sometimes yellow and frothy, less frequently green or black ; sometimes a tenacious puriform matter streaked with blood is discharged, which on some occasions alternates with healthy feculent matter, and at other times is mixed with it; the evacua- tions are always fetid in some degree, on some occasions most remarkably so. They are gener- ally more frequent than natural, but often they are not so, an evacuation sometimes not occurring oftener than once in two days. The stools are frequently discharged with considerable force, but occasionally there is tenesmus without any excre- mentitous discharge. The appetite is seldom much impaired. The complexion is pale or whitish, sometimes of a remarkable greenish paleness, and the body emits more or less of a cadaverous smell. The unfavourable progress of this disease is to hectic fever accompanied with oedema of the lower limbs and face, dejected features, and gradual exhaustion. Causes.—This complaint is a common conse- quence of the preceding form of dyspepsia, more frequently of" the medicines which have been im- properly used for its cure; the effect of distension from remora of faeces, or of harsh drastic medi- cines. It is also on some occasions produced by the irritation of worms, and may arise from acci- dental colds. Pathology.—The nature of this disease has been verified by repeated dissections, which have shown it to consist in various degrees of inflamma- tion of the mucous membrane of the colon, some- times very limited in extent, frequently termina- ting in ulceration, occasionally in thickening or induration. Treatment.—Leeches or cupping to the pain- ful parts used with caution and moderation; fo- mentations ; covering the abdomen with a flannel roller moderately tight; light, bland, pultaceous u;et; milk, if it is easily digested, or asses' milk; rest of body, sometimes confinement to bed or the recumbent posture, afford the only means of relief in this complaint. DI.—Irritable Colonic Dtspepsia. Synonyms.—'EptvyparwSr,^ vovo-o^, Hipp. ; CO. lica hypochondriaca, hysterica, Sydenham,- flatu- lentia hypochondriaca, hysterica, Juncker • flatu- lentia convulsiva, Sennertus,- hypochondriasis tympanitica, And.,- colique nerveuse; enteralgie, French. General Character—Intestinal digestion ac- companied with pain, uneasiness in some part of the abdomen, seldom fixed to one spot, but chang- ing its situation, and intermitting. Form of Disease. _ There exists a certain morbid condition of the intestines, referable only to irritability or morbid sensibility, without either proof or sign of an inflammatory state <.f the mucous membranes. It is certainly nn»t fre- quently met with in persons of irritable ami ner- vous temperaments, and is therefore probably a consequence of that constitutional state ; hut the symptoms show that this morbid condition is sometimes pre-eminently developed in the intes- tines, in which the patient is sometimes the sub- ject of the most painful, distressing, and unnatural sensations. It is always attended with hypochon- driasis, a constant watchfulness and attention to all bodily sensations, which depress and overwhelm the mind. These patients frequently complain of pain, or of a sensation of twisting at the umbilicus or in the course of the colon ; occasionally of acute pain in the same situation, seldom augmented, generally relieved, by pressure ; frequently a sen- sation of sinking or dragging of the bowels, giving the notion of the intestines falling out; some pa- tients experience this uneasy feeling to such a degree that they are obliged to confine themselves to the recumbent posture. Sometimes, instead of pain, the patient feels in the intestines an inde- scribable uneasiness or peculiar sensation, similar to those which are perceived in the stomach in irritable gastric dyspepsia; occasionally the pain and preternatural sensation exist together, fre- quently they alternate with each other. Frequently the chief subject of complaint in this disease is flatulence, which is generally accompa- nied with inodorous eructations, neither acid nor putrid, with stridulous noise in the bowels, bor- borygmi, with colic and spasmodic pains affecting different parts of the bowels, which are sometimes accompanied with ptyalism and copious discharges of limpid urine. A very aggravated form of this complaint has been described under the term flatulentia convul- siva. It occurs in men, and has a strong affinity to the hysterical passion of females, the sexual organs being strongly affected. Early in our medical career we witnessed a case of this disease, the paroxysm of which a more experienced and now justly eminent physician arrested by the ap- plication of cold to the testicles. The uneasy feelings in this disease return or are exasperated during the intestinal digestion, which is ordinarily difficult and laborious. They are frequently dissipated by travelling or agreeable occupation of the mind, and return with repose. They are sometimes, however, aggravated by the least motion, and are excited by a fit of passion, by anxiety of mind, by any disquietude, sometimes by the least effort of attention. The pains and colic often supervene upon stormy or unsettled weather. We recollect to have seen a case of this disease which co-existed with a remarkably pain- ful sensibility of the retina. Under these complaints the patient may pre- serve the appearance of health, and though the function of digestion is painful, it is yet satisfac- torily performed, the nutrition being little affected, and the stools healthy, though the bowels are generally disposed to be confined. Every form of this complaint is most obstinate, and rendered doubly so by the mutable and varia- ble state of mind of the patient, who is contet'»od INDIGESTION. 663 with no method of treatment, and is every day I transfixing pain. But instead of this direct symp changing his physician. He has not patience to wait for the operation of any medicine, but is un- ceasingly fretting his body with every description of medicine, particularly with aperients, by which his complaints are invariably aggravated. Pathology. — Concerning the nature»of this disease, we refer to our pathology of irritable gas- tric dyspepsia. Bonetus gives the case of a per- son who had this complaint, marked by great pain and rolling of the bowels, attended with a morning sibilous noise, for three years, in consequence of plum-stones lodging in the colon. Treatment.—The cure of this disease, always difficult to be obtained, is to be sought for by a mild bland diet, easy of digestion. If milk diet agrees, the patient should confine himself to it. He should avoid any thing heating and irritating, and should shun every form of medicine as much as possible. The bowels are to be kept soluble by the easiest means. The patient should live much in the open air, and take exercise, chiefly on horseback. Sailing, and even long sea voy- ages are very useful. Of direct medicines we can speak most in favour of chalybeates, and the other metallic tonics. We have known the Kesselbrun- nen of Ems of considerable service, but the worst case we have known was benefited by the artifi- cial Pyrmont water. IV.—Follicular Colonic Dyspepsia. Synonyms.—Colica pituitosa ; (Sennerti spe- cies tenia ; Fernel. pathol. lib. vi. cap. 9 ; Sal- muth. centur. i. obs. 78. Bonet. Sepulchret. obs. 23 ;) scelotyrbe pituitosa; (Pereywinger ;) chlo- rosis pituitosa; (Sauvages,-) diarrhoea pituitosa, (Id.,) And. Var.,- arthritis chlorotica, (Musgrave,) Sauvages; paraplexia rheumatica, Id.; infarctus, (Etmuller, p. 440,) Kiimpf.,- colique glaireuse, French. General Character. — Pain, spasm, or unea- siness in the course of the colon, with the evacua- tions of considerable quantities of mucus in vari- ous morbid states. Form of Disease. — In persons of sedentary habits, more frequently young persons, and most especially young females, who are generally sub- ject to costiveness and accumulation of faeces in the large intestines, the mucous follicles of those organs are liable to be disordered in the way we have already explained in the section on follicular duodenal dyspepsia, much to the aggravation and obstinacy of the other symptoms. Like that com- plaint, the present disease is most usually met with in cold phlegmatic habits, and its progress is insidious. After habitual costiveness and the es- tablishment of that state of general disorder of the Health which we have already considered under atonic colonic dyspepsia, the patient becomes sub- ject to acute attacks of pain or spasm in some part of the large intestines, frequently amounting to regular paroxysms of colic. The pain is occa- sionally confined to one particular part of the colon, frequently the ascending colon and the sig- moid flexure. Relief of these pains is only ob- tained by copious discharges of mucus in some of the various morbid forms already described. Gtmuller has observed that the pain in this species of colic is more confined to one part of the abdo- men, and conveys the feeling of a perforating or tom of disorder, it is not unusual for the patient to be seized with a violent nervous affection. Children are frequently seized with convulsions, to which succeed chorea, and sometimes paralysis of the limbs. Young women in this complaint are often affected with hysteria, which may, how- ever, be distinguished from the idiopathic form of that disease by the great variety of ways in which it attacks the patient, sometimes as catalepsy, at other times as imbecility of mind, neuralgic affec- tions of the heart, convulsive asthma, loss of voice, loss of speech; it very frequently leaves paralysis of some member, most commonly of the lower limbs, differing from ordinary paralysis in the sensation of the limb being seldom impaired. Painful affections of the heart, violent headach, extreme restlessness and agitation, rheumatic gout, severe pain in some part of the spine, frequently at the bottom, may be enumerated amongst the secondary affections of this disease. In women the uterine functions are always painfully per- formed ; and it is not unusual to see a metastasis of the function to other organs, to the lungs, ap- pearing as hemoptysis ; to the stomach, as hema- temesis ; to the bowels, as melaena. These de- rangements of the natural functions are various. Generally the patient becomes pale and delicate looking, but sometimes preserves a natural appear- ance, or even good looks ; the skin is cool, moist, and clammy, particularly the extremities ; the lips and gums are pale, and the tongue is invariably large, moist, and covered with a thin clammy coating; frequently it is swollen and cedematous, divided laterally or transversely by deep cuts or fis- sures, and retaining the impressions of the teeth. The bowels are always constipated, often obstinate- ly so, the most violent medicines having little effect; but when they do act, the stools are found to be abundant, gruelly, and light-coloured, frequently deficient of their natural smell, or having a faint muskish smell, and, if mixed with water, leaving a greyish calcareous deposit: sometimes they are extremely fetid. Occasionally the stools are mixed with shreds of membranous substance, or with mucus in various morbid states and forms, frequently in perfect tubes, some of which have been observed full half a yard in length ; an ap- pearance which has not rarely imposed upon the ignorant the belief that a portion of the intestines has been actually discharged. The urine is ex- tremely variable, being sometimes scanty and loaded, almost deficient, at other times copious and limpid like water. The pulse, except under the excitement of any violent attack, is always weak, small, and soft, generally slow ; the circu- lation seems hardly to arrive at the system of the capillary vessels. Pathology.—Under follicular duodenal dy* pepsia we have already sufficiently inquired into the nature of the morbid condition of the mucous membranes which constitutes the proximate cause of this disease; a condition in which their sur- faces are deprived both of their secreting and ab- sorbing function as well as their -atural sensi- bility, their vessels losing their permeability, and becoming, as it were, impacted and blocked up with viscid or concrete mucus—emphragma mu cosum. This state is the consequence of tin 664 INDIGESTION. membranes, either from atony or inflammation, losing the power of throwing off the mucus from their surface, and which, either accumulating or concreting in the follicles, gives rise to considera- ble tumours there ; or, collecting, forms itself into the various forms of excreted matters already noticed. This unhealthy state of the mucous membranes, the consequence of a depraved func- tion of secretion, is the proximate cause of many painful, even dangerous diseases, arising as well from the disordered function of the membrane as from the irritation of such unnatural substances in the alimentary canal, inducing different symp- toms corresponding with the different situations they may occupy. The most common cause of this state is the habitual costiveness of sedentary persons, or the repeated irritation of the alimen- tary canal by crude and indigestible articles of food ; but we have known it to be produced quite independently of these, by the long-continued use of laxative medicines, and these by no means of the most irritating kind. Treatment. —For the general treatment of this complaint we must refer to the corresponding form of duodenal dyspepsia. We have only to observe that, as a purgative for evacuating these infarctus, we have found the oleum terebinthinae superior to any other. IV. GASTRO-ENTERIC DYSPEPSIA. The disorder affecting the function of more than one organ of the apparatus of digestion. The preceding orders present dyspepsia in the simplest forms in which it is capable of existing, either such as it has been observed to assume, or to which it may be reduced by a careful classifi- cation of its causes, its symptoms, and its reme- dies. It is, however, neither pretended nor meant to be understood that it is met with always in these definite forms. In diseases there is nothing absolutely definite. They are not like animals or plants, each of which, nature, to preserve the integrity of the species, has surrounded with a distinct barrier. In strictness of language, dis- eases may be described, but cannot be defined. They pass so gradually into one another, that all the pathologist can hope to attain is to mark their leading and most constant phenomena. In de- scribing the different forms under which dyspepsia presents itself, this is all that we have either sought or professed to do ; and though we are too well aware that not only the species or forms of the different orders, but that even the species of the same order, may be complicated with each other, we venture to assert that, however inti- mately the different species may be combined to- gether, it is seldom that one will not be found predominating. A knowledge, therefore, of the elementary forms of dyspepsia gives the physician a most commanding advantage even in cases the most complex ; enables him to decompose and unravel their complications, furnishes him with indications which, as it were, throw daylight upon his operation, simplify and assure his method of procedure, and afford him the means, if not of foreseeing, most certainly of early descrying, the effect of his remedies. The characters which we have assigned to the different species of dyspepsia, are the result to which we have been conducted by the review of many cases in which the disease has been presented in its most simple as well as its most complicated forms, comparing the circumstances of one case with those of another, separating the constant from the contingent, referring each to the morbid con- dition Avith which it was found to be most con- stantly conjoined. And if any persons should be disposed to regard these morbid conditions as mere figments, or to regard the terms which represent them as mere empty words, we trust they will be reasonable enough to recollect that the name does not change the thing, and that if it serves to mark the constancy of conjunction of a group of phe- nomena, it matters not which word or what sign we may use for the purpose. Were time or space allowed us, it would be the object of the present section to indicate and de- scribe the complications of the different forms of dyspepsia, to trace the law of their combinations, and the order in which they coexist or succeed each other; circumstances welj deserving the at- tention of the physician. But this task we must reserve for another occasion, and content ourselves at present with merely indicating seme of the more common complications. We leave the full con- sideration of this part of the subject with the less reluctance, because we are convinced that a mode- rate attention to the elementary forms of this dis- ease will render a description of their complications almost superfluous. When the disorder of the function of digestion extends to the whole or to more than one organ of the apparatus—to the stomach as well as the intestines, the morbid condition may be the same throughout, or it may be dissimilar, thus giving rise to the division of gastro-enteric dyspepsia into what may be termed enopathic and polypathie. The species of the first division must be neces- sarily limited, and determined by the morbid con- ditions which the organs are liable to assume. Hence they will be the four following:— 1. Atonic gastro-enteric dyspepsia. 2. Inflammatory gastro-enteric dyspepsia. 3. Irritable gastro-enteric dyspepsia. 4. Follicular gastro-enteric dyspepsia. Even in these species it will seldom be found that the morbid condition exists in an equal degree in every organ of the apparatus; but, on the con- trary, that it usually preponderates more in one than the other, thus approaching to some of the elementary species. The second division admits of a much greater variety of species, co-extensive with the combina- tions into which the four morbid conditions are capable of entering. The following are those most frequently observed:— 5. Atonic Gastric with Inflammatory Duodenal Dyspepsia.—It is the constant tendency of long- continued dyspepsia of any form, whether it be atonic, irritable, or inflammatory, to localise itself, to attach itself to one part of the alimentary canal, which in consequence becomes the seat of morbid sensibility, morbid irritability, or of some modifi- cation of vitality, or of inflammation, or some other modification of its vascularity. Dr. Wilson Philip has observed that in atonic gastric dyspepsia this occurs most frequently at the pylorus or upper part of the duodenum. Hence one of the most INDIGESTION. 665 common forms of complicated dyspepsia is the species above indicated. It is deserving of remark that this localisation of the disease, this disposition to confine itself to one point, sometimes removes, frequently relieves, the original disease. 6. Irritable Gastric with Inflammatory Duo- denal Dyspepsia.—This, also, is the consequence of the tendency just indicated, after irritable gas- tric dyspepsia has existed for a considerable time, or when it has been treated by heating or irritating remedies. It is met with commonly in persons of anxious, energetic, enthusiastic dispositions, in persons worn out and exhausted with cares, as for instance, in over-anxious mothers. The tongue is generally clean, small, and tremulous ; its anterior edge of a smooth, glossy, light red colour ; more rarely it is of deep red colour; or it presents a loose velvety appearance, like red plush ; the lips are red, and there is a frothy saliva in the mouth. The patient complains of an uneasy gnawing sen- sation, a sense of fainting or sinking at the pit of the stomach ; sometimes there is a constant excru- ciating pain in that situation. The uneasy feelings are much increased by medicines ; they invariably irritate, produce discomfort, or disturb the digestion. The pulse is generally quick, wiry, and small, the skin dry and harsh, particularly the palms of the hand, which are rough; the urine is alternately pale and sedimentous. 7. Inflammatory Gastric with Atonic Colonic Dyspepsia.—This is a complication common in young scrofulous subjects, male as well as female. 8. Irritable Gastric with Atonic Colonic Dys- pepsia.—Vomiting, more especially after meals, is the most leading symptom of this complication. It appears to arise from pressure of the loaded colon upon the stomach. Of the complications of the different morbid conditions in the same organ of the apparatus of digestion, we must also reserve the consideration for another opportunity. The only apology we have to offer for having occupied so large a share of the time and atten- tion of the reader, is the importance properly attached to the disease which is the subject- of the present article ; for if considered in its almost universal prevalence and in its remote conse- quences, it is the source of more suffering to man than any other to which by his physical nature he is exposed, and, therefore, ought to precede all others in its claims upon the attention of the phy- sician. It is, indeed, a very egregious mistake to imagine that this opinion, which attributes health to a pure digestion, and every species of disease to its disorders, is one of recent growth. It is one which has been sanctioned by the experience of the greatest physicians of every age and country. To the greatest of them all, the healthy state of the function of digestion seemed so important, that he has not hesitated to declare, if not exactly in so many words, certainly in equivalent terms, that he who shall have discovered the means of a healthy digestion (which he considered to consist in the exact adjustment of food and labour,) jshall have discovered the great secret of health : r)v fiv yap fjv tbptT&v inl tovtois, xpbs iKdarriv (pvciv, oitov utrpov, Kai ndvuv dpidpbs, uf) exov *"r£/>0°^1/> Mre "" to irX/ov, unTc ini to eXaooov, tvpoiTO av hyelij ro'iaiv \0L. II. —84 3f* ivBpunroioiv dxptjluic. (De diaeta, lib. i. sect. 3.) In this respect Aretaeus has gone a step beyond the father of physic ; for to a healthy digestion he not only attributes health of body, but also health of mind : orduaxos r)$ovrjs Kai dnS'ins yyeuiAv Kap&ivs Kai- ptov ycirdvevua, is t6vov Kai Qvpbv i) ddvuipv, rrjs 'i'VX'15 crvp-radeirf 'f/ie oroudxov irpwrtoTa S^vajii;. (De causis et signis diuturn. morb. lib. ii.) And to give this opinion only its full extent, we may add with all propriety, that sweetness of temper, clearness of intellect, vigour of understanding, correctness of judgment, firmness of character, power of self- control, are preserved by a healthy state of the digestive organs, and may be lost by their disor- der ; for as it is by the diseases of these organs that intemperance works its mischief, all that sages, all that philosophers have delivered in praise of the virtue of temperance, may, without stretch- ing a point, be fairly predicated of the healthy state of the function of digestion. When will legis- lators stoop to consider, or when shall legislators be made to comprehend, the influence of physical causes upon moral conduct ? The state of the digestive organs has the greatest influence upon the state of the other organs of the body. Their disorders are frequently the cause, frequently the consequence, of the dis- orders of other organs. " Sur dix cas de maladies aigues," says one of the most distinguished pa- thologists of the present day, " qui ont leur point de depart ailleurs que dans le tube digestif, il en est huit a-peu-pres dans lesquelles on observe un derangement plus ou moins prononce, soit dans la texture, soit dans les fonctions du canal intesti- nai. Dans les maladies chroniqucs, quelle qu'en soit la nature, il est infiniment rare que le tube digestif ne subisse pas quelque alteration." (An- dral, Anatom, Patholog.) A similar opinion had been expressed by Cullen: " I am of opinion that we cannot bestow too much pains on the consid- eration of the affections of the stomach, as we find that, next to the pyrexiae, they are the most fre- quent occurrences in practice." From these state- ments we might learn, did we not all already know, that there is scarcely a disease which afflicts the human body that can be correctly treated if the nature of the diseases of the digestive organs be not properly understood; and we may infer how much the difficulty of their treatment is increased, when, as Aretaeus observes, the means which re- store the tiealth and recruit the strength in other diseases, are noxious in these; h iv rolai aWoioi ■Kadeai ptrd rrjv dcpairdrjv Siaira is lox^v Kai Kpdros rod oiiparos £i>7r£\l//»7 ayaQfi' CTopaxi^o'ici ii poivois 'rfit yiyvtrai irXr/pneXfis. (De curatione diuturn, morb. lib. ii.) A thorough knowledge of dyspepsia in all its forms and varieties may therefore justly be considered the key to the cure of many acute and of most chronic diseases. The mischief which springs from the disorders of the function of digestion is not limited to the individual—it extends to the offspring; for the disposition to these diseases being hereditary, and increasing in virulence as it descends, the dyspep- sia of one generation becomes scrofula, consump- tion, or some other malignant disease in the suc- ceeding ones ; hence the decay and extinction of families, and all the manifold attendant miseries. When will parents, besides, if not before, wealth 666 INDURATION and honours, think of bequeathing health to their children ? Moreover, as the diseases of the function of di- gestion may be said to belong peculiarly, if not exclusively, to a state of civilization, following it as closely as the body is followed by its shadow, they may be considered as the physical process by which luxury and refinement work the dete- rioration of the species, and prepare its decay— the under-current, which, setting against, stays 6r frustrates the progress of society. When will the physical state of the body cease to be deemed an unworthy means of promoting our moral—our religious improvement T. J. Todd. INDURATION, (induratio, from indurare, to become hard.) This term is employed to designate an increase in the natural consistence of organs, in contradistinction to that of softening, which is used to denote the opposite state, or a diminution of the same property. GENERAL PATHOLOGY OF INDURATION. 1. Physiological Modifications of Consistence. —In order to form an accurate estimate of the modifications which take place in the consistence of tissues or organs in a state of disease, it is es- sentially necessary to possess an accurate know- ledge of the degree of consistence which these tissues or organs respectively possess in the nor- mal state, as well as of the remarkable modifica- tions which this property manifests not only in the different periods of life, but also during the progressive development of animal organization. The changes of consistence which are observed to take place under these different circumstances, although sometimes great in degree and extent, are nevertheless to be regarded as physiological conditions, and which mark in a particular man- ner the intermediate stages and extremes of life. Thus, when the phenomena of organization are about to manifest themselves in. the impregnated ovum, nothing is discovered but a colourless liquid ; organs when first perceived in the embryo are a mere jelly ; and during their development, and in proportion as they approich to the perfect state, do they acquire a gradual increase of consistence. This p.ogressive increase of consistence keeps pace with their development, and does not acquire that degree which belongs to each tissue or organ in particular, until it has arrived at a perfect state of formation. Now, we cannot but perceive here that the degrees of consistence must serve some important end ; that even the almost fluid state of parts is not to be looked upon as a mere con- sequence either of an entire want or of an imper- fect state of organization, but that it is a condition of organs or of the materials of which they are com- posed, subservient—if we may so speak—to the elementary acts of life ; a condition which facili- tates the transitions of form which organs must present before they can attain their more perma- nent and perfect state. By means of this condition ol organs, whether transitory or permanent, nu- tritive elements subservient to growth and develop- ment find a nidus fitted for their reception, and fluids every facility for passing in whatever direc- tion the} are wanted ; organs are moulded to the forms of the parts destined to receive and protect them; and numerous relations of bulk, position, situation, &c, are reciprocally adjusted between the containing and contained parts, as the changes which they undergo may render it necessary, in order to maintain the integrity and secure the well-being of each. At the different periods of life, infancy, man- hood, and old age, the consistence of the various tissues of the body, and consequently of organs, present great variety. In the first they are soft, spongy, largely embued with fluids, easily torn or broken; in the second, firm, more compact; the fluids are less abundant, and the solids resist con- siderable efforts to tear or break them. In the last period, the proportion of fluids is still less, and the solids have arrived at their maximum of den- sity and cohesion. The consistence of organs varies likewise ac- cording to sex, constitution, and the various con- ditions of life in which the individual has been placed. The difference of consistence arising out of these states is, however, by no means equally marked in all, and least as regards sex, if we ex- cept the cutaneous and muscular systems, which, in the female, are more delicate and softer than in the male. Those states of the body which are connected with the predominance of the lymphatic system are characterized by a soft, flabby feel, the opposite of that which accompanies what is called a sanguineous temperament; and as an instance of the modifications of consistence which organs undergo in individuals submitted to the influence of external causes, we may refer to such as are the result of climate and various modes and con- ditions of life. The modifications of consistence, however, which depend on sex, constitution, or conditions of life, are, perhaps, never so great as to be confounded with those which constitute morbid states of this property of organs. It is far otherwise in the different periods of life; a degree of softness or induration equal to that which cha- racterizes even the extremes of certain pathologi- cal states, constituting the peculiar character of certain parts at the periods to which we allude. Thus, the brain of the new-born infant, the mucous membrane, and even the muscles of organic life, are so soft as to be ruptured or broken down into a pulp by a slight degree of pressure or traction, just as we find to be the case in softening of these parts from disease, in after life. On the other hand, in advanced life, the cellular tissue; mem- branes, particularly serous and fibrous; the mus- cles and tendons; bone ; the brain and nervous system; and particularly the uterus and ovaries, sometimes acquire a degree of hardness equal to that which is known to be produced by certain diseases, and which, by some pathologists, has even been described as a state of scirrhus of these organs. It may not be unimportant to observe here, that numerous modifications of consistence similar to those which take place in man at the different periods of life, are found to exist in certain parts of some kinds of animals. In them, however, it is a primary condition, necessary for the accom- plishment of important functions, and, generally speaking, in no way dependent on changes in- duced by subsequent development, as in man. The conditions to which we allude consist in an INDURATION. 667 increase of consistence, or a p isitive conversion of one tissue into another of a similar but denser kind; a change necessary to enable the animal to live in a manner suited to its wants and the place which it holds in nature. Thus, in some animals, the cellular tissue, instead of being soft, spongy, and highly extensible, is naturally firm, dense, and fibrous; the epithelium, an opaque, thick covering ; the sclerotic, a cartilaginous or osseous case; the epidermis, a horny envelope, &c, &c. The analogous changes which take place in man constitute pathological states, and not only sub- vert but entirely destroy the properties and func- tions of the organ in which they are accidentally produced. If the physiological changes in the consistence of organs which we have noticed are properly understood and applied, they will serve to explain many of the pathological changes which occur in man, whether we consider these in relation to the causes by which they are produced, the pheno- mena which accompany them, or the effects to which they give. rise. These varieties in the phy- siological consistence of similar tissues in different animals show likewise, that when they occur as pathological states, they are in all probability sub- jected to the influence of the same general laws as the former ; that the limits which separate the two states, that is, of health and disease, can be defined only by a reference to a change of structure or function as regards the particular tissue, system, or organ, in which it occurs, the age, sex, or kind of animal in which it is observed. Hence, in our examination of this, as well as of every other modification which takes place in the internal and external conformation and composition of organs, the necessity of taking as the point of comparison that state of each which is found to prevail at any particular period of life, and which constitutes the type of the condition whose changes we wish to describe. II. Pathological modifications of consistence, —We have already observed that the opposite changes of consistence of organs are named soften- ing and induration. The latter only will be ex- amined in the present article. A greater or less increase in the consistence of organs, particularly of the softer ones, has always attracted the atten- tion of the pathologist, and whether existing alone or in connection with other changes, has some- times enabled him to determine the particular na- ture of a disease, more frequently to detect dis- eases at their commencement, even when no altera- tion of the bulk, form, colour, sensibility, or tem- perature of the part, was perceptible. Hence the importance which has long been attached to this physical alteration, but which, as regards its dia- gnostic value, may be fairly considered as having seldom served any higher purpose than a signal of alarm of present or of future danger. It is only within these few years that induration and infe- rior degrees of this state have been more success- fully studied, and the knowledge thus obtained more usefully applied as a means of diagnosis. Several diseases, indeed, which were believed to consist simply in an augmentation of cohesion, in an increase of density of the solid materials of a tissue, are now known to depend on very differ- ent states; that a morbid increase of consistence is much more frequently dependent on the pre- sence of an accidental or new product, fluid or solid, external to or combined with the tissue which is so altered, and consequently, that it is in these cases merely an effect, and no index what- ever of the nature of the disease on which it de- pends. Mechanical, microscopical, and chemical analyses have shown that this physical condition varies much in its nature in the same or different tissues; and observation and experiment have also shown that it is produced by causes of a very op- posite kind, and that the modifications of function by which it is accompanied are no less diversified. Since, therefore, induration is, in general, to be regarded as a symptom of previous or co-existing diseased states, it would appear to us to be of great and essential importance to determine, before pro- ceeding farther, what the diseased states are on which induration depends. Every degree and form of induration may be referred to changes which take place in the con- formation and composition of organs.* 1. Induration depending on changes which take place in the conformation of organs.—The only change comprehended under this head, which gives rise to induration, is that of bulk. Under change of bulk we include hypertrophy and atrophy, and changes in the quantity of the fluids of nutrition and secretion, as conditions which are not unfrequently accompanied with an increase of consistence of the otherwise natural and healthy texture of organs. Hypertrophy, however, is the only state in which increase of consistence can be regarded as a simple disease, inasmuch as it does not depend on the presence of a foreign product; the increased consistence in such a case being a consequence of a superabun- dant, molecular deposit of nutritive matter of a homogeneous kind in a tissue, and arranged in the normal order. But, that an increase of con- sistence depending on these circumstances should follow, it is not necessary that it should be accom- panied by any change uf bulk of the organ in which it is observed ; for there may be hypertro- phy without change of bulk, from the mode in which the additional deposit takes place. The most remarkable examples of morbid in- crease of consistence, depending on an augmenta- tion in the quantity of healthy solid material which enters into the composition of organs, are met with in those which are naturally soft; as in the nfedullary and cortical substance of the brain and spinal marrow; in the lymphatic and salivary glands, and in the cellular and muscular tissues, and even in those tissues which are naturally firm and hard, as the fibrous and osseous, in which the induration is sometimes extreme. The brain has not unfrequently been found increased to twice and even thrice its natural consistence; that of glandular, cellular, fibrous, and muscular tissues, become so hard, that they occasion a particular grating sound when cut ; and the walls of some hollow organs, naturally soft and flaccid, acquire such a degree of firmness, that they preserve, when empty, a globular or cylindrical form, and spring up with considerable force after sudden pressuie- and parts of bones acquire that degree of hard- * We employ this arrangement here, having adopted It as the basis of our classification of all organic disease* 668 INDURATION. ness which has been called eburneoid or ivory- tike induration. Induration, as a consequence of a diminution in the quantity of the healthy solid material of an organ, is, perhaps, never observed, unless it is ac- companied by other morbid states. It is only ob- served in soft, spongy, hollow organs, from which the fluids of nutrition have been removed, and for this reason we shall give examples of it under the following head. Changes in the quantity of the fluids of nutri- tion frequently give rise to induration analogous to that which we have just now generally noticed, the one depending on an augmentation of the healthy solid, the other of the healthy fluid mate- rials of an organ. The accumulation of blood in the vessels of the lungs, in the spleen, and tumours of a similar structure in various forms of conges- tion, produces sometimes a great degree of ten- sion, hardness, and density of these organs. Great diminution in the quantity of the same fluid is also followed by an increase of consistence of organs. Like the former, it is chiefly observed in the lungs and spleen, which feel as hard as liver, or even cartilage. It is, however, to be ob- served that il e increase of consistence in this case does no* follow as an immediate consequence of the removal of the fluids of nutrition of these organs, but depends on the subsequent collapse and approximation of the walls in their vascular and cellular textures. In order, therefore, that induration of this kind should be great or perma- nent, it is necessary that there should be, besides the primitive cause, (viz., the removal of the fluids,) an external or compressing force. Hence it is that induration of the lungs, of this kind, is met with most frequently in pleurisy; the lung may simply be compressed by the effused fluid, as in the acute form of this disease, or it may in addi- tion be permanently enclosed in a dense fibrous membrane of new formation, as in chronic pleu- risy. When a lung in this state is examined, it is found to be indurated merely from the approximation of its solid textures, and may be made to assume by inflation its natural bulk and consistence when the accidental fibrous envelope has been removed from its external surface. The constricting force of such pseudo-membranes is, perhaps, nowhere so marked and so peculiar in its effects as when it covers a portion only of a lung or of a single lobe. When a whole hpng is contracted, reduced to the bulk of the fist, pushed into the hollow summit of the chest, or flattened and fixed along the spine by a dense fibrous cover- ing, the effused fluid is generally believed to be the sole cause of the diminution of bulk of the organ and of its subsequent condensation. Such, however, is not the fact. It is also owing to that very remarkable property possessed by accidental fibrous membranes, by means of which they con- tract during the last period of their organization, and thereby gradually compress, diminish in bulk or capacity, or entirely obliterate hollow organs. It is, as we have already observed, when pleurisy has been circumscribed, limited to a single lobe or ft portion only of one, that the effects of the con- tractile property of the fibrous membrane are most strikingly illustrated. The portion of lung in- cluded in this membrane feels quite solid, hangs pendulous, or projects outwards in the form of a small tongue or dog's ear; or it may have a coni- cal or cylindrical form of various dimensions. The portion of lung so compressed and indurated is immediately recognised not only from its diminu- tion of bulk and peculiarity of form, but by the pale, uniform, white colour of its accidental fibrous covering, instead of the mottled aspect of the lung under the transparent pleura; and the cause of its density is farther demonstrated from the absence of every external compressing cause, fluid or solid (for it is not necessary that effusion should be present in such cases), except the fibrous mem- brane, and from its bulk and consistence being restored in the manner already noticed. Condensation and induration of the spleen are often effected in the same way, that is, from the constricting force of an accidental fibrous mem- brane. The last form of induration which we shall mention here, produced by the fluid contents of organs, is that which is found to accompany an augmentation in quantity of the healthy fluids of secretion : as of the milk in the breasts, semen in the testes, bite and urine in their respective reser- voirs. The inordinate accumulation of any of these secretions in their proper vessels gives rise to a degree of hardness sometimes equal to that of hard tumours,—a circumstanee arising from the incompressibility of the fluids themselves, and the state of condensation of the walls of the organs in which they are accumulated. 2. Induration depending on changes which take place in the composition of organs.—The increase of consistence included under this head may be referred to the presence of accidental or new products. These may be either fluid or solid. Of the first kind we have the natural fluids of nutrition and secretion, and some anomalous fluid products ; of the second, we have all the solid accidental and new products which are found in the different textures and organs of the body. By far the greater number of these products require only to be named in this place, inasmuch as the induration which they produce depends on the degree of consistence which they themselves pos- sess, and not on any change induced in the tex- ture of the organ in which they are formed. There are, however, others, some of the natural fluids, and various anomalous fluid products, which, when effused into natural or accidental cavities, occasion from their accumulation, or the rapidity with which they are effused, great increase of con- sistence of the containing solids. When blood, or serosity containing various proportions of albu- men and fibrine, is effused into the cellular tissue or the cavities of organs, the distension which these fluids occasion is sometimes so great as to render parts naturally soft and flaccid, quite dense, and almost unyielding. Thus the parenchyma of organs and the cellular tissue in general, when they become the seat of hemorrhage, as pulmonary apoplexy, ecchymosis, &c, feel sometimes quite hard ; and such is the state of the walls of the abdomen from the great accumulation of serosity in ascites, and of the cellular tissue of the extre- mities in oedema. The effusion of serosity into the intermuscular cellular tissue produces some- times an extreme degree of induration, even when INDUR the muscular organ is not submitted to the influ- ence of any external compressing cause. This is particularly observed in oedema of the tongue, in which this organ becomes as hard as a piece of wood. The same state is met with in the heart, although in a much less degree; also in the brain, liver, salivary and lymphatic glands. What is called hepatization of the lungs is a modification of consistence of a similar kind, but is produced by the presence of coagulable lymph, pus, and blood, as well as serosity. To complete the general view of the diseases from which induration may arise, we have only to add that the accumulation of gases in the cavity of the abdomen and digestive organs sometimes occasions an extreme degree of tension and hard- ness of the abdominal parietes, and that collec- tions of pus, atheromatous, melicerous, and other adventitious products, constitute swellings which communicate to the surrounding parts various de- grees of induration. We may also note in this place, as a cause of induration, the accumulation of the contents of the stomach and intestines so frequently produced in these organs, particularly from stricture. Thus faecal matter may be accu- mulated in the caecum, and communicate to the hand the sensation of a hard tumour in that re- gion ; or the whole of the colon may be similarly distended from stricture of the rectum, and be seen as well as felt throughout its whole course of an enormous size and extremely hard; and the sto- mach may be so distended in stricture or obstruc- tion of the pylorus as to occupy the greater part of the cavity of the abdomen in the form of a globular swelling, offering considerable resistance to pressure. Although the state of induration which we have been considering has always been confined by pathologists to changes directly or indirectly in- duced in the solids, whereby their consistence is increased, we do not see any reason why the same alteration, when considered in a general point of view, and as implying merely a modification of consistence, should not embrace changes of a sim- ilar kind which take place in the fluids of nutrition and secretion. The various degrees of fluidity which these products are found to possess, appear, in fact, to present us with some of the most sim- ple forms under which the various degrees of con- sistence of matter can be subjected to our senses, at least in so far as regards the material of organic composition. Various degrees of fluidity of the blood are observed, from a watery thinness to a state of inspissation approaching to coagulation, which last is, perhaps, a manifestation in an ex- treme degree of one and the same property. It is, indeed, highly probable that the consistence of the blood depends principally on the fibrine which it contains, and may vary in degree with the quantity and quality of this important constituent, —an opinion, the truth of which appears to be proved by the fact that coagulation of the blood is no other than spontaneous solidification of the fibrine. The opposite state, or extreme fluidity produced by frequent hemorrhage or bloodletting, reduces this fluid to the consistence of serosity, chiefly by the removal of the greater part of its fibrine—a further evidence of the influence which fibrine exercises on the consistence of the blood. ATIOK. 669 The consistence of the blood is always increased in a greater or less degree by whatever reduces the velocity of the circulation below that of the* healthy state. The blood that first flows from a vein in phlebotomy is not only darker but thicker than that which escapes some time after, on ac- count of its having been brought to a state of rest by the constricting force of the bandage; and as the buffy coat is generally increased under similar circumstances, it would appear that the fibrine had already assumed a disposition to coagulation ; for cessation in the motion of the blood, even when very limited in duration, is always accompanied by a tendency to separation in its constituent parts and to coagulation of the fibrine. Hence it follows that ligature, tumours, and other me- chanical obstacles situated in various parts of the body, and certain adynamic states, as local and general debility, which retard or arrest the motion of the blood, occasion, in the manner just stated, inspissation and coagulation of this fluid,—effects which often lead to other diseased states that some- times terminate in death. It may not be out of place to remark here, in- asmuch as it is not our intention to discuss after- wards the changes which take place in the fluids of nutrition and secretion in the different organs of the body, that the study of this physical pro- perty, whether existing as a primary or secondary diseased state, seems to us to be one of consider- able interest, and, as well as many other still more important changes of these fluids, deserves to be carefully prosecuted, and promises to those whose knowledge of animal chemistry enables them to do so, results of the highest importance. There was, indeed, a time in the history of humoral pathology when some of the physical qualities, and in particular the consistence of the blood and other fluids of the body, attracted almost exclu- sively the attention of the physician. But, whilst an acquaintance with the laws of fluids in motion enabled him to explain some of the changes which he observed to take place in the circulation of the blood, it was at the same time the great source of the many errors which were introduced into the humoral pathology at the period to which we al- lude. Nevertheless, not a few of the morbid states of consistence of the circulating and secreted fluids were known to the humoral pathologist, and sug- gested to him the use of various remedies for their cure. The doctrines of solidism, as exclusive as those of its now too much neglected predecessor, led away the mind of the physician from the study of the diseased states of the fluids, or in- duced him to ascribe the origin of those which he occasionally recognised to some previously exist- ing disease of the solids, of which they were sup- posed to be merely effects, and to be removed by the cure of the primary disease. Such opinions contain much that is untrue as regards the origin of diseased fluids, and even when effects of dis- ease of the solids, it by no means follows as a consequence that the cure of the one wdl neces- sarily be followed by the cure of the odier. Facts are not wanting to prove the contraiy, and tu show the necessity of directing the operation of remedies in such a manner as to effect a salutary change in the pathological conditions of the fluids But as regards the subject of our immediate 070 INDURATION. consideration — the increased consistence of the fluids of nutrition and secretion—we find not un- frequently examples of this change in the blood of certain individuals labouring under plethora from various causes, and also in many cases of great local congestion, as we have already ob- served. Inspissation of the bile is a common occurrence, particularly in the gall-bladder; and here, as in the blood-vessels, the transit of the respective fluids must be more or less impeded by such a change. The formation of gall-stones appears in some in- stances to depend chiefly on this condition of the bile, which, being thus prevented from passing along the ductus communis choledocus, undergoes the chemical changes necessary for the formation of these accidental products. Alarming and even fatal consequences arise from inspissation of the mucous secretion of the bronchi, larynx, and even posterior fauces, particularly in individuals debilitated by disease. In such cases the mucous secretion may be perfectly healthy, but having its fluid portion absorbed, it becomes thick and viscid, adheres to the mucous membrane, and accumulates to such a degree as to obstruct the passage of the air, and thus sometimes produces fatal asphyxia. We have ourselves seen the life of more than one individual saved by the removal of this viscid secretion from the posterior fauces and larynx, by mechanical means and change of posi- tion. The copious use of cold water given with a view to diminish the plastic property of the blood, is said to have prevented the deposition and forma- tion of the false membrane in croup, or to facili- tate greatly its subsequent removal. Are the bene- ficial effects obtained from the use of mercury in this disease to be attributed to a similar mode of operation 1 From these general observations on the diseased states on which induration depends, we may now refer this increase of consistence of the fluids and solids of the body to the following heads :— 1. To a superabundant molecular deposit of solid nutritive matter of the same kind as that which enters into the healthy composition of a tissue— hypertrophy. 2. To an increase in the quantity of the fluids of nutrition and secretion—various forms of con- gestion, retention, &c. 3. To a diminution in the quantity of the fluids of nutrition—diminution of bulk from compres- sion. 4. To the presence of solid, fluid, and gaseous, accidental and new products — scirrhus, cancer, &c, hemorrhage, dropsy, oedema, tympanitis, &c. 5. To changes which take place in the qualities or elementary composition of the fluids of nutri- tion and secretion—thickness, inspissation, coagu- lation. It is hardly necessary to observe that several of these diseased states may exist at the same time, and by their combination give rise to compound forms of induration of one or several tissues of the same organ. The characters of each kind are, in this manner, much obscured, and can only be de- termined by a careful examination of the part, so as to discover the particular diseased state on which each kind depends. Independently of this source of obscurity, the characters of induration are frequently rendered still more obscure from the changes of bulk, form, and colour with which it is accompanied. The principal changes of bulk which accompany indu- ration are already known to the reader. It is only necessary to remind him that induration may exist without any change in the dimensions of an organ, and that an increase is infinitely more frequently observed than a diminution of bulk. The changes of form with which induration may be connected are extremely numerous ; but as they are of no great importance in the present inquiry, we shall only observe that induration is not necessarily accompanied by any modification of this state. Various kinds of colour are, perhaps, still more frequently found to accompany the induration of tissues, and modify the appearance which they present in a much more remarkable manner than changes of form or bulk. In the second, third, and fourth kinds of induration which we have enumerated, the sources of the greater number of the changes of colour which accompany these states are obvious. But there are others which are derived from the colouring matter of the blood deposited in tissues, or afterwards modified by the operation of external agents. Hence, the colour of an indurated tissue may be quite healthy, diminished, or increased in intensity, or it may be entirely dif- ferent in kind ; examples of which are met with in hypertrophy, atrophy, congestion, hemorrhage, jaundice, and melanosis. Changes in the weight, humidity, transparency, and sonorousness of organs, are not only compli- cations, but frequently the immediate effects of induration. Those of weight, humidity, and so- norousness, are all strikingly exemplified in pneu- monia terminating in hepatization; and those of transparency are not rare in membranous tissues. Having pointed out these sources of complica- tion, we should now proceed to describe the dis- tinctive characters of each kind of induration; but having already entered sufficiently into this part of our subject, which we regard as embracing only the generalities of a morbid state, the physi- cal, anatomical, and chemical characters of which belong to or are derived from other diseases, we have to refer the reader to these diseases, which we have named, for further information on this head. There are, however, certain modifications of function produced solely by the state of indu- ration, and which may be regarded as constituting the physiological characters of this state. These are, modifications of sensation and motion. Thus pain, sometimes of the most acute kind, is produced by the hard unyielding nature of certain tumours compressing or constricting the nzrves of sensa- tion distributed to, or which pass in the vicinity of, the diseased organ. Similar effects on the nerves of motion give rise to paralysis. Motion of the solids is, besides, mechanically impeded by induration, which prevents the change of situation and bulk which ought to follow muscular contrac- tion or that of elasticity; and the motion of the blood, bile, urine, and other fluids, may be greatly impeded, or even entirely arrested by the hard un- yielding nature of accidental products. Having already pointed out the greater number of these facts which are of any degree of importance, we INDURATION. 671 shall conclude the general part of our subject with a few remarks on the symptoms, causes, and treat- ment of induration, considered as a morbid affec- tion in the living body. Symptoms. — The symptoms of induration, considered in a general point of view, are not to be separated from those of the diseases on which it depends; and although the modifications of sensation and motion which we have just noticed are the immediate consequences of this physical change, they do not furnish us with any positive sign of its existence, unless it be at the same time felt or otherwise perceived. Induration, therefore, is not to be detected during life, except in cases in which it is perceived by the touch, or the mediate sense of auscultation and percussion, — means which, together with the modifications of sensa- tion and motion mentioned, and those of bulk, form, and colour, to which we have also alluded, will enable us, when properly employed and ap- preciated, to detect in certain organs the kind, situation, degree, and extent of this morbid state. Causes. — The causes of induration are also, properly speaking, those of the diseased states on which it depends, and, therefore, anything we might say on this head would be foreign to the present inquiry. Much, however, has been said on the causes of induration, when employed as synonymous with the term scirrhus; but as we regard this state as something more than indura- tion, or induration and hypertrophy united, we think it more consistent with the order which we have hitherto followed, to leave the etiology of scirrhus to be investigated in its proper place. Treatment.—The principal part of the treat- ment of induration to which we have to direct the attention of the reader in this place, is that sug- gested by the modifications induced in the func- tions of sensation and motion as immediate effects of this physical condition. When pain arises from induration, and the consequences which frequently follow this change, as weight and tension, it is seldom removed or even much mitigated when seated in internal or- gans, unless the exciting cause be a fluid. In this case the removal of blood is found to be some- times followed by great diminution or even the entire cessation of the uneasiness, anxiety, or suf- fering, which its presence had occasioned; as in great congestion, for example, of the brain and lungs. The good effects of venesection in most cases of plethora are also in part to be attributed to the removal of a quantity of the same incom- pressible fluid, whereby the organs of circulation, respiration, and innervation are allowed more free and extensive action. The pain which always accompanies the vascular tension of an inflamed part, and more particularly that occasioned by the effusion of serum and pus in the cellular tissue, and beneath unyielding fibrous coverings, is still more remarkably relieved by the destruction of the constricting causes and the evacuation of the incompressible fluids. The relief which patients expenence on the removal of the fluids collected in the cavity of the pleura and abdomen in acute inflammation of their respective serous coverings, in some forms of ascites and oedema, in retention of the milk, urine, &c. is to be attributed in no small degree to the judicious application of the same principle. When pain is occasioned by the pressure of a hard tumour, it may be mitigated or removed by the following means—change of position, warm fomentations, anodynes, extirpation, and other mechanical means. Change of position seldom accomplishes much in the way of removing pain, and has only been found to be occasionally sug- gested by patients themselves who have accident ally discovered that their sufferings were relieved when in certain positions ; as in some cases of pendulous tumours contained in cavities. Warm emollient applications, from the relaxing effect which they produce on the parts to which they are applied, are often of the greatest benefit. Independent of the benefit which for a time may be derived from the general administration of anodynes, more decided and more permanent ad- vantage has of late been obtained from their local application, in the manner recommended by some French physicians, and called by them la methode endermique. (Essai sur la Meth. Enderm. par Ant. Lembert, Paris.—Trousseau, Journ. Univer et Hebdom. de Med. et de Chir. Pratique, tom. iv. p. 82.) This method, so far as we know, has not been employed to remove pain produced by the pressure of hard accidental products or tumours ; but from its successful application in several cases of acute and chronic neuralgia in external parts of the body, we feel strongly disposed to believe that the continued and sometimes excruciating pain which accompanies certain sub-cutaneous and even deeper-seated tumours of the nerves would be greatly relieved or entirely removed by the application of the salts of morphia or bella- donna (the remedies hitherto employed) to the denuded skin in the tract of the affected nerve The cure of these cases and others of a similar kind belongs, however, to the province of surgery, and consequently we can only name the third mode, viz. extirpation, excision, and other me- chanical means employed in that department of medicine. With regard to the means to be employed with a view to facilitate the motion of solids and fluids, impeded by an abnormal increase of consistence, we have little to add to what we have already suggested on this head. The physician when compared with the surgeon is wonderfully limited in the means which he has to employ in many of these cases. Those remedies alone which exer- cise a special influence on the great function of nutrition in general, or on those of hematosis, cir- culation, absorption, and secretion in particular, seem sometimes to afford a well-grounded hope that many of the diseased conditions which give rise to induration are not altogether beyond the salutary influence of medicine. Special Patuology of Induration Having entered rather fully into the general pathology of induration, we do not think it ne- cessary to discuss the special pathology of this disease, unless in the two following cases—indu- ration of the cerebral substance, and induration of the cellular tissue. I. Induration of the cerebral substance.—Pei- haps no term has been more vaguely employed by 672 INDURATION, physicians to designate a particular diseased state of the brain than that of induration. There are, in fact, few accidental products which, at one pe- riod or other of their development, and formed in the substance or on the surface of the brain, have not been described as induration of this organ. Much of this ambiguity has, however, been re- moved by a more accurate knowledge of the ana- tomical characters of these diseases; and however obscure or uncertain may be the origin, nature, symptoms, and treatment of many of them, their being thus brought before us under a distinct and tangible form has already been productive of much good. It is, perhaps, owing to this circumstance alone that so much progress has of late years been made in the pathology of the brain. The substance of the brain is, as we have al- ready said, subject to an increase of consistence independent of the presence of any foreign pro- duct deposited within or upon it. It is only under such circumstances that we admit the existence of induration as a disease. Hence, it is only in certain forms of hypertrophy and atrophy that we find a simple increase of the consistence of this organ. It is, however, by no means easy in every case to determine that an increase of consistence depends alone on a modification of one or other of these conditions of nutrition; for colourless effusions, containing a greater or less quantity of albumen and fibrine, may take place in the fibrous texture of the brain, and produce various degrees of consolidation of the cerebral substance. But when such effusions are not to be detected; when there is no other morbid product present; when the brain or a portion of it is harder than we know it should be at the period at which it is sub- mitted to our examination, we are then to consider it to be in a state of simple induration, whether its colour be altered or not. The degree and ex- tent of such a condition of the cerebral substance may present very considerable variation. Some- times the increase of consistence is so slight that we only admit its existence as probable; at other times it is so great as to be perceived even before it is touched, on account of the soft surrounding substance falling down when divided, and leaving the indurated portion more elevated. If, in the first case, the augmentation of consistence be cir- cumscribed instead of being general, we have then in almost every case the means of determining how far it is a pathological state, by comparing the part supposed to be diseased with the corre- sponding healthy part, — a mode of examination which ought always to be had recourse to under similar circumstances in every organ of the body whenever it can be employed. We of course suppose that a previous knowledge has been ac- quired of the several degrees of healthy consist- ence of the brain in general, and of its parts in particular. The several degrees of morbid increase of con- sistence of the cerebral substance may be repre- sented to the mind of thp reader by the changes of consistence which the brain itself undergoes after it has been submitted to the action of alcohol, acids, or boiling oil, for a given length of time. It then cuts like the white of a hard-boiled egg, the udder of the cow when boiled, or firm smooth cheese, such as that of Gruyere. It has been represented to be sometimes as hard as fibrous or cartilaginous tissues ; but such degrees of indura- tion of the brain do not, we believe, exist as simple states, and depend on the presence of accidental tissues. The greater the degree of induration, the greater the change of colour the affected part undergoes: this consists in a diminution or entire want of the natural colour of that part. Hence, the natural colour of the medullary substance being pale, a diminution of colour is principally observed in in- duration of the brown or cortical substance, which may become so pale as not to be distinguished from the medullary with which it is in contact. The first as well as the succeeding degrees of induration may present this state of pallor, but it may likewise be redder than natural—In the for- mer the substance of the brain, when cut, is some- times moistened with serosity, at other times drier than natural; in the latter it presents a greater number than usual of red points or streaks of blood. A thin slice of the indurated portion may be held out between the thumb and fore-finger, and, when pressed, sometimes snaps through like a bit of boiled albumen. It is only when this dis- eased state is circumscribed that it has been ob- served to be great in degree; and when it occu- pies the whole brain, it generally amounts to little more than what may be called a state of firmness. An increase of bulk in induration of the cere- bral substance is not easily ascertained unless the affected part be in the convolutions, in some of the circumscribed and distinct portions of it, or occupies the whole brain. A diminution of bulk accompanying the same state presents the same difficulties. Both, however, have been observed; but the former much more frequently than the latter. The brain is far more frequently the seat of in- duration than the cerebellum; the cortical sub- stance perhaps more so than the medullary; the peripheric portion of the latter more so than the central; the basis than the surface of the hemi- spheres. The medulla spinalis, in which this change has also been observed in a circumscribed or general form, is much less frequently affected than the brain, and has seldom been seen to acquire the same degree of morbid consistence, except at its upper portion, and more particularly the medulla oblongata. Symptoms of Induration of the Brain.— Of the various authors who have observed and described induration of the brain and spinal mar. row, some of them have regarded it, when gene- ral, as giving rise to ataxic or typhoid fever, and some forms of mental derangement, being in the former an acute, in the latter a chronic state of disease. Others have endeavoured to show that tetanus, epilepsy, and other nervous and convul- sive disorders, may also sometimes originate in the circumscribed form of the same pathological state. Whilst we add our testimony to the truth of the anatomical part of the facts on which these opi- nions have been founded, we must at the same time say that we feel but little disposed to place much reliance on the diagnostic value of the symptomatic details which these authors have col- lected on this subject. In the present state of our INDURATION. 673 knowledge we believe that we possess no means of detecting the existence of induration of the brain and spinal marrow during life, the symp- toms which have been found to accompany it__ such as various modifications of sensation, motion, and intelligence — being common to many very different morbid states of the same parts. The derangements of function which follow as the im- mediate consequences' of induration of the cere- bral substance are, indeed, sufficiently obvious to the physician ; but, for the reasons just stated, they afford him little or no assistance in determining the nature of the lesion on which they depend. Causes.—The etiology of this morbid state is by no means so well understood as some patholo- gists would have us believe. That certain forms of it depend on a previous state of irritation, every one must admit; but that this state of irritation, or any modification of it, is the sole cause of in- duration, is by no means in accordance with the results of observation. In that firmness of the brain in general, observed in some forms of fever accompanied with more than ordinary excitement, and in some cases of acute hydrocephalus, in some kinds of mania accompanied or not with paralysis, irritation of the brain or its membranes may be regarded as at least the probable cause. Circum- stantial induration of the cerebral substance may also originate in the sanie cause, inasmuch as we find it present and in juxta-position with other diseased states, such as ulceration and abscess, having a similar origin. But for reasons equally cogent, we are led to reject the evidence on which it has been attempted to establish the general ap- plication of this principle to the etiology of this disease. When, as we have stated in the intro- ductory part of this article, we find that portions of organs, and even whole organs, acquire a great increase of consistence without presenting any, even the slightest, modification of function as is observed to accompany irritation ; that the same organ (the brain too) is soft at one period of life and firm at another; that an organ that is soft in one animal is hard in another; we cannot resist the conclusion that increase of consistence—that is, induration—when occurring out of the usual order of place and time, may nevertheless be something else than a consequence of any morbid state with which we are yet acquainted, however much we may pretend to be familiar with its ways of working. It would seem to us to be much more consistent with a sound philosophy to attri- bute the production at least of some of the forms of induration of organs to the influence of other and still more general laws than those of irrita- tion, viz. those of organization; and, moreover, that instead of occupying the rank of a cause, irritation in this as well as in numerous other in- stances follows as an effect, and thence becomes a valuable evidence of the existence of the former. Treatment.—As the causes of induration are obscure, and more particularly as we are unable to recognise the existence of this state during life, we have of course no indications or modes of cure to propose. We except, however, from this bar- ren and unsatisfactory result that form of indura- tion which we have stated may arise from an augmentation in the quantity of blood usually ad- mitted into an organ. Such is the state of the Vol. II. —85 So brain in congestion, the treatment of which is given in another place. It may not be unimpor- tant to remark that the principal phenomena of congestion, loss of sensation and motion, seem to be the immediate effect of the state of induration induced in the cerebral substance by the accumu- lated blood : the degrees of density alone, which is thereby induced, being sufficient to unfit -the organ for the accomplishment of its functions, independent of the other changes which we well know follow as a consequence of such congestion. II. Induration of the Cellular Tissue.—Syn. Induratio telae cellulosae, sclerema; squirrhosarquc; cedeme concrete; cedeme du tissue cellulaire des nouveaux nes; zellegewebsverhiirtung; skin- bound disease. The cellular tissue affords so many facilities for the formation and development of disease, that it has been regarded by several pathologists as the primary seat of almost all morbid products. Va- rious circumstances, the exposition of which does not come within the scope of this article, concur to give rise to such a belief, but which is as little founded in fact as every other exclusive theory regarding the common origin of diseases. The pathological state which we have to examine fur- nishes a striking example of the fallacy of such generalizing principles, induration of the cellular tissue being, in point of fact, one of its most equi- vocal characters. Induration of the cellular tissue constitutes a case of complicated induration, depending exclu- sively, as regards the local affection, on an accu- mulation of serosity or sero-albuminous fluid in the cellular tissue. It is therefore only in accord- ance with custom that we have introduced this state under the appellation of induration of the cellular tissue. We shall, however, employ the term adema (instead of induration) of the cellular tissue, as it fully and accurately expresses the condition on which the induration depends, to which we may add of new-born children, to dis- tinguish it from that which occurs at an after period of life. Although this affection is generally observed in children a very few hours after birth, it may occur several days later; and there are examples of children having been affected with it when born. The subjects of this disease are for the most part feeble ; sometimes imperfectly developed, and generally born before the full period. They do not seek the breast, but refuse to suck; they are agitated almost continually, and have a peculiar cry. The skin is dry, cold, as if stretched ; gen- erally of the natural red colour, but sometimes purple or livid. The soft parts feel firm, or even hard; when pressed they become pitted, and of a dull yellow colour; but the primitive form and colour soon return, unless the oedema be extreme. These appearances are generally observed to begin in the inferior extremities, passing from the feet upwards, and sometimes proceed with great rapid* ■ ty, attacking the hands and arms; the inferioi part of the abdomen, back, and face. Sometimes it appears to affect almost all these parts simulta neously, and nearly to the same degree. More rarely it is confined to the feet and hands. The bulk of the affected parts is increased, particularly that of the inferior extremities, but by no means 674 IN D U R in proportion to the degree of induration which they communicate to the hand when pressed. The diminution of temperature of the affected parts follows in a descending ratio the progress of the oedema, and in some cases has been observed to precede it. The production of heat is rapidly di- minished over the whole body ; the inferior ex- tremities become quite hard and stiff; the superior extremities and trunk less frequently to the same degree. In extreme cases the application of heat to the body only acts upon it as on dead matter, its temperature being suddenly raised or cooled as the warming medium is applied to or removed from it. The other signs of functional derangement which accompany this affection increase in sever- ity with the same rapidity. The respiration, at first imperfect, becomes difficult and laborious, and the pulse so feeble as sometimes not to be felt. In this state death supervenes from asphyxia, generally within the fourth day, sometimes on the first, and more rarely at the end of one, two, or even three weeks. These are the most prominent and remarkable symptoms; those which may be regarded as pro- per to the disease. The symptoms of jaundice, although frequently present, are, however, per- fectly distinct from those of this form of oedema. The same may be said of those of cerebral, gas- tric, intestinal, and acute pulmonary affections, which have been regarded by some as giving rise to the affection. The characters of this disease are so well marked that it cannot be confounded, unless when circumscribed, with any other disease by the most careless observer ; and even in this form it is only necessary to note the diminution of temperature which accompanies cedematous swelling, to distin- guish it from any inflammatory affection of the skin which gives rise to a similar state of the cel- lular tissue, and in which the temperature of the affected part is always morbidly increased. It is rare that the physician has the satisfaction of being able to pronounce a favourable prognosis in this affection after it has arrived at a certain stage. It is only when the oedema is limited in extent and not great in degree; when the circula- tion and respiration are not much affected ; when the temperature has not sunk much below the natu- ral standard, and when the strength of the infant can be supported by its taking the breast, that a fa- vourable termination may be reasonably expected. In such cases, as well as in those of a severer kind which recover, the signs of a favourable issue are to be drawn from the amelioration which takes place in the state of the respiratory function, which becomes less embarrassed; the increasing strength of the pulse ; the gradual elevation of the temperature of the skin; the diminution of the swelling, and particularly of the induration ; the disappearance of the deep red or livid colour which it may have presented, and the supervention of a gentle moisture over its hitherto dry surface—the child becomes quiet, sleeps, and manifests a desire for food. Before proceeding to examine into the causes oi oedema of the cellular tissue of new-born chil- dren, we shall, in the first place, endeavour to give a correct statement of the facts which the LTION. morbid anatomy of this disease has enabled us to collect. The external aspect of the body is but little changed after death. The affected parts still preserve the same colour; the face and upper part of the trunk are even more swollen, and the induration in general is rather increased than otherwise; the softer parts, such as the face, evi- dently so. When a section of an cedematous extremity, the teg for example, is made so as to expose fully the subjacent cellular tissue, instead of finding this tissue compact and indurated, we find on the contrary its cellular aspect much increased, from the cells being filled with a serous or #ero-albu- minous fluid, which is either quite limpid, of a citrine colour, or tinged with blood. The quantity of this fluid is in proportion to the degree of swelling and induration which accompanies it. If small in quantity, the cellular tissue requires to be pressed before its presence can be recognised; but when abundant, it distends the cells of the sub- cutaneous cellular tissue, and a part of it oozes or flows out from the compression which the divided skin exercises upon it, or by its own specific gra- vity. When the whole of this fluid is forced out by pressure from the subcutaneous cellular tissue, it then feels soft and extensible ; and the skin, which was before stretched and fixed, becomes lax, and can be moved over it as in the healthy state. When examined narrowly, it is found to present no thickening, opacity, or change of con- sistence. Its colour may be natural, or reddened by a slight degree of vascularity. The intermus- cular cellular tissue may present the same appear- ances, but in a much less degree. When the serous effusion occupies the adipose as well as the cellular tissue, the feeling of hard- ness is increased. The granules of fat, so con- spicuous and firm in the child, are in this way compressed between two forces. They appear whiter than usual, resemble the fat of meat, and are hard, as if frozen. This state of the adipose tissue does not necessarily accompany oedema of the cellular tissue, as it occurs frequently with- out it. From these facts, the truth of which we have had ample opportunities of verifying in a large hospital set apart for the reception of new-born children—the Enfans Trouvis at Paris, it must appear obvious that the state of induration ob- served in these children is a purely mechanical effect, depending on the accumulation of a fluid in the subcutaneous cellular tissue. The term induration never could have been employed to designate such a morbid state, had those who first observed and described it submitted the affected parts to careful anatomical investigation. Den- man, Underwood, and others since their time, have stated that the cellular tissue, in the cases which they observed, was not only hard but dry. As we have never met with one example of such a nature among the great many cases which we have examined, and as we know that the disease which they described is the same as that of which we are now treating, we feel disposed to doubt the reality of such cases. It would serve no good purpose to multiply facts to prove that those pa thologists have been also deceived who hav INDURATION 675 described the cellular tissue in this disease as thickened and hardened ; particularly Allard, who considered it in this respect as analogous to the elephantiasis Arabum, or what is commonly called Barbadoes leg. (See Elephantiasis.) The presence of a greater or less quantity of serosity or sero-albuminous fluid in the subcuta- neous cellular tissue constitutes the essential ana- tomical character of the disease we are describing; and in this respect it is to be regarded as oedema, differing perhaps little even in its nature from that which is much more commonly observed in adults, as a consequence of disease of the organs of circulation and respiration, and in whom it also presents to the touch the sensation of various degrees of induration. Not satisfied with this simple explanation of induration of the cellular tissue of new-born chil- dren, some pathologists would have the effused fluid possess the property of becoming concrete, and to this circumstance they attribute the degree of hardness which the affected part communicates when pressed. For this reason, also, they regard it as different in its nature from the oedema of adults, and have on that account, and to distin- guish it from the latter, called it concrete oedema. The results of some experiments made by Chev- reul on the effused fluid taken by Breschet from the cellular tissue of children affected with oedema and jaundice at the same time, (a very frequent complication,) appeared to confirm the opinion that the induration depended on the coagulable nature of this fluid. Subsequent experiment, however, has shown that the inference drawn from the fact of the coagulable property of the effused fluid was by no means correct; for not only is this fluid not found in a concrete state in the cellular tissue of new-born children affected with oedema, but the property which it possesses of coagulating spontaneously when placed in a state of rest, and exposed to the influence of the ordinary temperature of the air, exists also in the fluid found in the cellular tissue of adults affected with ordinary oedema. In all cases, in fact, of oedema produced by an obstacle to the return of the venous blood, does the effused fluid possess this property ; and so far as our experience ena- bles us to judge, the more sudden the production of the oedema, the greater the spontaneous coag- ulability of the effused fluid. Hence the reason why in the oedema of new-born children, in whom the effusion generally takes place rapidly, this coagulable property is more marked than in the chronic oedema of adults. Notwithstanding these facts, we must repeat that the state of induration is neither caused nor increased by this circum- stance, for we have never found the fluid coagu- lated in oedema of the cellular tissue after death. That it is not coagulated during life we know, from the fact that it flows out when the skin is punctured. Besiles the state of the cellular tissue which we have described, various morbid appearances are observed in different parts of the bodies of those who die of infantile oedema. Some of these are always present, and are therefore to be regarded as essential to the production of the disease; others are only occasionally met with, and on that account must be viewed in the light of coincidences. The most remarkable among the constant le- sions is a state of general venous congestion. The heart and great blood-vessels are filled or dis- tended with blood; the lungs and liver, and in- deed all the soft parts, are in a high state of con- gestion, particularly the former, which, when cut, discharge a great quantity of dark venous blood. There exists no mechanical obstacle in the heart, great blood-vessels, or lungs, to which this accu- mulation of blood can be attributed ; and on that account it resembles plethora more than any other affection. We need hardly observe that it is to this state of general congestion that the effusion of serosity in the cellular tissue is to be attributed, and that the same state of congestion, and the oedema which follows it to the lungs, are the causes of the difficulty of breathing which is present in this disease. The languid state of the circulation, and the stagnation of the blood in the capillary sys- tem in general, appear to us sufficient to account for the remarkable diminution of temperature which takes place in infantile oedema. With this state of congestion there is, also, a greater or less degree of oedema of the cellular tissue of the viscera of the thorax and abdomen, and effusion of the same fluid into the serous cav- ities. The submucous cellular tissue in general is more or less cedematous; and it is this state of that glottis which occasions the cry peculiar to children affected with this kind of oedema. These are the most remarkable of the constant lesions in infantile oedema. Those which occur accidentally, but which have been regarded by some pathologists as the causes of this kind of oedema, are numerous. The principal of them are acute affections of the lungs and liver, of the stomach and intestines, or of these and the sub- cutaneous cellular tissue at the same time ; the non-occlusion of the foramen ovale ; and a dimi- nution in length of the intestinal tube. Without denying that most of these morbid states, and some of them much more than others, contribute, when present, to increase the effusion into the cellular tissue, we are more disposed to believe that they are much more efficacious in re- tarding or rendering its cure impossible ; and we are persuaded that they have no direct effect in producing it, since we have found it to exist in an extreme degree when there was no other appre- ciable morbid condition to be detected but the general state of congestion which we have de- scribed. After these remarks we trust it will not be con- sidered an omission, if we overlook most of the theories, or rather hypotheses, which have been entertained regarding the etiology of oedema of the cellular tissue of new-born children. Andry and Auvity, the first who gave a good description of this disease, attributed its production to the action of cold ; but although it occurs more frequently in winter than at any other time of the year, it is often observed in summer and under circumstances the most favourable as to external temperature. The opinion of Breschet, that the effusion 01 serosity in the cellular tissue depends on the per manent opening of the foramen ovate, was soon shown to be unfounded. Indeed it is difficult to CT6 INDURATION. conceive how this intelligent pathologist could have offered such an opinion as the result of his observation. " In seventy-seven children," says Billard, (Traite des Maladies des Enfans Nou- veaux-Nes, &c, Paris, 1828,) «affected with oedema of the cellular tissue, there was in forty of them complete occlusion of the foramen ovale, and in twenty-eight of these even the ductus arte- riosus was considerably contracted, and did not allow the passage of the blood through it. The explanation of Mons. Breschet falls, therefore, be- fore the evidence of facts. If the foramen ovale is still found frequently open in hard children, it is because induration of the cellular tissue affect- ing particularly very young children, the changes which take place in the heart and ductus arterio- sus of the new-born child, after the establishment of the independent circulation, have not had time to be completed when the oedema appears. I think, therefore, that there is no relation between the two phenomena in question." The last opinion which we shall notice is that of Mons. Denis, who has endeavoured to show that an inflammatory condition of the cellular tissue which becomes affected with oedema, and of the mucous membrane of the stomach and in- testines at the same time, are the causes of this disease. To characterize this complication, and no doubt anxious to do honour to the Doctrines Physiologiques, Mons. Denis has conferred upon it the appellation of phlegmasie entero-cellulaire. Inflammatory affections of the gastro-intestinal mucous membrane are extremely common in in- fants, and must consequently be met with in those affected with oedema of the cellular tissue ; and when we find oedema without them, and vice versa, we are not permitted to regard their simul- taneous existence otherwise than as a coincidence. That the oedema of the cellular tissue is the con- sequence of inflammation, no pathologist who has examined it, and whose judgment is not biassed by preconceived notions, will believe. Were such the fact, we should find sometimes, if not always, some of the products or effects of inflam- mation of the cellular tissue, such as coagulable lymph or pus, or softening; which we ourselves (or, we believe, anybody else, not excepting even Mons. Denis,) never once have met with. Mons. Baron, who for a number of years has been physician to the Enfans Trouves, regards the oedema of new-born children as analogous in every respect to that of adults. An accurate observer and distinguished patho- logist, Mons. Billard, who has had ample oppor- tunity of studying this disease, considers its pre- disposing causes to be, 1st, a natural state of de- bility of the new-born infant; 2d, a state of gene- ral congenital plethora ; 3d, a superabundance of venous blood in the tissues; 4th, a state of dry- ness of the skin before the exfoliation of the epi- dermis : and the direct causes, 1st, an obstacle to the course of the blood, resulting from the abun- dance of this fluid in the circulating system ; 2d, its regurgitation in the cellular tissue, to which it furnishes an inordinate supply of the materials of secretion ; and lastly, the action on the skin of external agents, which, without condensing, as has been said, the serous fluids, are capable of suspenumg the cutaneous transpiration, and thereby favour the accumulation of the serosity in the cellular tissue. [M. Valleix (Clinique des Maladies des En- fans Nouveau-nes, Paris, 1838) from a considera- tion of the difficulty of breathing, which constantly exists, even in slight cases, along with the feeble- ness and slowness of the circulation, and the san- guineous congestion which is the result, is led to believe, that the development of the disease is re- ferable to the disturbance in those two important functions, and to the stasis of the blood; hence, he has proposed for it the name of Asphyxie lente of the new-born ; and MM. Desormeaux and Paul Dubois (Diet, de Med. xxi. 161, Paris, 1840) be- lieve that this term will ultimately prevail, in the place of the one most in use, which merely desig- nates one of its symptoms and results.] Treatment. — Reasoning on the evidence which we have endeavoured to lay before the reader on the nature and causes of infantile oedema, the curative indications which it suggests are but few in number. The state of general venous con- gestion that prevails; the diminution of tempera- ture which accompanies this state; the dry atonic condition of the skin, and the state of debility of the little patient, constitute the chief points in the pathology of the disease to which the attention of the physician is to be directed. With a view to diminish the quantity of the blood, and thereby favour its circulation, leeches may be applied to the chest or cedematous parts; a practice which, although we have not seen it fairly tried, is said to have been remarkably successful in the hands of Paletta. A more safe, and perhaps equally successful method of treatment employed to accomplish the same end, consists in the use of repeated friction with warm flannel, the body in the intervals being well covered with the same material, which is not to be allowed to become cool. The vapour-bath has been recommended ; but it has not been found to answer the expectations of some physicians who had ample opportunities of giving it a fair trial. Mons. Baron has found friction and the application of warm flannel to the skin much more beneficial. The difficulty of breathing is sometimes greatly increased white the child is in the bath, and con- gestion and even sanguineous effusion have been known to take place in the lungs and brain soon after its administration. If, under the judicious use of the means we have recommended, the pulse improves and becomes steadily more strong, the temperature soon rises, and the physician has the satisfaction to perceive that a gentle moisture breaks out over the surface of the skin. The oedema soon after begins to diminish, and with it the induration which it had occasioned ; the motions of the child become more free, and the cry natural; the desire for food re- turns, and convalescence is complete, sometimes in a few days. Although we are not acquainted with any method of treatment so successful as that which we have recommended, it requires in many cases, either on account of their severity, the debility of the child, or the coexistence of other affections, much discrimination on the part of the physician, and a degree of care and patience not often to be found in those in whose hands it may be said the lives of these little sufferers are placed, to regulate INFANTICIDE. 677 its application, and obtain from it its beneficial effects. Acute affections of the lungs, stomach, and in- testines, are, as we have said, extremely frequent at the same period, and when severe, destroy, per- haps, a greater number of children affected with them than the disease which we have described, and for which no mode of treatment can then be said to offer any reasonable hope of accomplishing R. Carswell. INFANTICIDE.—Before the end of the seven- teenth century, medical men were not consulted in cases of infanticide. In the criminal code (Be- obachtungen und Abhandlungen von osterreichi- schen Aertzen, 3er. Band. Wien. 1823,) of the Emperor Charles V. it was merely directed that the breasts and parts of generation should be in- spected by an experienced and sensible woman, and the delivery being, as it was supposed, ascer- tained, the proof of the death of the child at birth was imposed on the mother. We are told also by Bohn (Dissert, binae de partu enecato, p. 336,) that a mother suspected of infanticide which could not be proved, was put to the rack to extort con- fession of her imputed guilt. In this country the statute of James I. was conceived in a similar spirit, for it concluded the mother to he guilty of the murder of her child, who could not prove, by at least one witness, that the child was actually born dead; a condition under certain circumstances obviously impossible, and thus rendering the statute unjust in its operation by confounding the unfortu- nate with the guilty. This act continued in force for nearly a century, but at length it became cus- tomary to require more direct proof of homicide; and by an act passed in the 43d of Geo. III. it was provided that trials for infanticide should be regu- lated by the same rules of evidence and presump- tion as were usual in other trials for murder ; and thus the subject was brought more distinctly within the pale of medical inquiry. Infanticide has been divided into foeticide, or the destruction of the fcetus whilst yet in the womb, commonly called criminal abortion ,- and infanti- cide strictly so called, or the destruction of the life of the child either newly born or in the course of parturition. The present article will treat of the latter division only; and the evidence respecting it naturally divides itself, 1st, into that which has reference to the child, and 2dly, into that which relates to the mother. The investigation of the following questions will comprise the most material points of medical evidence: 1. Was the child born living or dead 1 2. What was the cause of its death ? 3. Has the suspected mother been recently de- livered 1 4. Do the phenomena presented by the supposed mother and child confirm the suspected relation- ship? [It may be proper to make a few remarks as to the meaning of the term «born alive.' This is a question applicable not to infanticide only, but to other cases. According to the English law, where a man marries a woman, seised of an estate of inheritance, and has by her issue born alive, which was capable of inheriting her estate, in such case, be shall, on the death of his wife, hold the lands 3e» for his life as tenant by the courtesy of England. It has, consequently, been a point of moment for the husband to show, that the child was born alive; and the said authorities have, with singular infelicity, attempted to define what shall be re- garded as evidences of this condition. According to Blackstone, (Commetitaries, B. ii. 127,) "Some have had a notion, that it must be heard to cry, but that is a mistake. Crying, indeed, is the strongest evidence of its being born alive, but it is not the only evidence." According to Coke, (Institutes, 30, a.,) "if it be born alive it is suffi- cient, though it be not heard to cry, for peradven- ture it may be born dumb. It must be proved, that the issue was alive; for mortuus exitus non est exitus.- so as the crying is but a proof that the child was born alive, and so is motion, stirring, and the like." It need scarcely, by the way, be said, that the deaf and dumb cry at the moment of birth the same as other children. The natural cry is effected by them as well as by the infant that possesses all its senses. It is the acquired voice alone which they are incapable of attaining. Still, this blunder of Lord Coke does not materi- ally concern the present inquiry ; not so, however, the latitudinarian definition, contained in the lat- ter part of the sentence cited from him. In a case that was tried before the Court of Exchequer in England, about forty years ago, the jury agreed that a child was born alive, because, although, when immersed in a warm-bath immediately after death, it did not " cry or move, or show any symp- tom of life," yet, according to the testimony of two females,—the nurse and the cook,—there twice appeared a twitching and tremulous motion of the lips; and this was sufficient to make it fall under Lord Coke's definition. It is manifest, as else- where remarked, (Human Physiology, i. 371, Philad. 1844,) that granting such motion to have actually occurred, it was of itself totally insuffi- cient to establish the existence of vitality. On the application of appropriate stimuli, the muscles of a body may be thrown into contraction for hours after the cessation of respiration. Instead, therefore, of referring the irritability or contracti- lity to the existence of life at the time, it must be regarded simply as an evidence, that the parts had previously and recently formed portion of a living system. According to Mr. Taylor, the English law authorities will admit evidence of life in a child before the establishment of respiration. In the case of R. v. Brain, Judge Park properly said, that a child might be born alive, and not breathe for some time after birth. (Archbold, Crim. Plead. 367.) The same thing was almitted by Mr. Justice Coltman, in the case of R v. Sellis, tried on the Norfolk Spring Circuit, in 1837. In this instance, it was alleged, that the prisoner had murdered her child by cutting off its head. The judge told the jury, that if the child were alive at the time of the act, it was not necessary, in order to constitute murder, that it should have breathed. Respiration is regarded as one but only one evi- dence of life. In England, some decisions have been made as to the legal meaning of the term «boru alive,' in connection with infanticide. According to Dr. Guy, (Principles of Forensic Medicine, p 678 INFANTICIDE. 120, Lond. 1843,) it has been decided, in more than one case, that to constitute live birth, the child must be alive after the whole body has been brought into the world. (R. v. Poulton, 5 Car- rington and Payne's Reports, 329; R. v. Crutch- lrv, 7 C. and P. 814; R. v. Sellis, Ibid. 850; cited by Guy, loc. cit.;) and that it must have an independent circulation. (R. v. Enoch, 5 C. and j P., 539 ; Reg. v. Wright, 9 C. and P., 154.) It would appear, however, that it is not necessary, that the umbilical cord should be separated, for , the child may still be connected with the mother by the cord, and yet the killing of it will consti- tute murder. (R. v. Crutchley, 7 C. and P. 814; Reg. v. Reeves, 9 C. and P. 25, cited by Guy, p. 121. See also on this subject, M. A.Taylor, Ma- nual of Med. Jurisp. p. 472, Lond. 1844.)] Writers on infanticide, in proceeding to discuss the first question in the inquiry, have generally deemed it necessary to prefix a statement of the development of the fcetus at the different periods of utero-gestation, a knowledge of which is re- quisite in proving the viability of the child, that is, its capability of supporting extra-uterine or independent existence. Some difference of opin- ion has existed concerning the precise period from which the viability of the child should be dated; but it is generally agreed on among medico-legal writers, that no well-authenticated examples are recorded of children living which had been born before six months of utero-gestation. (Beck's Elem. of Med. Jurisprudence, Dunlop's ed., p. 119.) An exception to this opinion may be thought to have occurred in a case recorded by Dr. Rodman, (Edin. Med. and Surg. Journal, vol. ii. 445,) who describes his patient as having been delivered at the end of the 19th week of preg- nancy. The feebleness of the child would ap- pear to justify the correctness of Dr. Rodman's opinion, for when three weeks old, it measured but eleven inches in length, and weighed two pounds and a half avoirdupois, the clothes form- j ing eleven ounces of this weight. But a case has subsequently been published by Mr. Baker, which j renders it probable that Dr. Rodman was mistaken, for the child described by Mr. Baker (Transactions of the Med. and Phys. Society of Calcutta, vol. ii.), although born undoubtedly at the full period of utero-gestation, corresponded pretty closely with the one alluded to by Dr. Rodman. The absence of all allusion to the external characters of the child in the latter instance prevents any reliance being placed on it. If the membrana pupillaris had existed, it may be reasonably presumed that it would not have eluded Dr. Rodman's observa- vation, nor escaped remark. A description of the leading phenomena which the organization of the foetus presents from the fourth to the ninth month will include everything on the subject which can be interesting in relation to infanticide; and these phenomena relate to its length and weight, the proportional length of its parts, the state of the skin and its appendages; of the pupil of the eye ; of the internal viscera, par- ticularly of the abdomen; of the organs of gener- ation ; of the brain ; and lastly, the progress of ossification. The weight and absolute length of the body furnish but uncertain data, since they nry much in different foetuses of the same age. But Chaussier (Medecine Legate, &c. par Lecieux, &c. 1819, p. 17,) has pointed out an excellent criterion, founded on a very extensive examination of subjects, in the comparative length of its seve- ral parts at different periods. If in a well-pro- portioned adult a line be drawn from the top of the head to the heel, its centre corresponds with the upper edge of the pubis. But in the foetus this central point is situated much higher ; for in a mature child it corresponds with the umbilicus or a little above it; at the end of the eighth month it is about an inch higher; at the end of the seventh still nearer to the sternum; at the end of the sixth it falls just at the end of that bone. The average weight of the fcetus at four months is from five to seven ounces ; at five months, about a pound ; at six months, two pounds; at seven months, from three to four pounds; at eight months, from four to five pounds; at nine months the average weight in this country is about seven pounds (Phil. Trans, vol. lxxvi. p. 394; Hunter's Anatomy of the Gravid Uterus, p. 68), the most frequent range being from five to eight pounds. Lecieux and Bernt have remarked that the length of children at the full period is less liable to varia- tion than the weight. The following is a tran- script of the table of the former. Months. Inches. 4.................... 5 to 6 5.................... 9$ 6....................12 7....................14 8....................16 9....................18 And he agrees with Baudelocque in stating the extremes in mature children to be from sixteen to twenty-two or twenty-three inches. (Mtdecine Legale ou Considerations sur l'lnfanticide, p. 11.) At the end of the fourth month the skin is rosy and moderately dense. The pupillary mem- brane is very visible ; the meconium a little co- loured, and occupying the commencement of the sinall intestines. The brain exhibits the interlob- ular furrow. There is a commencing ossification of the vertebrae of the sacrum. The kidneys are very voluminous, consisting of from fifteen to eighteen lobes, the suprarenal capsules being as large as the kidneys. At the end of the fifth month, the scalp is covered with short silvery thinly scattered hair; the skin is of a deep red colour, but without seba- ceous covering; the adipose membrane is but lit- tle developed; the nails are scarcely perceptible. There is commencing ossification of the first bone of the sternum, of the pubis and os calcis. The volume of the lungs is small, the heart is large, the ventricles little distinguishable from the auri- cles ; the liver very large and near the navel, con- sisting of two equal lobes. The gall-bladder con- tains a little, almost colourless, serous fluid; the spleen is little developed and close to the stomach; the meconium is in small quantity, and only oc- cupies the caecum and a small portion of the colon. In the mate fcetus the testicles are situated be- neath the hidneys, near the lumbar vertebrae. In the female the ovaries are small, soft, elongated, very distinguishable from, and in a similar situa- tion to, the testicles in the male. The brain on the surface is smooth, but several deep furrows INFANTICIDE. 679 and convolutions are now visible on the inner aspect of the hemispheres where they are applied to the falx cerebri. At the end of the sixth month, all the external parts are very distinct. The skin is very fine, of a deep red or even purple colour, particularly in the palms of the hands and soles of the feet, face, lips, ears, and breast. The stomach is filled with mucus; a part of the large intestines with meco- nium. The colon begins to exhibit its sacculated character. The testicles are still in the abdomen under the peritoneum. The bladder, hard, pyri- form, and above the pelvis, has but a small cavity. About this period two points of ossification are formed in the second cervical vertebra; near the seventh month the superior point, which answers to the odontoid process, is larger than the inferior, which relates to the body of the bone. Accord- ing to Tiedemann, the posterior lobes of the cere- brum now cover the corpora quadrigemina, and almost the whole cerebellum. The three cornua of the ventricles are quite distinct. The choroid plexus is very voluminous. The laminae of the septum lucidum are joined so as to form the fifth ventricle. The corpus callosum extends further backward, but does not yet cover the thalami and third ventricle. At the end of the seventh month the skin is dense and fibrous, and is covered with the vernix caseosa cutis, unequally thick in different parts of the body. The pupillary membrane has disap- peared. The hair is longer and of deeper hue; the nails are firmer, but do not extend to the ends of the fingers. The bile is yellowish and bitter. The meconium occupies a considerable part of the large intestines. The valvulae conniventes begin to appear. The testicles and ovaries are nearer the pelvis. The posterior lobes of the cerebrum now cover and extend beyond the cerebellum, and several furrows and convolutions are observable on the surface. The corpus callosum covers the thalami, and consists of transverse fibres passing from one hemisphere to the other. The corpora quadrigemina are divided by a transverse line or furrow rendering them complete and distinct, the two superior, or nates, being somewhat longer than the two inferior, or testes, and their parietes so thick that the iter a tertio ad quartum ventri- culum may be considered perfect. At the eighth month the skin becomes covered with very fine short hairs, the skin itself is denser and whiter, and the nails are firmer and more elongated. The sebaceous covering is more gene- ral. Oftentimes the breasts are projecting, and a milky fluid may be expressed from them. In the male the testicles are generally engaged in the abdominal ring. About this period the transverse processes have begun to ossify in the first lumbar vertebra. The structure and configuration of the interior parts of the brain, already completely formed, have only to be augmented in volume, the surface to be farther developed. The two hemispheres of the cerebrum extend backward considerably beyond the cerebellum. The hemi- spheres on each side are traversed with furrows, into which the folds of the pia mater enter, but these furrows, or the convolutions which they pro- duce, arc nowhere so marked as on the anterior and middle lobes. At nine months ossification is more complete. The descending ramus of the os pubis and the ascending ramus of the ischium are consolidated. Ossification has commenced in the first cervical vertebra, and also in the first bone of the coccyx. The body of the fourth lumbar vertebra, which is the most voluminous, is three lines in depth and six in breadth. The lateral portions of the six superior dorsal vertebrae begin to unite so as to form a ring posteriorly to the bodies of these bones. The bones of the cranium, although movable, are in contact at their margins. Gene- rally the testicles have passed the abdominal ring, or even descended into the scrotum. The nails are thicker and firmer, and are prolonged to the extremities of the fingers. Capuron states that the grey matter is now visible in the brain, but Tiedemann asserts that at no period is it possible to distinguish between the cortical and medullary substance in the fcetus. We shall not be understood to pretend that the preceding details will be found precisely to indi- cate the age of the fcetus. Much variety is found in different children at the same age ; but an at- tention to the criteria now laid down, particularly as they relate to the progress of ossification ; to the development of the brain, and relation of the umbilicus to the centre of the body, for which we are indebted to Beclard, Tiedemann, and Chaus- sier, will enable the inquirer to form a tolerable approximation to the truth. [In another work, (Human Physiology, 5th edit. ii. 470, Philad. 1844,) the writer has drawn attention to the wide discrepancy that exists amongst observers in regard to length, weight, &c, at different periods of foetal existence. Nor are they more agreed in regard to the test pro- posed by Chaussier. Of 500 children examined by M. Moreau, at the Maternite, in Paris, the umbilicus corresponded to the centre of the body in four only. In the majority of cases, it was eight or nine lines below the centre ; and he found that in some children, born about the sixth or eighth month, the cord was inserted at the middle point of the length. (La Lancette Francaise, 1837.) Among many cases, too, of mature chil- dren, which Mr. Alfred L. Taylor had an oppor- tunity of examining, the umbilicus was found to be generally from a quarter to half an inch below the centre of the body. (Guy's Hospital Re- ports, April, 1842; and Manual of Medical Jurisprudence, p. 489, Lond. 1844.)] The advantage arising from the investigation of the anatomy of the foetus is, that it enables the inquirer to decide on the maturity or immaturity of the child, and to set at rest its capability of being born alive. If the child were mature, the greater is the probability of its having been born living; if immature, the likelihood of death from natural causes is considerable. And in either case it is creditable to the investigator, and indeed necessary in drawing up a medico-legal report on a child found dead, to indicate with some precision the age of the subject under examination. I. At the time when concealment of birth and evidence of the life of the child were allowed to form conclusive proofs of the commission cf in fanticide, the inquiry, whether the child was bom living or dead, was of paramount importance. 686 INFANTICIDE and it is still one of considerable interest to the medical jurist and lawyer. The proof of the child having been born alive forms, in trials for infanti- cide, presumptive evidence in favour of the charge; whilst evidence of its having been still-born will confine the investigation to the proofs of death from criminal violence during parturition, — a species of child-murder commonly requiring the aid of an accomplice, and hence an infrequent form of infanticide. The proofs of the survival of the child after delivery must be drawn from the phenomena of respiration and circulation, as it is chiefly by the performance of the former, and the changes which take place with respect to the latter, that the com- mencement and continuance of extra-uterine life are indicated. These phenomena relate princi- pally to the colour of the lungs, their consistence, specific and absolute weight, and their volume ,- to the contraction of the ductus arteriosus Botalli, and its diameter in relation to that of the pulmo- nary artery and its two great branches. 1. Colour. — The colour of the fcetal lung is dark red, sometimes inclining to the brownish red of the liver, or the blueish red of the thymus ; but in those parts of the lung in which respiration has had an influence, it is pale red or scarlet, unless they are gorged with blood, in which case it may be brownish or blueish red. From the experiments of Bernt (Experimentorum Docim. Pulmon. Hy- drost. illustrantium Centuria I. curante Jos. Bernt, M. D., &c. Viennae, 1823,) it results that artificial respiration in a dead child, if it changes the colour at all, causes a pale or greyish red tint. In chil- dren who have breathed imperfectly, or only for a short time, the lungs on the anterior surface are of a pale red, on the posterior surface dark red, whilst in different parts of the lungs patches of scarlet red are visible. In children who have breathed perfectly and lived a longer time, the lungs are pale red with numerous patches and stripes of cinna- bar or scarlet red; posteriorly they present a dark red colour, owing to the subsidence of the blood. 2. Consistence.—The lungs, in the fcetal state compact, become from respiration looser and ex- panded. They are vesicular on their surface, and air-bubbles or froth may be squeezed out of them. These are circumstances to be determined by the touch and sight, and result from their mechanical distension by the air. Three sources have been enumerated, besides natural breathing, from which air found in the lungs may be derived, namely, artificial inflation, putrefaction, and emphysema. The two latter produce vesicles which are super- ficial, large, and irregular, and which may be pressed out, so that the fcetal lung will sink, which can never happen when the lungs have been dis- tended by natural breathing or insufflation. A general presumption only can be drawn from the consistence of the lungs. If they are soft and have a regularly vesicular appearance, respiration either natural or artificial must have taken place, and a reference to the other tests of independent life will show which of the two has happened. [According to Dr. Guy (Op. cit., p. 123,) the smallest quantity of air, received into the lungs by respiration or insufflation, serves to develop some of the air-cehs on their surface, and these developed •ir-cells form the best proof of the admission of air in one of the two modes mentioned. The air- cells, thus developed, present, he remarks, an ap- pearance not to be confounded with any other. If the lungs are fresh and filled with blood, the posi- tion of these developed air-cells is marked by bril- liant vermilion spots; if the lungs contain less blood, the spots are of a lighter colour; and if they be examined some days after the birth of the child, they will be found to have lost their bright vermil- ion hue, and to have assumed a light rose colour. In the lungs of children who have survived their birth some days, the air-cells have very nearly the colour of those of the healthy adult lung.] 3. Specific Gravity.—It was known to Galen that the fcetal lung sank in water, but that after respiration it floated, and these facts form the foundation of the hydrostatic test. Swammerdam affirmed that the lungs would float if only one inspiration had taken place, in which assertion he has been followed by Halter, Daniel, and Dr. W. Hunter. But subsequent experience has shown that the specific gravity of the lungs before and after birth does not observe an uniform ratio. It has been ascertained, first, that newly born children may live some time without respiration ; secondly, that after respiration has been carried on for some time, the lungs are not uniformly dilated, and occasion- ally to so trifling an extent only, that they sink in water, or sometimes that the lungs are unequally dilated or diseased ; and thirdly, that in some still- born children the specific gravity is less than that of water, which may arise from breathing before complete birth, from artificial inflation, or extrica- tion of air through other causes ; and objections to the conclusiveness of the hydrostatic test have been alleged for these several reasons. a. It is a fact familiarly known to all obstetrical practitioners, that children occasionally do not breathe till they have been born for some time; but there are no means of determining whether a child found dead could have been animated had the proper measures been resorted to. And the proof that a child so circumstanced had been mur- dered must rest on the evidence of existing mortal injuries, which it was morally impossible could have been the consequence of accident, but must have resulted from criminal violence. In short the evidence of murder in such a case must be similar to the proofs of infanticide during parturition. b. But the lungs may sink, although the child have breathed for some time, owing to their im- perfect dilatation. Craanen (Commentatio de In- fantum nuper natorum Umbilico et Puhnonibus, Auctore G. F. Daniel, Hallae, p. 100,) described it as a frequent occurrence, and had the merit of pointing out how the fallacy might be obviated. He recommended that each lobe of the lungs be cut into small portions and thrown into water. If all sank, he inferred that the child died in utero ; but if a few fragments floated, he concluded that the child had survived delivery. The imperfect dilatation of the lungs after respiration has been usually found in immature children, but cases have been related by Schenkius, Bernt, and others, of children born at the full time, and who had lived one or more days, whose lungs sank in water; and we recollect an example of the same kind which occurred to the late Dr. Wm. Cullen of Edin- INFANTICIDE. 681 burgh ; [and a similar case is related by Mr. A. Taylor, (Guy's Hospital Reports, No. V.)] The proceeding recommended by Craanen is, no doubt, applicable to all such cases; and the conditions of the ductus arteriosus Botalli and pulmonary arte- ries, to be hereafter noticed, would, in conjunction with other proofs, remove all doubts concerning the conclusiveness of the hydrostatic test in similar instances. c. A diseased condition of the lungs may also prevent their floating after respiration, but it is extremely rare to find the fcetal lungs in such a state of disorganization as to admit so little air that the whole lung will sink in water. Such a pathological state mmst be quite conspicuous, and the proceeding recommended by Craanen would easily obviate the fallacy, for if life had been main- tained at all, some portion would float. d. Hoffmann, (Tom.vi.p. 213,) Bohn, (Daniel, op. cit. 108,) and Hutchinson, (Essay on Infan- ticide, 1820, p. 52,) have related examples of lungs which have sunk from congestion of blood in consequence of suffocation. The best informed pathologists, Meckel for instance, have doubted the possibility of such an occurrence; but the fact has been attested by the three authors just named. This is an objection to the hydrostatic test easily corrected, for after gently pressing out the blood, the lung will float. Thus, although the lungs may sink in a child which has outlived birth, the circumstances under which this may happen are known, and can be readily detected and allowed for. It has been further observed that the lungs in children notoriously still-born will sometimes float, and the circumstance has been adduced as a ground of objection to the hydrostatic test. Such float- ing has been ascertained to depend, first on breath- ing before delivery, the child nevertheless dying before complete expulsion; and secondly, the lungs may be rendered specifically lighter than water by artificial inflation, by putrefaction, or by a species of emphysema, first noticed by Schmidt, (Neue Versuche und Erfahrungen, &c. S. W. Wien, 1806,) and subsequently more distinctly characterized by Chaussier. (Lecieux, op. cit.) e. The possibility of uterine respiration was denied by all writers down to the time of Bohn. (Daniel, op. cit.) He first maintained, in 1700, that in difficult labours a child may draw in air enough to suffice for the distension and floating of the lungs, and yet die before delivery. Brede- noll has related a remarkable example in Siebold's Journal fur Geburtshulfe, Band I. It was a case of twins; the first child had been delivered by the forceps, the membranes ruptured, and the hand introduced to turn the second, whom he heard distinctly to cry for at least a dozen times. Bernt has mentioned four somewhat analogous cases. In a child delivered by turning and de- struction of the brain, every fragment of the lungs floated. (Edin. Med. and Surg. Journ. xxvi. 371.) Of the other three cases, two foetuses were ex- tracted after the mother's death, the vagina in the one and the neck of the womb in the other having been ruptured ; and the third was extracted by the forceps on account of tedious labour. In these the lungs sank when entire, but many frag- ments floated, and in all the four examples every other test coincided with the hydrostatic to justify Vol. II. —86 the inference that the children had respired. Until recently the evidence in favour of uterine respira- tion had been altogether supplied by German au- thorities; lately, however, Professor Marc has recorded an unequivocal example of the kind communicated to him by M. Henry, which has removed the scepticism formerly entertained on the subject by the learned professor, and others also we presume. A woman, having a deformed pelvis, and pregnant for the third time, was in labour on the 10th of October, 1827. M. Jobert was in attendance, and called in M. Henry to his assistance. Having ascertained that the deformity occasioned an obstacle to delivery, M. Henry ob- serves,—» M. Jobert and I thought that it might be necessary to turn the child, but as the head did not appear to be very voluminous, we hoped to be able to disengage it by means of the forceps. That instrument was applied ; and as soon as M. Jobert commenced the attempts at extraction, the foetus uttered repeated cries during a dozen sec- onds, so distinct as to be heard by all the assist- ants. But as the head remained impacted in the pelvis, notwithstanding the efforts made with the forceps, we were obliged to desist from this at- tempt. " Whilst we were discussing the necessity of turning the child, these cries were renewed as distinctly as on the former occasion, and in such a manner as could only take place in consequence of repeated inspirations. Finally, when intro- ducing my hand to seize the feet, the moment it passed over the left shoulder the fcetus for the third time uttered cries, less prolonged than the preceding, yet sufficiently loud to be heard by all present. " The delivery was completed with much dif- ficulty, and the child did not breathe after its ex- pulsion ; but as the pulsations of the heart were pretty strong, we tried various means to resusci- tate it, among others insufflation of the lungs Our attempts were fruitless, for at the end of some minutes the circulation had ceased. I regret that I cannot describe the state of the lungs, but as insufflation was practised, an examination of them could not have afforded precise and unex- ceptionable information." (Diet, de Medecine, xii. 154.) But the case now to be related proves incon- testabiy that these cries may be uttered by a child in utero, and subsequently born alive without as- sistance. It is described by Dr. A. F. Holmes, Lecturer .on Chemistry and Materia Medica, Mac- gill College, Montreal. (Edin. Med. and Surg. Journal, No. cii. 215.) « On the 29th of Novem- ber, 1828, I was called to a lady in labour of her sixth child. The fontanelle presented, but the pelvis being capacious, and her labours generally easy, no attempt was made to change the position. The head continuing to descend, the mouth lay on the pubis, and the examining finger could easily be introduced into it. The occiput did not yet occupy fully the cavity of the sacrum. At this time I heard sounds like the cries of a child whose mouth was muffled by some covering, but not being very distinct, and not being at all pro pared for them, I thought, when they ceased, *hal they must have been produced by flatus in the intestines of the mother. In the course of a short 6S2 INFANTICIDE. time, however, the cries were repeated, and with the greatest distinctness, so as not to admit of a doubt that they proceeded from the child. The mother, much alarmed, inquired the cause of these noises, and required to be assured that they were not indicative of any danger. The pains being brisk, the head was soon forced down and ex- pelled. The child was a female, and is still (Au- gust, 1829,) alive and thriving." [See, also, an undoubted case, on the authority of Dr. Collins, of Dublin, in his Practical Treatise on Mid- wifery, &c. Lond. 1835.] The evidence for vaginal respiration is equally conclusive. Formerly Professor Marc (Manuel d'Autopsie Cadaverique, traduit par C. C. H. Marc) endeavoured to show that, from the com- pression of the foetal thorax in the passages, it was impossible; but his reasoning must yield to the unquestionable testimony of Schmidt, Osian- der, and Capuron, each of whom has witnessed it. In relation to infanticide it has been usual to dis- regard the vagitus vaginalis, as occurring only under circumstances which could not lead to doubt in the decision ; either because it was only heard after the expulsion of the head, when there could be comparatively but little difficulty on the part of the mother, and as little danger to the child in j the accomplishment of complete expulsion ; or that it occurred in presentations of the face and feet, in which delivery could not be completed without great difficulty or foreign manual assistance, and was therefore not likely to occur in medico-legal practice. The experience of practitioners will not com- pletely justify this view. It is undoubtedly for the most part true, that when the head is expelled, the complete birth of the child is attended neither with difficulty nor danger ; but the case related by Dr. Hosack (Beck's Med. Jurisprudence, p. 164) r roves that a child may perish after the ex- pulsion of the head and before complete delivery, and that in the interval it may breathe and cry. The editors of the London Medical and Physical Journal (Vol. lxii. p. 423) have observed a similar occurrence; and every practitioner of experience must have met with presentations of the face and feet, in which delivery has been completed by the unassisted expulsive efforts of the uterus. (Heath's Baudelocque, ii. 224.) Uterine and vaginal respiration appear therefore to constitute a possible objection to the determina- tion of the life of the child after birth, which may sometimes be insuperable. The correct^objection to oppose to it, is the rarity of such a conjunction of circumstances as is indispensable for the occur- rence ; and the full expansion of the lungs, if pre- sent, would render such a plea more than doubt- ful. The lungs may float from insufflation or arti- ficial respiration, and Bohn (Beobachtungen und Abhandlungen von Osterrischen Aerzten, u. s w. iii. Band, S. 45) and Camper (Daniel, op. cit. p. 163) have quoted instances in which it had been successfully practised by blowing air into the lungs with the mouth. Schmidt (Neue Versuche, u. s. w.) has investigated the subject of artificial respiration, and established the facility with which :t may be practised. According to his experi- ments ciepitation is always present, and the dis- tension of the thorax is permanent, but the ratio of the weight of the lungs to the rest of the body remains as in dead-born children. The results of the static test, the colour of the lungs, and the unaltered conditions of the ductus arteriosus Bo- talli and pulmonary arteries would distinguish insufflation of the lungs in a dead child from re- spiration, either natural or established artificially in a living one. It is impossible to conceive, however, that a woman charged with infanticide, who had at- tempted to resuscitate her child by insufflation, could fail to produce satisfactory proofs of her innocence; for it may be reasonably presumed that a child subjected by a mother to such an at- tempt would not exhibit any signs of criminal neglect or wilful ill-treatment5, whilst the attempt to inflate the lungs would form a presumption in favour of the accused. Morgagni (De sedibus et morborum causis, Epist. xix. art. 47) and Dr. W. Hunter have suggested that insufflation may be practised by another person from a malicious mo- tive towards a mother; but were such an appa- rently incredible occurrence to happen, the results of the other indications of life would demonstrate by what means the lungs had been expanded. " Medical jurists," says M. Devergie, (Diet, de Med. et Chir. pratique, vi. p. 345, [and Med. Leg.,]) "have endeavoured to represent the inex- pediency of drawing positive conclusions from the evidence under consideration, by alleging that a woman may have inflated the lungs of her own child for the purpose of restoring it to life; or that another person may have done so from a criminal motive towards the mother. Such observations are just, but a multitude of cases occur where the circumstances in which the body of the child and the author of the crime are found, totally exclude them from consideration. For example, a child has been thrown alive upon the ice of the Seine, undoubtedly living at the time, for it presents all the signs of injury which can result from such a fall; another is found in the water, inclosed in a bag firmly sewed up; a third is thrown into the street, the mouth and pharynx filled with linen, so as to produce suffocation ; a fourth floats on a river inclosed in a paper box, and so enveloped in linen as to prevent the access of air; a fifth has been thrown into a privy ; a sixth dismembered and buried in an unfrequented situation. Cer- tainly none of these proceedings could have been the act of a mother who had practised insufflation in order to restore her child to life, nor could it be attributed to a person, who, having wickedly simu- lated a crime, would have an obvious motive in proclaiming its apparent existence." [M. Devergie (Med. Legale, 2de edit. art. In- fanticide, Paris, 1840) affirms that in many cases he could determine, whether the distension of the lungs with air had been the effect of respi- ration or of insufflation. In the case of air in- troduced by respiration, he states, there is a minute injection of capillary vessels on the surface of the air-cells, which injection does not take place in the case of insufflation. It is properly remarked, however, by Dr. Guy, (Op. cit., p. 125), that although this distinction may be well founded, it deals with parts so extremely minute, and accord- ing to M. Devergie's statement is to be relied on INFANTICIDE. 683 only in many, but not in all cases, that it may be fairly set down as unfit for the use of those who have not taken the pains to examine the lungs carefully and minutely for themselves; and he adds, that there is one case in which the distinction laid down by M. Devergie would entirely fail; that is, where lungs that have respired contain but a very small quantity of blood ; in such case, the capillary vessels would, in all probability, present no strong signs of injection. It has been affirmed, too, of late years, (Mr. Alfred Taylor, Lond. Med. and Phys. Journ., Nov., 1832, and Jan. and May, 1833; and Mr. Jennings, Transactions of Provinc. Med. and Surg. Association, for 1833,) that if air be intro- duced into the lungs by insufflation, it may be always forced out by pressure, so that the lungs will sink; whilst no pressure will force the air from lungs that have respired. It would seem, however, that the test does not distinguish imper- fect respiration from imperfect insufflation ; and on the other hand, the experiments of Dr. Guy (Op. cit., p. 138,) would seem to have proved that lungs completely distended by insufflation, cannot be made to sink by a degree of pressure short of that which will destroy the texture of the lung; and that lungs so distended with air differ from those which have breathed completely only by requiring somewhat more pressure to make the latter sink ; and he infers from his experi- ments, that where portions of lungs that have been inflated are submitted to the same amount of pressure with portions of lungs that have respired, the only difference observable is one of degree, the inflated lung, like that of the lung which has breathed, not sinking until its texture is destroyed, but a less amount of destruction being necessary in the former than in the latter.] An objection to the hydrostatic test has been drawn from the putrefaction of the lungs, and the consequent floating from the air thus disengaged. Although this is an objection of very little practical importance, it has occasioned much controversy. Heister, (Bernt, in Abhandlungen und Beoba- chlungen, S. 56,) in 1722, observed the lungs of a child which had died in the womb, to float both whole and in pieces, and the known circum- stances of the case proved that insufflation could not have been practised. Halter (Bernt, Ab- handlungen und Beobachlungen, S. 56) instituted experiments on the subject. He allowed the lungs of a dead-born child to become putrid in water, and saw them float after seven days in the same water. The colour was changed from dark to light red, and they were covered with air-bub- bles. A dark-red compact-feeling lung out of another body, already powerfully offensive, sank both entire and in pieces. He concluded, there- fore, that considerable putrefaction was necessary to cause the floating of the lungs. Camper had previously made the same remark, and had found that, when the whole body was so far advanced in putrefaction that the joints separated with the slightest touch, the lungs had only begun to decay, and would not float in water. Jaeger, from experiments and observations on the difference between sound and putrid lungs, drew the follow- ing conclusions: a lung which floats from putre- faction is distinguished from one which does so from breathing, by the situation of the former against the spine, by its dark red colour, and by the air being found under the outer membrane in the form of bubbles, (See Hunter, Med. Observa- tions and Inquiries, vol. vi. p. 284,) and by the easy escape of the air after cutting into the lungs and the subsequent sinking of them. The air developed by putrefaction he found to escape with much facility by means of incisions and gentle pressure; not so in those which floated from respi- ration. Mayer (Schlegel's Collectio Opusculo- rum, vol. i.) also engaged in an extended series of experiments on the putrefaction of the lungs. He found that on placing the lungs of still-born chil- dren in water, in the course of two or three days their colour changed, and they increased in vo- lume. By the eighth day at latest they floated, both whole and cut into pieces, in the water in which they became putrid, but, transferred to clean water, although they still floated, yet on the slightest compression they sank. The rays of the sun accelerated the putrefaction, but a current of air retarded it, so that they did not float until the tenth or eleventh day. After having once floated, they continued to do so, emitting daily a more offensive odour and acquiring an increased volume, until the twenty-first or at latest the thirty-fifth day. After that period they gradually sank down, without a single exception, to the bottom of the vessel, nor did they afterwards in the least float, although kept for seven weeks or even longer. Beck (Medical Jurisprudence, p. 157) and Orfila have confirmed these results of Mayer, to which M. Devergie has added the following interesting practical correction. Referring to the above expe- riments, M. Devergie observes, (Diet, de Med. et Chir. prat. vi. p. 342, [and Med. Leg.)] "Al- though the above experiments appear incontest- able, an accidental circumstance may completely change their results, so true is it that practical deductions drawn from experiments are frequently liable to error. In the number of the Annates d'Hygiene et de Medecine Legale for Oct. 1830, I published two cases of infanticide submitted to my examination, in which putrefaction of the lungs with development of gas was evident. The children had been thrown into the Seine, remained in the water seven or eight days, and subsequently exposed to the air from twenty-four to thirty-six hours before being opened. "It is ascertained that, whenever a person drowned is taken out of the water after having been submersed for ten or fifteen days, if the tem- perature of the atmosphere ranges between 15° and 25°, a considerable development of gas takes place in the body immediately on its exposure to the air. In consequence of this disengagement of aeriform fluid, which takes place not only in the subcutaneous tissue, but even in the internal organs most protected from the agency of the at- mosphere, the fluids of the body are conveyed to the surface, bullae are formed, sanies exudes from the cutaneous pores in general, and escapes adsc by the natural openings. In a great numb'ji of bodies the development of putrid gas is so ton- siderable as to effect an alteration in the pjsture of the limbs, and even to change the ge/,i./al po- sition of the body. Thus, it has been fUmd ne- cessary to secure the bodies, publicly exposed a* ?B4 INFANTICIDE. the Morgue, to the tables on which they are placed. Before this precaution was adopted, the bodies occasionally fell to the ground ; and stran- gers frequently hastened to inform the porter that an individual placed there was not dead, for they had seen him move. " The phenomena observed in the body of an adult found drowned, develop themselves with equal or greater rapidity, under the same circum- stances, in the fcetus. Now it is very rare that a medico-legal examination of a body takes place, before the procureur de roi (in England the coro- ner) has been informed of it; hence at least twenty-four hours generally elapse, during which period the body is undergoing the changes indi- cated above, and the lungs become as emphyse- matous as possible." We have said enough, however, to show that air developed in the lungs by putrefaction must be an extremely rare event, that it is easily recog- nised, and any fallacy arising from it readily avoided. Alberti (Daniel, op. cit. p. 120) in 1728 threw out a hint that the lungs sometimes contained air which was derived neither from putrefaction nor respiration. In 1806, Schmidt (Neue Versuche, u. s. w.) confirmed the observation, remarking that bubbles of air appear in the lungs which do not betray the least trace of putrefaction, and that they are thereby rendered capable of floating. The same phenomena occurred to the observation of Chaussier, (Lecieux, p. 56,) who suggested the following method of obviating the fallacy : " In these instances," says he, " the aeriform fluid is contained in the cellular tissue of the lungs, whence it may be expelled by pressure, after which the lungs thrown into water immediately sink. This docs not happen if the air was con- tained in the minute air-cells." The preceding observations include all the ob- jections alleged against the conclusiveness of the hydrostatic lest as a proof of extra-uterine life. If we except the rare and barely possible occur- rence of uterine or vaginal respiration, it must be evident to every candid mind that these objec- tions possess neither conclusiveness nor force; and that the circumstances on which they depend can be so easily and fully appreciated as to avoid any error which could lead to the crimination of the innocent. Of the considerations to be opposed to the vagitus uterinus we have already spoken, and shall again advert to them before the conclusion of this article. 4. The difference between the weight of the lungs before and after natural respiration.— This constitutes the static test first proposed by Ploucquet* in 1777. Experience, however, soon showed that this test was limited in its practical application, since, in some children who had lived several days, the weight of the lungs proved to be less than that frequently observed in still-born children. [The recent experiments of Dr. Guy (Lond. Lancet, Oct. 1, 1842, and op. cit.) have shown in a signal manner the limited application of the Rbsolute weight of t:~ ungs as a test; for, of 34 rases, there was not a single one in which it could * Ahuandiung iiuer gewaltsame Yodesarten, L. 153— iSG. have been pronounced, by means of this test alone, that respiration had or had not taken place ; whilst in two instances the great weight of the lungs would have led to the inference that respiration had been effected, although the children were still- born.] It was, therefore, suggested to substitute as a criterion, the relative weight of the lungs, before and after natural respiration, to the whole body. But the experiments and observations of Chaus- sier, Schmidt, and Bernt, have shown the inutility • of this modification of the static test, by pointing out that in many still-born children the ratio was a lower one than the average for children who have breathed, and vice versa". Schmidt, seeing therefore that this method was not an improve- ment, proposed to return to the original mode of judging by the absolute weight of the lungs, and to confine the application of the static test in this form to those cases in which the weight is such as is never attained by the natural and healthy fcetal lung. In twenty-four still-born children examined by Bernt,-j- the greatest weight of the healthy lungs was 993 grains, and he states the medium at about 550 grains. The form of the static test recommended by Schmidt is very limited in its application for the lungs of children who have outlived delivery ; not more than one in six or seven equal their former weight. When the foetal lungs, being naturally formed and of healthy structure, exceed 1000 grains, such weight may be considered as constituting decisive proof that the floating of the lungs and their loose and ex- panded appearance do not result from insufflation practised on a dead child, but must be a conse- quence of the continuance of respiration and of the circulation of blood through them, and there- fore of life ; and even if the weight exceed in any considerable degree 550 grains, the same inference is a reasonable presumption. 5. Size of the Lungs.—As respects the volume or circumference of the lungs, it is observed by Bernt (Handbuch, 266) that naturally formed and healthy foetal lungs which have not respired, oc- cupy the posterior part of the thorax, merely touching the pericardium with their anterior bor- ders. The posterior half only of the arch of the diaphragm is covered with them : the edges are sharp, the margins of the right, middle, and left upper lobes forming small pointed, tongue-shaped elongations. If, however,. the child have lived a very short time after birth, and breathed only im- perfectly, the lungs are found to occupy the late- ral parts of the thorax also ; their anterior borders and the tongue-shaped elongations of the right, middle, and left upper lobes are become round either partially or altogether. After full and com- plete respiration the lungs entirely fill the lateral cavities of the thorax ; their anterior borders cover the sides of the pericardium, and their concave surface the whole arch of the diaphragm ; their borders are everywhere rounded, and the tongue- shaped prolongations of the right, middle, and left upper lobes are short and obtuse. 6. State of the Ductus Arteriosus.—Passing t Experimentorum Docimasiam, &c. Edinburgh Medi- cal and Surgical Journal, p. xxvi. p. 375. Handbuch det perichtlich. Arzneikunde, u. s. w. von J. Bernt. Wien. 1828,8.256. INFANTICIDE, 685 over the changes which take place in the foramen ovale, the ductus venosus, and umbilical vessels, changes which take place at too late a period after birth to supply satisfactory evidence in trials for infanticide, we come to the consideration of the comparative state of the ductus arteriosus Botalli, and the branches of the pulmonary artery before and after respiration. Previous to the investiga- tion of Bernt no minute observations had been made on the changes which these vessels undergo soon after delivery. It might have been antici- pated that the occlusion of the ductus arteriosus must be rapid, since its perviousness would form an impediment to the perfecting of the child's new mode of existence; but it had not occurred to medical jurists to seek for any indication of extra- uterine life from this source. In the foetus the ductus arteriosus proceeds from that part of the trunk of the pulmonary artery where it divides into its two great branches, and running parallel with the arch of the aorta and in contact with it, joins it at a very acute angle. It is about half an inch long, cylindrical, equal in diameter to the trunk of the pulmonary artery, and almost three times the diameter of its two branches, each of which branches is about the thickness of a crow-quill. (Experimentorum Do- cimasiam, &c. Proleg. p. xiv. Handbuch, 277.) If the child, says Bernt, have breathed for a few moments only, the aperture by which the duct enters the aorta becomes oval; if a little longer, it loses its cylindrical form, and assumes the shape of a cone, the apex being at the aortal end, but sometimes, though much more rarely, at the opposite extremity ; the diameter is diminished so as to be smaller than that of the trunk, but about equal to that of the two branches of the pulmonary artery, the latter, owing to the esta- blishment of the pulmonary circulation, having already increased in diameter. If the child have lived for some time, and breathed perfectly, the ductus arteriosus Botalli resumes the complete cylindrical form, but has be- come shorter, and is not thicker than a crow-quill, whilst the two pulmonary branches are thicker than a goose-quill. As these comparisons are de- termined by the relative size of objects situated close to each other, an observer would not be lia- ble to fall into error, as he is otherwise apt to do in estimating relative magnitude. (Edinburgh Medical and Surgical Journal, vol. xxvi. p. 378.) The observations and experiments on which the preceding inferences relative to the blood-vessels are founded, were made previous to the year 1823 ; and in the Manual of Medical Jurisprudence pub- lished in 1828, Professor Bernt adheres to the same conclusions,, and informs us that they have been confirmed by the observations of Kilian (Abhandlung fiber den Kreislauf des Blutes im Kinde welches noch nicht geathmet hat, Karls- ruhe, 1826), a writer of authority on the fcetal anatomy. As we have attentively examined these observations and experiments, which are seventy- five in number, and not been able to concur with Bernt in his inferences in every particular, we shall briefly state those which appear to be con- clusive, and of practical application in medico- legal inquiries. In every instance of respiration whether natu- 3 H rally accomplished or the effect of resuscitation from insufflation, a general or partial diminution of the diameter of the ductus arteriosus was found. But a diminution in general diameter (so that the natural relative diameter between the ductus arte- riosus and the trunk and branches of the pulmo- nary artery did not exist) was sometimes found in children notoriously still-born, and who had not breathed artificially; hence a smaller relative di- ameter of the duct cannot be relied on as a proof of extra-uterine life. But the contraction of the extremity (either aortal or otherwise) of the duct, though sometimes absent in children who had re- spired, was never present unless respiration had been carried on; so that, if the ductus arteriosus represent a cone in figure, it may be regarded as a decisive indication of the continuance of the pul- monary circulation, and hence of breathing. [It may be desirable to cite from M. Devergie (op. cit.) the various changes that take place in the organs of circulation, the cord, and the skin, at different periods, beginning with the first and ending with the thirty-fifth day, which may enable some judgment to be formed of the age of the child. First day.—Cord beginning to wither; foramen ovate, ductus arteriosus, ductus venosus, and umbi- lical vessels open. Second day.—Withering of the cord complete ; foramen ovale closed in two out of eleven cases; partially closed in one out of seven ; ductus arte- riosus beginning to close ; umbilical arteries oblit- erated to a greater or less extent; umbilical vein and ductus venosus still open. Third day.—Desiccation of the cord ; foramen ovate sometimes closed ; ductus arteriosus obliter- ated in one in eleven cases ; umbilical arteries very often bliterated ; umbilical vein and ductus veno- sus still open. Fourth day.—Cord beginning to fall off; for- amen ovale closed in about one-third of the cases : ductus arteriosus still open in the majority of cases; umbilical arteries closed, but sometimes open near the iliacs ; umbilical vein and ductus venosus much contracted. Fifth day.—Separation of the cord with rare exceptions; foramen ovale closed in more than half the cases ; ductus arteriosus closed in about half the cases; umbilical vessels closed ; vein oc- casionally open ; separation of the cuticle ad vanced. Eighth day. — Entire separation of the cord. with commencing cicatrization; foramen ovate closed in three-fourths of the cases; ductus arte- riosus completely obliterated in half the cases; vessels closed. Ninth to eleventh day.— Cicatrization of the umbilicus often complete; sometimes, however, there is an oozing of mucus from the cord for many days, so that the cicatrix is retarded ; se- paration of the cuticle in the trunk, chest, and abdomen, and at the articulations. Twentieth to twenty-sixth day.—Separation of the greater part of the cuticle. Thirtieth to thirty-fifth day.—Separation of the entire cuticle, excepting that of the hands and feet, which is often delayed until the 40th day. (See, on the same subject, Billard, Maladies dr* Enfants, and Guy, op. cit. p. 149-)] 636 INFANTICIDE. Having now investigated the evidences of inde- pendent life, which may be supplied by the ex- amination of the body of a child found dead, we proceed to arrange the inferences of practical value in a compendious form. The state of the stomach, bowels, and urinary bladder, and of the umbilical cord, has been purposely omitted, as in a large majority of cases they do not furnish any indications which can be relied on. First.—A child may be concluded to have been still-born who does not present the signs of having arrived at the sixth month of uterine life : or The colour of whose lungs is uniformly dark- red, or verging towards the brown-red of the liver or the bluish-red of the thymus: If they are of a fleshy compact structure, some- what like liver, presenting no traces of cells on the surface, nor yielding a crepitating sound when cut, nor bubbles of air when portions of them are pressed beneath the surface of water : If the whole lungs and every fragment when they are cut into small pieces immediately and rapidly sink in water; and when the weight of the whole lungs (being naturally formed and healthy) is below five hundred grains: If the lungs have occupied the posterior cavities only of the thorax, merely touching the pericar- dium with their anterior borders, and covering with their concave surface the posterior half of the arch of the diaphragm, the edges being sharp, and the margins of the right, middle, and left upper lobes forming small tongue-shaped elongations : and if the ductus arteriosus is cylindrical through- out, being of equal diameter with the trunk of the pulmonary artery, and two or three times the diameter of the two pulmonary branches. Secondly.—It may be concluded that a child has lived a short time and breathed imperfectly, Whose lungs being for the most part dark-red, brownish, or bluish-red, present, here and there, in one or both lungs, but particularly on the edges, insulated scarlet or cinnabar-red spots or streaks; when there are visible, particularly in the upper lobe arid edges of the right lung, insulated groups of cells surrounded by portions retaining the com- pactness of liver; when this cellular portion yields a crepitating sound on being cut, and bubbles of air if pressed under water; when the lungs oc- cupy more or less the lateral cavities of the thorax, and their margins, particularly the prolongations of the right middle and left upper lobes, are par- tially or altogether of a rounded form: When the lungs, with or without the heart, sink in water, but some fragments of them, when di- vided, float, even after having been subjected to pressure; and when the absolute weight of the lungs much exceeds five hundred grains : If the ductus arteriosus is smaller in diameter than the pulmonary trunk, and about equal to the pulmonary branches, and particularly if with these signs it is contracted either at the aortal or other extremity, so as to assume a somewhat conical shape. Thirdly.—A child may be concluded to have lived for some time and breathed perfectly, If the lungs are of a pale-red colour generally, but with numerous spots and streaks of scarlet; the posterior surface only being dark-red, in conse- queuce of the gravitation of the blood to that part : If the lungs completely occupy the lateral ca- vities of the thorax and cover the sides of the peri- cardium, and if their lower concave surface cover the whole arch of the diaphragm, their edges being everywhere rounded, and the tongue-shaped elongations of the right middle and left uppei lobes short and obtuse: if insulated groups of in- numerable cells distended with air are visible with the naked eye in the substance of the lungs; if they are everywhere expanded and spongy in texture, crepitating audibly when cut, and yielding on pressure under water, numerous bubbles of ai- or bloody froth: If the lungs connected with the heart, or separated from it and each separate lobe, pro- ject above the surface of the water, and every fragment when they have been divided and subjected to strong pressure, float; and if their absolute weight exceed one thousand grains : And if the ductus arteriosus is short and much contracted in diameter, so as to be as sinall as 01 smaller than the branches of the pulmonary artery; or if it be decidedly contracted at the aortal or other extremity, so as to represent in form a trun- cated cone. To every indication, hitherto adduced, of the extra-uterine life of the child, the possible occur- rence of uterine or vaginal respiration presents an objection which deserves farther consideration. In the preceding remarks we have adverted to cases of this kind, which refute the opinion hitherto entertained that this species of respiration cannot come in the way in medico-legal investigation, because it can only occur in cases requiring in> strumental or, at least, foreign manual assistance. Although there can be no doubt of the general correctness of this opinion, it is manifestly not true in all instances; for the cases of Dr. Hosack and Dr. Holmes (see page 681) prove that it may be met with in instances of delivery capable of completion by the natural efforts only. Admitting, however, the possibility of intra-ute- rine and vaginal respiration, we must contend on the other hand for the extreme rarity of the occur- rence ; so rare, indeed, that, until very recently, it has been regarded with the greatest distrust by European practitioners in general with the excep- tion of the Germans: and it is doubtful whether any other positive evidence than that recorded in the present essay, exists in the writings of French and English authors in its favour. Ought, then, so rare an occurrence to be admitted as a decisive reason for uniformly rejecting the conclusiveness of the indications of life which we have hitherto been discussing 1 We think not, and doubt ex- tremely whether the signs of perfect respiration which we have just detailed aTe ever to be met with in such cases; whilst we have every reason to believe that they are commonly found in the bodies of children who have died from criminal violence or neglect. Vaginal respiration may occur in natural pre- sentations, but the delivery in such a case must be delayed to admit of it, and thus the labour would become "difficult." In every such case the tumour of the vertex would plainly indicate its nature. Face presentations, in which vaginal respiration may occur, are capable of proof from the absence of the tumour just named, and from th« tumid INFANTICIDE. 6P7 and distorted features ; and footling presentations are recognisable, if death have taken place soon after birth, by signs not difficult of detection. Such are the cases most favourable to the possible occurrence of vaginal respiration; and although they demand full consideration, they seem never- theless capable on careful inquiry of tolerably easy detection. Should there be no proofs of difficult labour, whilst indications of full and complete respiration are found, and conjoined with these there exist signs of fatal injury, which could not have been accidental, and must have been inflicted during the continuance of the circulation, the proofs of infanticide would be indubitable; for to reject them would be to disallow the force of the strongest circumstantial evidence. II. In proceeding to inquire into the cause of the death of the child, we may remark that it may have died in the womb previous to the commence- ment of labour ; or during the act of parturition, or after birth ; and in each case death may have been produced by natural or criminal causes. 1. The death of a fcetus in utero criminally in- duced in the early periods of utero-gestation, falls under the head of criminal abortion ; at a later period death arises most frequently from natural causes, from disease in the mother, in the foetus itself, or in the secundines; but it may result from premature labour brought on artificially by punc- turing the membranes. A foetus having died in utero, may remain there an indefinite time, and even be converted into adi- pocire. Generally it is expelled in from five to twenty days, exhibiting unequivocal signs of pu- trefaction ; the members are relaxed, the muscles flabby, the epidermis detached by the slightest touch, the skin is of a purplish or brownish-red. Frequently there is a sanguineous or serous infil- tration of the whole subcutaneous tissue, particu- larly under the hairy scalp. The umbilical cord is thick, soft, brittle, and infiltered. The chest is sunken or flattened. The head is deformed, fall- ing flat by its own weight; the pericranium and dura mater are separated from the bones, which are nearly, if not altogether, disunited, and the cerebral substance is converted into a putrilaginous mass. Jaeger observes that these signs are quite peculiar, and that their concurrence distinguishes this state from death by injury, and every tiling else. (Schlegel, Opuscul. Collectio V. 48. Le- cieux.) 2. Capuron, (La Medecine Legale relative a I'art des accouchemens,) who has given the best summary of the causes of death during par- turition, has divided them into innocent and criminal. Of the former kind are difficult labour with pre- mature evacuation of the liquor amnii; total or partial separation of the placenta; premature expulsion of the funis ; presentation of the feet; detention of the body from mal-position after the expulsion of the head ; and the " entortille- ment," or turning of the funis around the neck of the child. The effects on the child of difficult labour with premature evacuation of the liquor amnii, are such as result from severe and continued pressure ; and the death of the child takes place in the way of apoplexy. The sigvs which indicate it are the sero-sanguineous tumour of the vertex ; if the head have presented, deformity and elongation of the head, attended even with fractures of the bones, tearing of the membranes, or separation of the pericranium, and effusion under it. (Fodere, iv. 503.) The position of the injuries of the head, and the absence of any distinct sign of im- pingement from a bruising body, combined with the absence of the signs of respiration, would satis- factorily elucidate these phenomena. In the case of total or partial separation of the placenta, the death of the child is of course from hemorrhage, and the body would present the signs of anaemia. It might be confounded with death from hemorrhage from the umbilical cord ; but the absence of the signs of respiration would be a decisive means of discrimination. The mother would also present signs of anaemia. In premature expulsion of the funis, the death of the child is from asphyxia. No sign of injury would be present, nor would there exist any proof of respiration. Presentation of the feet, with all but the head expelled, and the delivery tedious: in such a case a woman might assist herself, and in so doing inflict so much injury on the child by her injudi- cious attempts, as to excite strong suspicion against herself; and the more particularly, as this is a conjunction of circumstances under which vaginal respiration may occur. Such a case would require a circumspect observation of all the particulars; but there are circumstances which could scarcely fail to lead to its correct elucidation. The indi- cations of difficult delivery and of the presentation of the feet would be easily observed, and an exam- ination into the situation and nature of the inju- ries would show whether they were of a kind which a woman might be expected to inflict on her child in promoting her own delivery. If death were not the result of injury, it would take place in the way of apoplexy, and the corresponding signs would be found. In retention of the body from* mal-position or otherwise after the expulsion of the head, death results from asphyxia, from the compression of the funis, if the child have not breathed; and if it have, from impediment of the free expansion of the thorax. In the former the absence of the signs of respiration, with the want of proof of criminal neglect or violence, would rebut the charge of infanticide; in the latter, imperfect respiration would be recognised by its appropriate indications, the severity of the labour would be proved by the tumour of the vertex, and other signs, and the want of proof of criminal act or intention would render the charge of murder un- tenable. The only other innocent cause of death during parturition deserving of particular attention, is the " entortillement," or turning of the funis around the neck of the child. If this circumstance lead to fatal consequences, it is either by inducing apo- plexy or asphyxia, according as respiration have or have not been carried on. Should any sign ol injury be left, it will consist of a spiral impressioi., or (if the cord have passed round more than once) of the circular and spiral line discoverable on the neck. The epidermis is never puctered, nor ta cartilages of the trachea injured. If it were a) 088 INFANTICIDE. leged that the cord have passed round the neck more than once, it should be ascertained whether it was sufficiently long for that purpose. It is proper to add that fractures of the bones sometimes take place in the uterus, of which Chaussier (Bulletin de la Faculte de Medecine, tom. iii. See also Otto's Handbuch de Patholo- gischen Anatomie, 394) has related a remarkable instance. In this example each of the long bones presented one or more fractures, some of which were recent, others beginning to unite, and others had unitnd. The criminal causes of death during parturition are various, and for the most part evidently betray the intention with which they were employed. They almost always imply the aid of an accom- plice, and hence are of comparatively infrequent occurrence. Of these the following are the most usual:—puncture of the brain through the fon- tanelles or sutures, or of the spinal marrow be- tween the first vertebra and the occiput; torsion or compression of the head ; detruncation ; strang- ling and suffocation. Belloc (Cours de Med. Leg. 101) has reported an instance of child-murder in which the brain was punctured through the interior fontanelle. The external wound did not exceed half a line in length. On examination it was discovered that it penetrated the brain to the depth of two inches. At this point the cerebral substance was lacerated in several directions. Blood was effused both between the membranes and in the left lateral ventricle. Gui-Patin, Alberti, and Brendel have cited similar examples; and in the article Acu- puncture in this Cyclopaedia, reference is made to a trial in the " Causes Celebres" for the same horrible offence. It is doubtful, however, whether these means would prove so rapidly mortal as to destroy life before the expulsion of the child. In the case related by Belloc, death appeared to have been produced by suffocation, the laceration of the brain not having been effectual. In torsion of»the neck the injury inflicted on the spinal marrow might be immediately fatal. The marks of violence presented by the ligaments of the vertebrae and neighbouring muscles would irrdicate the nature of the case ; and it is highly probable that the marks of the pressure of the fin- gers would be visible. Fodere (Vol. iv. p. 524) has related the trial of a widow, who destroyed her child in the act of parturition, by compressing its head between her thighs till it was dead. It is doubtless possible that a child may be strangled or suffocated before complete respiration has taken place ; but the nice accomplishment of such a purpose requires a more refined applica- tion of injury than is almost ever practised.; and without such caution the remains of intentional injury would be demonstrable. If strangulation were attempted whilst the circulation was pro- ceeding vigorously between the mother and child, continued pressure would be necessary for its ac- complishment, as death would take place in the way of apoplexy ; and for such continued pres- sure a longer intermission of the uterine pain would be required than is usually found to occur. 3. The causes of death after delivery are natu- ral or criminal: and the latter are subdivided into those which are fatal by omission and by com- mission. The following is a general summary of the natural causes of death after delivery : immaturity, disease, malformation ; omission of the usual and necessary attentions ; injuries from severe labour or from sudden expulsion ; sudden and simulta- neous expulsion of the placenta, and consequent hemorrhage; prevented respiration from envelop- ment in the membranes ; or suffocation in the discharges. The two causes last enumerated arc not distinguishable from the same causes of death intentionally applied. Of the others, injuries from severe labour and from sudden expulsion are most likely to be confounded with the effects of crimi- nal violence, and hence demand the most careful and deliberate examination. With reference to the former, it should be recollected that " fluid blood effused at the base of the brain is met with in all children, when the head has been long in the pelvis, and the child has died in that situation." (Fodere, iv. p. 503.) The cerebral ventricles of newly-born children, Fodere adds, usually contain much reddish serum, and the brain much blood. And when the superior aperture of the pelvis is narrowed by deformity, even fractures of the bones may occur with depression of them into the brain. But all these effects require for their production a disproportion between the size of the head and dimensions of the pelvis. The state of the former should indicate the difficulty of the labour by its deformed and elongated appearance, and by the unusual size of the sanguineous tumour at the vertex. Signs of laceration and contusion ought not to exist. Injuries arising from sudden expulsion are very rarely fatal, or even dangerous; and they are less likely to be confounded with the causes of infan- ticide, inasmuch as they are of infrequent occur- rence in first labours, on which occasions the crime is for the most part perpetrated. No in- stance of the death of a child from sudden expul- sion has come within our knowledge. Suffoca- tion in privies under such circumstances is of course possible, and Hutchinson (Dissertation on Infanticide) says instances are reported ; he has not, however, supplied any reference to them. Several years ago Chaussier (Lecieux, Op. cit.) experimented on dead children to ascertain the effects of falls from a given height, and also of blows, on the cranium. These experiments, nei- ther very refined nor conclusive in their charac- ter, are superseded by the more recent observa- tions of M. Klein (Diet, de Medecine, tom. xii. p. 188) of Stutgardt. M. Klein, taking advantage of his situation of Member of the Superior Coun- cil of Health, caused a circular to be addressed to the midwifery practitioners of the kingdom of Wurtemburg, requiring reports of the cases of sudden expulsion of the fcetus which might be observed by them. Returns were made of one hundred and eighty-three cases. Of these, one hundred and fifty-five children were expelled whilst the mothers were in the upright posture, twenty-two when sitting, and six when on the knees. Twenty-one happened at the first labour. Of the whole number not one child died; no fracture of the bones took place, nor any other severe injury. Two only suffered temporary in INFANTICIDE, 689 sensibility, and one an external wound with sugil- lation over the right parietal bone. Not one suf- fered from umbilical hemorrhage, although in several the cord was ruptured at four, three, and two inches, and even one inch from the umbilicus. In twenty-one children it was torn off close to the abdomen, yet no serious hemorrhage followed. We are entitled, therefore, to conclude that in ac- cidents of this kind the death of the child, if not impossible, is highly improbable; and if it should occur, we have no reason to think that it would be immediate. The criminal causes of death by omission are, the neglect of removing the child from under the bed-clothes, or from the state of supination; the want of suitable warmth; neglect of nourish- ment ; and the neglect of the ligature of the um- bilical cord. Death has resulted not unfrequently from the first of these causes; but the medical man possess- es no peculiar means of determining whether this has happened from design or from the mother's inability to render the usual succours. Dr. Wil- liam Hunter has mentioned a case which shows how readily neglect of this kind may prove fatal. Death from want of suitable warmth, which is almost always conjoined with public exposure, is proved by the evidence of respiration and circula- tion ; by sanguineous congestion in the large ves- sels, with comparative absence of blood in the su- perficial ones ; by the position of the body ; and most conclusively perhaps by the cadaveric con- gestion or lividities (Chaussier, Recueil de Me- moires, &c, 424) which are met with in the de- pending parts of the body. Neglect of nourishment is also generally com- bined with public exposure ; under which cir- cumstanees death may be attributable to the com- bined causes. It would be very difficult to prove the death of a newly-born child from neglect of nourishment only, because to establish that it would be requisite to show how long the child had lived, which there are no means of determin- ing with strict accuracy. The changes superven- ing in the umbilical cord would furnish the best evidence; and being applicable on other occasions, we shall describe them in this place. The umbilical cord varies in different children considerably, (Traite des Maladies des Enfans, &c, par Billard, p. 18) : in some it is slender and comparatively firm, in others thick and soft; the thickness varying from the greater or smaller quantity of the albuminous fluid, called the gela- tinous fluid of Warton. The changes which take place in the cord are, first, flabbiness, then desic- cation, and lastly separation from the abdomen ; and all these processes occur at different periods of time in different children, according to the thickness or thinness of the cord. Immediately after birth, or at farthest in a few hours, the flal> biness commences, and it is complete in the course of a day, or at most in two days. Desiccation, which commences after the fading of the cord is complete, begins generally at the end of the first day, and is completed on the fourth or fifth, when the separation takes place. The desiccation is a purely physiological phenomenon, for it does not take place in children born dead ; in them the cord remains soft and flexible, and then becomes Vol. II. —87 3h* putrid. The desiccation of the cord is more speedy when it is thin ; and it is rare that separa- tion of a slender funis is attended by suppuration. or even inflammation. When it is thick, the case is otherwise ; suppuration at its junction with the abdomen takes place, with a red and thickened base. The slowness of the separation appears to occasion the inflammation. A consideration of these circumstances will in- dicate the age of a child approximatively within the first four or five days after birth. The neglect of the ligature of the umbilical cord may be accidental or intentional. The ab- sence of it is unfavourable to the accused, and more particularly if the funis be cut. The effects of the absence of the ligature of the umbilical cord have been a fruitful source of controversy ; many, Capuron among others, having doubted whether fatal hemorrhage could result if the ligature were not applied. (Daniel, Commentatio de Infantum nuper natorum Umbilico, &c, 1780.) Fodere (Tom. iv. p. 516) has related a case which we deem quite conclusive in the affirmative ; and the signs he has described will no doubt be generally met with under similar circumstances. They were the following: — extreme paleness of the whole body ; no wound or external sign of vio- lence ; the umbilical cord flaccid ; floating of the lungs with or without the heart; complete vacuity of the heart and great vessels, of the vena porta- rum, of the ductus venosus, and even of the ca- pillary vessels. All the blood which could be collected did not weigh two ounces. The child lived long enough to be carried three leagues; hence death from this cause is not speedy, and the signs of respiration would be certainly found. Roederer has remarked that the ligature may be applied to the cord after fatal hemorrhage for the purpose of deception, but the proofs of anaemia would elucidate the case. If three ounces of blood can be collected, it may be presumed that the child has not died of hemorrhage. In Fodere's case, not two ounces could be collected. We now pass to the consideration of the causes of death after delivery by commission ,- and it is commonly in this manner that infanticide is per- petrated in this country. They may be as vari- ous as those of homicide generally ; but there are some which are more easily or more commonly employed than others. The following enumera- tion embraces the more usual and important varie- ties. Suffocation from division of the fraenum linguae and turning back of the tongue ; stoppage of the aerial passages ; asphyxia by strangulation or by deleterious gases, or by plunging into privies ; torrefaction ; drowning; wounds and bruises about the head or in different parts of the body ; crushing of the head; punctures per rec- tum or in the region of the heart: to which may be added some of the causes mentioned under the criminal means of death during delivery. The criminal intention in many of these injuries would be self-evident. A recent case of infanticide in Guernsey was perpetrated by laceration of the fraenum linguae and puncture per rectum. (Edin. Med. and Surg. Journal, No. cvii. p. 548.) The proofs of murder were unquestionable. The effects of injuries about the neck demand the strictest scrutiny ; for strangulation is perhaps 690 INFANTICIDE. the most frequent of all causes of infanticide by commission. The fallacies by which it is beset are the " entortillement" of the umbilical cord; supposed injury from compression by the os uteri and vagina; or from the assistance which a woman might endeavour to render herself; possi- bility of post-mortem injury ; and livor, or spon- taneous sugillation. The turning of the umbilical cord around the neck requires that the funis should be of a certain length; (See Scott's Case of Infanticide; Edinb. Med. and Surg. Journal, vol. xxvi. p. 75 ;) and the mark, if any remain, cannot be circular unless it have made a second turn. No abrasion or puckering of the skin ever takes place from this cause. (Ploucquet, Ueber die gewalt. Todesarten, 378.) M. Klein, (Diet, de Medecine, tom. xiii. p. 183,) who has made special observations on the subject, denies that any sugillation or even impression ever occurs from compression of the neck by the cord, by the os uteri, or vagina. He has seen many children who have died from the first of these causes; and in none did he observe any mark left about the neck. But in infanti- cide, as in homicide generally, criminal efforts to extinguish life are executed most frequently with characteristic violence, and accordingly injuries of the tracheal cartilages or of the deep-seated muscles of the vertebrae are sometimes found, or plain impressions of the fingers. A few years ago we had occasion to examine the body of a child which had been destroyed by strangulation with the fingers. The impressions were distinctly perceptible on each side of the trachea, and the mark of the fingers gradually increased in distinct- ness from the back of the neck forwards. The trachea was not injured, but on each side of it coagulated blood was found. The assistance which a woman might have endeavoured to afford herself would be generally recognisable by the nature, situation, and direction of the marks. The case of Marguerite Granger, related by Fodere, (Op. cit. tom. iv. p. 502,) af- fords an excellent, perhaps an extreme illustration of the kind of injury which might be expected in such a case; and his report shows that, though such injuries may be numerous, they will be super- ficial. Chaussier (Recueil de Mem. p. 470,) asserts that injuries have been inflicted on the dead body for the purpose of determining an accusation against an individual. If such wounds or bruises have not been inflicted for twenty-four hours after death, there is no difficulty in deciding that they were not received during life. The lips of wounds are pale, without swelling or retraction. There is no clot of blood adhering to the surface, nor, in the case of contusion, is coagulated blood found in the surrounding cellular texture : hence there is no tumour. The characteristics of blows in- dicted during life are tumour from extravasation of blood and serum; or clots of blood in the sub- jacent cellular tissue without tumour, or " incor- poration of the blood with the whole thickness of the true skin, rendering it black instead of white, and increasing its firmness and resistance." " In respect to external contusions," says Dr. Christison, (Cases and Observations in Med. Ju- risprudence. Edinb. Med. and Surg. Journal, No. xcix. p. 247,) " experiments show that for some hours after death, blows will cause appearances which in point of colour do not differ from the effects of blows inflicted recently before death; that the discoloration generally arises like lividity, from an effusion of the thinnest possible layer of the fluid part of the blood on the outer surface of the true skin, but also from an effusion of thin blood into a perceptible stratum of the true skin itself; and that dark fluid blood may be even effused into the subcutaneous cellular tissue in the seat of the discolorations, so as to blacken or redden the membranous partitions of the adipose cells, but that this last effusion is never exten- sive." " It is impossible," continues Dr. Christison, " to fix absolutely the limit of the interval beyond which contusions cannot be imitated by violence applied to the dead body. It appears to vary with the state of the blood, and the time which elapses before the body cools and the joints stiffen. Some- times the appearance of contusions can hardly be produced two hours after death; sometimes they may be slightly caused three hours and a quarter after it; but I should be inclined to think this pe- riod very near the extreme limit." The testimony of Chaussier (Recueil de Mem. p. 471,) corresponds with what has just been stated. " If," says he, " the injuries have been inflicted soon after death, whilst the muscles pre- serve their contractility, there will neither be tume- faction, nor infiltration of blood into the cellular tissue, or the blood will only form a clot without adhesion to the divided surfaces." Lividities or livor, which are the terms employed to express the nature of discolorations occurring spontaneously after death, may be easily distin- guished from ecchymoses, which are the result of injury during life. Livor is generally found on the back and thighs, or on the parts of the body on which it has remained when becoming cold. Sometimes it extends more particularly to the head or neck or genital organs. Lividities as- sume varieties of appearance, but they are con- fined to the skin, and are greatest when the blood has long retained its fluidity. Infiltration or ef- fusion of blood into the cellular tissue never oc- curs from them, nor are they ever attended by tumour. Ecchymosis or sugillation, on the contrary, is characterized by a true effusion of blood, which has formed a coagulum, and this coagulum is in- timately adherent to the meshes of the cellular tissue, and frequently forms a tumour. In the progress of putrefaction, indeed, the blood resumes its fluidity, escapes from the vessels, and collecting under the skin forms soft fluctuating tumours, which, on being opened, are found to contain a dark sero-sanguineous fluid. But it would be impossible for any person of moderate information to confound such appearances with the phenomena of true ecchymosis. Death from torrefaction or burning is of rare occurrence in criminal cases, yet we are informed by Dr. Ryan, (Manual of Med. Jurisprudence, p. 169,) that an instance of this crime has been re- cently perpetrated in London. The circumstances to be investigated by the medical jurist would be, whether the child was killed by burning or the INFANTICIDE. 691 body was thrown into the fire after death from other causes. Some late experiments of Professor Christison (Edin. Med. and Surg. Journ. No. cvii. p. 323,) show that " a line of redness near the burn not removable by pressure, and likewise the formation of blisters filled with serum, are certain signs of a burn inflicted during life." The ap- plication of a cauterizing iron ten minutes after death did not cause redness, although vesica- tions were produced; which vesications, however, did not contain serum, but were dry and filled with air. Instances of infanticide by drowning are infre- quent. The proofs would be found in the signs of extra-uterine life, the absence of other efficient causes of death, and thfe presence of phenomena which are usually observed in asphyxia from sub- mersion. (See Asphyxia.) We may observe that the presence in the bronchi of a portion of the fluid in which the body was found is no proof of death by submersion ; for fluids will pass into the bifurcations of the bronchi if the body have been thrown into water after death. If, however, any of the fluid, and particularly any foreign matters contained in it, were found in the stomach, death from submersion would be unquestionable, as it could only have arrived there from degluti- tion. The indications of struggling which are sometimes met with in adults destroyed by drown- ing, could not be expected in a newly-born child under such circumstances. Death from criminal injuries of the head are distinguishable by the fracture of one or more bones in situations which, neither in the course of natural parturition nor in the case of sudden expulsion, are liable to them. Ecchymoses and wounds almost always accompany them. In injuries of the head from violent compres- sion criminally applied, it is highly improbable that the marks could be confounded with those which sometimes, though very unfrequently, occur during labour. The unusual situation, severity, and complications of the injuries, with the indica- tions of extra-uterine life, would, in the absence of the signs of difficult labour, dissipate all doubt as to their origin. We shall here detail the marks of difficult labour which are usually met with. In a first labour, even when there is no unu- sual disproportion between the head of the child and pelvis of the mother, and the delivery has been accomplished with moderate celerity, we ob- serve in the presenting part of the child a tume- faction of uncertain extent and size. On dis- secting this tumefied part, a serous infiltration, sometimes with sanguineous engorgement, is found under the subcutaneous cellular texture, and which does not exist in other parts of the head. In a woman who has borne several children, whose pelvis is large, and the os uteri soft and yielding, this impression is so slight as to be scarcely perceptible, especially if the child is small, and the delivery have been quick. On the contrary, when the head of the child is large, the bones firm, and the labour slow and painful, so that the head have been delayed in the pelvis, the tumour is large, prominent, and unyielding. When cut into, we not only find a sero-san- guineous effusion into the subcutaneous cellular tissue, but the pericranium is detached and ele- vated by a collection of dark fluid blood, the bone is brownish, and the connecting membranes are more or less elongated. These changes are still greater when the superior aperture of the pelvis is narrowed by an unusual projection of the pro- montory of the sacrum. Then the head is de- formed, elongated in its greater diameter, flattened in the transversal. Sometimes even a depression or fracture, longitudinal, angular, or starred, of one or both parietal bones, may occur. All these phenomena are distinguishable from those pro- duced by accidental or criminal violence, by the nature and position of the tumour, and of the other injuries which result from the unnatural projections of the pelvis. Such deformity of the pelvis is ascertainable at any period after delivery ; and where the usual proportions between the head of the child and pelvis of the mother exist, the appearances above adverted to are never met with. We here terminate all the remarks we have to offer on the causes of the death of a newly-born child,* and venture to state that the indications afforded by them will be found applicable to the solution of the difficulties which can be reason- ably anticipated on trials for infanticide. Un- doubtedly instances may occur in which it will not be possible to demonstrate the causes of death, but such is the case also in other varieties of homicide. In infanticide the victim is incapable of resistance, and hence some of the ordinary proofs of homicide may be absent; but the kind and degree of injury necessary for the destruction of the life of a child are very rarely nicely mea- sured by the perpetrator of the crime; and the violence committed is most frequently such as to leave no doubt as to the cause of death, and to constitute, at the same time,' the most indubitable evidence of extra-uterine life. It is unquestiona- ble, however, that medical evidence on trials for infanticide has not influenced the decisions of juries in the same degree as on trials for other kinds of murder. By some this has been attri- buted to the doubtful and hesitating manner in which medical witnesses have generally delivered their testimony, (Edin. Med. and Surg. Journal, vol. xxvi.); bv others, to the impression that the killing of a new-born child, when perpetrated under the impulse of injured honour and fear of disgrace, should not be classed with the other va- rieties of murder. The latter question we shall not attempt to discuss; but as regards the former explanation, we unhesitatingly express our con- viction that the anatomical, physiological, and pathological phenomena on which medical evi- dence is founded on these occasions are as sus- ceptible of positive conclusion as any other facts within the sphere of medical investigation. Never- theless, we are not surprised that medical men should frequently be unprepared to deliver their testimony with clearness and decision in criminal trials. The facts and information connected with these subjects are rarely applicable in the dis- charge of the ordinary duties of medical practice , and general practitioners in active occupation have, therefore, no great inducement, and seldom * For the signs of death by poisoning and deleteno'i* gases, see Toxicology. C92 INFANTICIDE. sufficient leisure to devote to the literary and ex- perimental researches which investigations in medical jurisprudence demand, whilst it is to this class of practitioners that reference is generally made in medico-legal proceedings. The custom which prevails in Germany and other northern countries of Europe of appointing a medical offi- cer for each district, whose especial duty it is to investigate all cases which become the subject of juridical proceeding, seems worthy of imitation in this kingdom. The establishment of such an office creates individual responsibility, and ensures a due preparation for the faithful discharge of it; and the concentrated experience thus acquired has contributed to the exactness and extension of medico-legal knowledge. Under existing arrange- ments in this country, the infrequency with which individual practitioners are called on to act, con- stitutes perhaps the chief reason why this depart- ment of professional study has hitherto been com- paratively neglected. III. We next proceed to inquire into the proofs whether the suspected mother has been recently delivered. As collateral evidence, it is advisable to ascer- tain whether the general symptoms of pregnancy have pre-existed. It is evident that no conclusive opinion can be formed in such a case, auscultation and the ballottement supplying the only positive evidence of pregnancy. But if the menses have been suddenly suppressed, the mammae and abdo- men have enlarged, and no other symptoms of disease than inappetency, irritability of the sto- mach, and dyspepsia have followed, it may be reasonably presumed that the woman has been . pregnant. The proofs of recent delivery are furnished by an aggregate collection of signs, which, separately considered, do not admit of positive inference. In a woman recently delivered, particularly of a first child, the following appearances are very generally met with : the fece is rather pale, the eyes are sunken and surrounded with a dark circle; the pulse is rather quick, full, and undulating; the skin soft, with some heat and moisture, having a peculiar acid odour. The breasts are tumefied, distended, and painful, yielding on pressure or suction a fluid having the characteristic proper- ties of milk; the belly is soft, and the skin is wrinkled and marked with short red or white lines passing in different directions, chiefly towards the umbilicus; a separation of the linea alba is perceptible, particularly towards the umbilicus. The uterus is felt above the pubis. There is a discharge from the vagina either of a red, greenish, or light colour, and of peculiar odour. The geni- tal organs are more or less tumefied, and consid- erably dilated in their whole extent; the fourchette is lacerated ; the os uteri is soft and relaxed, so as easily to admit of the introduction of the fingers, and a discharge similar to what has been just mentioned flows from it. There is no known disease which will produce the concurrence of signs now enumerated, whilst ifter parturition, and particularly after a first labour, they almost uniformly occur.* * A curious application of the knowledge of the signs of recent delivery has been mentioned byCapuron Med legale, p. in. A young woman simulated pregnancy But the discovery of such a series of symptoms will depend altogether upon the period of time at which the examination was made. Zacchaeus long since observed that the proofs of delivery were uncertain after the tenth day. (Quaestiones Med. Legal, ii. lib. 7, quaest. 2.) After the fourth or fifth they become less distinct, gradually dimin- ishing, and at the end of a fortnight are indecisive. The possible fallacies are the sudden cessation of dropsies ; the expulsion of hydatids or moles. The Foreign Quarterly Journal of Medicine and Surgery contains a case of the sudden disappear- ance of dropsy, in which the water was discharged per vaginum by passing down the fallopian tubes. In Rust's Magazine (Vol. 21) a case is related of the discharge of a " mote" preceded by the general symptoms of pregnancy, and accompanied by flooding and other signs of parturition. The dis charge of the menstruous fluid after long retention might simulate some of the symptoms of recent delivery, but many of them and those the most decisive, would be absent in all such cases: whereas, after delivery, and particularly of a first child, almost all would be found to concur. IV. Do the phenomena presented by the sup- posed mother and child establish the suspected relationship ? The solution of this question is almost always easily determined in cases of infanticide by moral evidence; and indeed it is by moral evidenci alone that it can be positively settled. Medica' testimony must be confined to showing that then is an agreement of the phenomena presented b the child with the indications of delivery observe ble in the woman. The data thus derived can b of a general nature only, and are confined chiefh to a comparison of the state of conservation oi decomposition in which the body of the child was found, with the presumed period of delivery. If the inquiry were not instituted for some days after delivery, it would be necessary to take into consideration the circumstances capable of accele- rating or retarding decomposition. For instance, putrefaction proceeds most rapidly when the atmosphere is humid and still, and the heat ranges between 60° and 80° Fahr. It proceeds most rapidly in parts of the body which have sustained injury either before or after death. It is important to remark that in bodies plunged into privies, putrefaction does not commence so soon as when they are exposed to the air; but having begun, it proceeds more rapidly in such a situation. Decomposition is retarded by submer- sion in water, so that two or three weeks generally elapse before, in bodies so circumstanced, putre- faction commences. Some remarks on post-mortem examination, and on the drawing up of medico-legal reports with reference to the present subject, would fur- nish practical information of value, and hence form an useful appendix to this essay. It already, however, ocupies the limits which can be assigned to it in the Cyclopaedia, and we content ourselves and pretended to have been delivered, in order to obtain from her lover the execution of a promise of marriage. The latter claimed the child, which could not, of course be produced. A charge of infanticide was brought against the pretended mother, who was compelled to show that she had not been delivered. This was atte?» ed by the medical examiners. INFECTION. 693 with referring the reader to the Thesis of Lecieux, where the points now adverted to will be found admirably exemplified. Robert Arrowsmith. INFECTION, infectio, (not classical,) infec- tus, and inficere, Lat.—The meaning of this word has been, and perhaps still is, unsettled. It will be employed in this article to signify the delete- rious or offensive qualities which certain matters designated by the terms malaria, matter of conta- gion, emanations, and effluvia, communicate to the air and other inert bodies ; and likewise the per- nicious effects which some of these substances produce on the human constitution. This descrip- tion comprises, if we mistake not, all the physical senses in which the word is usually employed. It will be observed that, according to one of them, it is to a certain extent synonymous with conta- gion, and it is likewise made so by the custom of the majority of the profession ; a custom which is in a great measure owing, we believe, to the word contagion being destitute of the verbal form, whence the phrases to infect or to be infected become convenient modes of expression. A good deal of confusion has resulted from an attempt to discriminate between contagion and infection, when the latter term is employed to express the trans- mission of disease from man to man ; and in the article Contagion we have expressed an opinion that in this case the words should be regarded as strictly synonymous; but it will be observed that infection possesses a wider sense than contagion, being applied to cases of contamination which are never designated by the latter word. Deleterious qualities may be communicated to certain bodies either by matters known only by their effects on the human constitution, or by those which affect perceptibly the sense of smell. Of the former an account will be found in the article Contagion, and in those on Malaria and Mi- asma. The latter consists of hydrogen and its compound gases, carbonic acid, azote, and perhaps other gaseous matters which are the result of ani- mal and vegetable putrefaction aided by the pre- sence of moisture. Their sources are various, such as cemeteries in which bodies are deposited at an insufficient depth from the surface, or from which it has been found necessary to remove the accumulated remains ; slaughter-houses ; dissect- ing-rooms; neglected privies and drains ; stagnant waters, in which organic recrements are undergoing decomposition, as is often exemplified in noisome swamps, or at low water on the banks of rivers near their mouths, when in the vicinity of popu- lous towns; human beings accumulated into a small space with deficient ventilation, &c. The two genera of infecting substances fre- quently co-operate in producing an effect on the human system. Thus it is commonly observed that contagious diseases are more generally diffused and assume a worse character in an atmosphere abounding in manifest impurities than in one which is free from them. During the prevalence of typhus at Paris in 1814, the mortality was observed by M. Jadioux to be frightful in those wards of the Sal- petriere which are situated near the sewer of the hospital ; and it were very easy indeed to multiply examples of this description. The bodies which are sensibly contaminated by infecting particles are various, and differ much in their power of receiving and retaining the con- tamination. Confined masses of atmospheric air receive it readily and retain it long, as likewise do solid bodies which possess the property of holding air in a quiescent state within their interstices, such as cotton, wool, cloths fabricated from these substances, fur, feathers, &c. On the contrary, smooth and polished surfaces are tainted with dif- ficulty, and are readily cleared of the pollution. These facts are illustrated by the well-known ex- periment of Mead, who placed a portion of carded cotton near a morsel of putrefying meat under an inverted bell-glass, and thus ascertained that the downy substance became strongly impregnated with the odour, and retained it long, whilst the contrary was the case with the smooth surface of the glass. The same rule is observable with re- spect to certain infecting particles of which oui senses are unconscious, for the downy substances named retain contagious matter long, and hence become powerful fomites ; but there is no reason to think that the species of marsh effluvia called malaria adheres to them so as to render them the media by which it is communicated to the human system. Action of Infecting Substances on the Animal Economy.—We now come to the second branch of our subject, the consideration of the mode in which infecting agents operate on the human constitution, and the kind of change which they produce there. If common odorous infecting matters are freely diluted with atmospheric air, we find that persons do not suffer from exposure to them, as is exem- plified in the case of butchers, tanners, &c; but in a more concentrated state they produce very deleterious effects, and occasionally instant as- phyxia, which was illustrated by the well-known case of the exhumations in the cemetery of the Innocents at Paris, and is not unfrequently ex- emplified in attempts to empty privies which have been long neglected. The slower but yet perni- cious effect of the same cause is shown in the un- healthy aspect of the inhabitants of filthy and ill- ventilated alleys in large cities of which the police is neglected. Those agents whose existence is recognised only by their influence on the animal economy are likewise found to be affected by ad- mixture with pure air. The effect of dilution is very conspicuous in the case of human effluvia, which have their intensity much diminished in a free and pure atmosphere. Marshy emanations retain considerable noxious power at a distance from their source, but there is a point beyond which they are inoperative, showing that diffusion in the atmosphere is ultimately destructive of their agency. There are two hypotheses regarding the mode in which these matters act injuriously on the economy. According to one, their operation is on the nerves of the part to which they are applied , the other supposes them to be absorbed from the same part into the circulation. In the present state of our knowledge, it is impossible to decide in favour of one or the other of these modes, or to say that either of them is that which is uniformly operative. The very rapid action of certain me 694 INFECTION. phitic gases leads to the supposition that an im- pression on the nerves of the air-passages is suffi- cient for the production of their poisonous effect on the system. The cutaneous surface, the mu- cous membrane of the air-passages, and the corre- sponding surface of the alimentary canal, have each of them been supposed by different medical reasoners to be the channel by which noxious agents find access to our system. Lancisi, who first reasoned with any degree of accuracy on this subject, conceived that such agents might be trans- mitted by all these media to the interior; and we believe that he was correct in supposing that any of them might be the channel through which the system is contaminated. When the epidermis is entire, the absorbing power of the cutaneous sur- face is so very feeble, and its nerves are so protected by an inert covering that it is probable that gase- ous matters of a noxious nature rarely act in this way; but more concentrated substances often do so when the surface is broken, as in inoculation or injuries from dissection, which last certainly pro- duce a species of infection. The first impression from infecting matter diffused in the atmosphere was supposed by the late Dr. Jackson to be made on the alimentary canal ; and it is very probable, at least, that by the act of deglutition, which per- sons are almost incessantly performing to swallow their saliva, noxious particles may be conveyed thither, and whether we regard its mucous mem- brane as an absorbing or sentient surface, it is one through which such particles are very likely to act on the animal economy. But the most ready ac- cess for atmospheric poisons to the system is af- forded by the air-passages. The experiments of Nysten and Edwards have proved that hydrogen, azote, and other gases, are rapidly absorbed by the lungs; and analogy would lead us to attribute a similar susceptibility of absorption to contagious and other miasmata; whilst if we reject the ne- cessity of absorption, and assume that a nervous impression is all that is required, we find a widely extended and sensible membrane on which the deleterious corpuscles may operate. The local operation of these poisons has been considered as far as our present knowledge of the subject admits. It remains that we should notice their more general effect, or their operation on the animal economy, if we are to take such a view after they are absorbed into the circulating mass. To discuss the various changes which odorous infecting matters effect in the system—the modes in which they destroy life or impair its vigour, would lead to a very lengthened disquisition, and one which perhaps belongs rather to the physiolo- gist than the practical physician. But the agency of the morbific poisons by which what is strictly called infection of the human constitution is pro- duced, and diseases are engendered ranking among the most important of our nosologies, demands some notice in this place. To whatever parts of the body morbific animal poisons or marshy efflu- via may be in the first instance applied, and how- ever various the diseases ultimately engendered by them, we believe that their primary constitutional effect is on the nervous system. The period which generally intervenes between the application of a contagious or paludal poison and the full develop- ment of the disease engendered by it, is not one of health; and the slight signs of indisposition which exist are referable to the nervous system solely, excepting in a proportion of the cases aris- ing from marsh effluvia, where some disorder of the bowels is after a time associated with the in- dications of nervous affection. These indications are extreme debility, inertness in motion, irrita- bility and despondency of mind, incapacity of continued attention, noises in the ears, occasional giddiness, inappctency or morbid appetite, and ex- treme susceptibility of the impression of cold, the vascular system being during this period free from manifest disturbance. The firrt symptoms of the invasion of the actual disease partake of the same nervous character. They are giddiness of the head, pain there and along the spine, marks of irregular distribution of heat, rigors, inappctency, nausea, and in a proportion of the cases of some diseases, the exanthemata for instance, convulsions. One morbific poison, that of hydrophobia, appears to confine its whole operation to the nervous tissue, an extraordinarily erethismal state of this tissue giving rise to all the phenomena of the disease, and at its fatal close there being no traces of local affection of uniform occurrence or of such import- ance as to be considered as the source of the symp- toms witnessed during life. In most diseases the vascular and other systems are ultimately involved, but accurate observation will always discover pre- ceding indications of an affection of the sentient portion of the frame. For the mode of purifying infected substances, see Disinfection. t „ Joseph Brown. INFLAMMATION, from infiammo, to burn; hence, also,phlogosis, phlegmasie, phlegmon, &c. from a »"" •—■ - Jews refusing at the present day to eat the flesh of any animal which has not been bled to death, and ot their having their own butchers. This opinion was embraced by Harvey, and in modern times has been warmly advocated by John Hunter. He considered, like some of the ancients, the principle of life to be a kind of distinct agent, independent of the conditions of matter, and endowed as it were with consciousness ; he be- lieved, however, this principle to reside chiefly in the blood, and made a great many ingenious experiments tending to support this opinion. Hunter's arguments in favour of the independent vitality of the blood, were its property of sponta- neous coagulation, and of assuming under certain circumstances the most complete organization. When blood is drawn from the vessels, the glo- bules, which consist of pure fibrine, are attracted together and disposed to arrange themselves in lines or fibres, constituting the crassamentum. This fibrous arrangement bears a great analogy to the fibres of muscles, which consist also chiefly of fibrine.-j- Many causes of sudden death, such as lightning, the bites of venomous animals, some acrid and narcotic poisons, by which the nervous action is suddenly paralysed, have also the re- markable effect of suddenly changing the compo- sition of the blood, preventing its coagulation, and rendering it incapable of supporting life. Under similar circumstances, the muscles are also found relaxed and incapable of being excited by the ac- customed stimuli. These facts have been sup- posed by Hunter to prove an identity between the property of muscular contraction and that of the coagulation of the fibrine :+ this idea seems to be further supported by the circumstance of the che- mical composition of the fibrine and of muscle being nearly the same. There have been many speculations on the cause of the spontaneous coagulation of the blood, some ascribing it to its death, and others, like Hunter, to its life, whilst some have attributed it to the escape of carbonic acid gas. The remark- able properly of spontaneous organization which has been so frequently observed in coagula of blood, seems directly opposed to the idea of its coagulation being the effect of its death ; on the other hand, if blood is frozen and then thawed, it coagulates the moment it becomes liquid. We must admit that the blood was dead when frozen, and its coagulation after being thawed cannot therefore be reasonably attributed to its life. (Elli- otson's Lectures, Med. Gazette, Dec. 1831.) The opinion of the coagulation depending on the escape of carbonic acid, which has been advanced by Sir C. Scudamore, is proved to be equally fal- lacious by the fact, that no carbonic acid has been f Dr. Hodgkin, having made numerous microscopic observations on the minute structure of various tissues and on the composition of some of the animal fluids, de- nies that the particles of the blood have a globular form, and gives a description of them totally different from that of preceding physiologists. (Catologue of the prepa rations in the anatomical museum of Guy's Hospital, ob- servations on section xi.) t Dr. Stevens, who has made many experiments on the coagulation of the blood, mentions the following remarkable fact: " If at a certain period after the coagu- lation has commenced, we add muriate of soda or a saline solution to the coagulating blood, the moment that the fibrine feels the stimulus of the salt, the whole of it be- comes suddenly solid ; and I have seen the fibrine of in- flammatory blood, which had been drawn during thu hot stages of the marsh fever, contract on the applica tion of salt with almost as much rapidity as the mus cles, when we apply the same stimulus to the fibres i» the living body."—Stevens on the Blood, p. 1&3. 702 INFLAMMATION. detected in the blood by the most accurate chemi- cal analysis. Dr. Stevens has attempted to prove that the fibrine partly owes its fluidity within the body to the circumstance of being held in solution by the saline substances contained in the serum; that this saline solution, together with the influ- ence of the living principle and of constant mo- tion, contributes to preserve its fluidity in the vessels, but becomes insufficient to hold it in solu- tion when removed from the body. The insur- mountable objection, however, to this hypothesis is, that fibrine is found to be totally insoluble in solutions of neutral salts. Dr. Bostock's explana- tion of this property of the blood appears to us on the whole the most rational. He states in his valuable System of Physiology: " Perhaps the most obvious and consistent view of the subject is, that fibrine has a natural disposition to assume the solid form when no circumstance prevents it from exercising this inherent tendency. As it is gradually added to the blood, particle by particle, while the fluid is in a state of agitation in the vessels, it has no opportunity of concreting; but when it is suffered to be at rest, either within or without the vessels, it is then able to exercise its natural tendency. In this respect the coagulation of the fibrine of the blood is very analogous to the formation of organized solids in general, which only exercise their property of concreting or coales- cing under certain circumstances, and when those causes, either chemical or mechanical, which would tend to prevent the operation, are not in action." (Elementary System of Physiology, vol. i. p. 444.) [It is proper, however, to remark, that the blood may remain fluid in the vessels, and coagulate when removed from them long after the death of the body. In a case observed by the author, it flowed freely from the vessels of the brain, and coagulated fifteen hours after the total cessation of respiration and circulation, (Proceedings of the American Philosophical Society for May, June, and July, 1840, p. 216, and Amer. Med. Intelli- gencer, Aug. 1, 1840); and many such cases have been observed by others, (Dr. J. Davy, Researches, Physiological and Anatomical, Amer. Med. Lib. edit., Philad. 1840.) These facts would favour the idea, that the coagulation of the blood is a purely physical phenomenon.] But the great argument in favour of the vitality of the blood is its property of spontaneous organi- zation. When the fibrine and albumen [liquor sanguinis] are exuded in the form of coagulable lymph, it frequently happens that, although not in immediate contact with any of the surrounding solids, blood-vessels are seen shooting in every direction through the mass of concrete lymph, and it is gradually transformed into a new and perfectly organized living solid, having blood-vessels, lymph- atics, and nerves, and performing all the functions of an original texture. The blood and the solids, when submitted to chemical analysis, are found to consist excited by any stimulating injection, or the passing . of a seton, the blood, instead of being absorbed, is 3 rapidly converted into pus : it would appear, there- , fore, that a certain degree of inflammation is indis- 1 pensable for the transformation of extravasated 1 blood lymph into pus. 3 It is deserving of notice that venous bloou ap- , pears to possess a greater tendency to conversion j into pus than arterial, while the latter is much 710 INFLAMMATION. more disposed to become immediately organized ; and likewise that suppuration is favoured by a high degree of inflammation, whilst immediate organization is more generally the result of mode- rate inflammation : these considerations point to a variety of important practical precepts. Suppuration, however, is not merely the result of the conversion into pus of a mass of extrava- sated blood or coagulable lymph, but takes place both on the surface and in the interior of inflamed organs by a regular process of secretion, through the medium of vessels either previously in exist- ence or newly formed. It constitutes in this man- ner a new function, which sometimes persists for a considerable period after the inflammation has subsided, as is seen in fistulous sinuses, chronic ulcers, setons, &c. Gendrin has minutely investi- gated the nature of this process by exciting violent inflammation in the web of a frog's foot and in the mesentery by means of a seton, the actual cautery, or boiling water, and watching its pro- gress with the microscope. The following inter- esting account of the result of these experiments is favourable likewise to his opinion of the globules of fibrine being directly converted into globules of pus. (Op. cit. vol. ii. p. 477.) After the inflammation has attained its height, the circulation remains for some time stagnant, the vessels and intermediate cellular texture being both filled with coagulated blood and lymph; the colouring matter gradually disappears, the part assuming more and more an opal tint; small yel- low soft molecules may be seen interspersed through the coagulum, and some of them agglo- merating in large globules evidently purulent. A slow degree of motion gradually becomes apparent by the oscillation of some of the globules in the old vessels; whilst a passage seems to be made for others through the mass of softened lymph by the formation of new canals, especially near the surface. It is stated, moreover, that the various alterations which the globules of the blood un- dergo during their conversion into pus can be dis- tinctly followed by the eye, especially in the blood- vessels of the mesentery; that the globules are first seen corrugating themselves and separating from their colouring envelope ; that they then lose their transparency, becoming, as they approach the edge of the wound where the irritation is the strongest, more opaque, larger, softer, and com- pletely converted into purulent globules. Small lacerated portions of the substance of the part are in some cases apparently dissolved by and carried along with the pus. The vessels soon become more distinct and numerous, and the circulation more regular, although it continues very slow as long as the vessels convey pus. As the swelling subsides by the discharge of the pus, the vessels in the centre re-admit red blood, and their circu- lation becomes more active. As soon as the sup- puration ceases, a coagulable globular lymph of a pale flesh colour, and covered with red streaks, is exuded on the surface of the wound instead of pus; the red streaks are converted into vessels, by ineans of which the stratum of lymph becomes organized, and the cicatrization is completed. When suppuration is prolonged and rendered habitual by artifical means, the vessels secreting pus are increased in size and number, and assume a more regular action. Gendrin concludes from his experiments that the conversion of the fibrine of the blood into pus takes place independently of the action of the vessels or of any vital influence of the inflamed part, and by a mere chemical process not yet well known. This is an opinion, however, which we think scarcely admissible, for it would be extreme- ly difficult to account for the great varieties ob- served in the qualities of pus in different forms of inflammation, and especially for its specific properties in certain diseases, on any other princi- ple than that of referring them to the vital in- fluence of the diseased vessels, as at least one of their essential causes. The preceding, which is the most simple form of the suppurative process, usually attends mild inflammation. In violent inflammation, when the parenchyma has been much lacerated by the ex- travasation of blood and coagulable lymph, instead of the pus being entirely collected in vessels, it accumulates towards the centre of the tumour, where it is mixed with loose fragments of cellular tissue and coagulated blood. When the loss of substance has been considerable, the circulation is only partially restored, and the parts destroyed may undergo a degree of putrid fermentation; the pus itself assumes a dark livid colour and an acrid un- healthy character, and this leads to gangrene 01 sphacelus. Suppuration in this case takes place more by a process of decomposition than of regu- lar secretion; it is a species of imperfect suppu- ration. The alterations which the blood and other fluids undergo in different textures during inflammation, correspond in general to those just described as occurring in the cellular texture ; they present- however, a few modifications, which we shall no- tice in this place, in order to give a complete and connected view of the nature of the inflammatory process.* When a serous membrane, as, for in- stance, the pleura, is slightly inflamed, there is, first, an effusion of a yellowish serous fluid, slightly viscid and alkaline, and consisting almost entirely of a small portion of albumen held in solution by water. As the inflammation increases, the sur- face of the membrane is lined with a thin layer of a soft viscid substance of a greyish colour, con- sisting of a semi-transparent jelly, interspersed with small globules of a yellow tint, and charac- terized by the property of spontaneous coagulation. This coagulated substance increases in thickness, viscidity, and density with the inflammation, con- stituting on the third or fourth day a distinct plastic, laminated, pseudo-membrane. When sub' mitted to analysis, this membrane is found to con- sist of fibrine with a small proportion of albumen, and corresponds in every respect with the coagu- lable lymph of phlegmonous inflammation; it is insoluble in water, otherwise it would be dissolved by the serous fluid contained in the cavity of the membrane, instead of adhering to its surface. The serous fluid poured out at this period of the inflammation loses its transparency, becomes tur- bid, viscid, and more alkaline ; its albumen is * See Gendrin. Op. cit. Alterations des fluides, &c. vol. ii. p. 492, from which the facts contained in the follow ing account have been partly derived. INFLAMMATION. 711 considerably increased, and it deposits a greyish flocculent coagulable matter, exactly similar in its properties to false membrane, containing only a larger proportion of albumen and aqueous fluid. When the inflammation has lasted several days, the liquid assumes a yellow or greenish tint, and there is added to the coagulable lymph a yellow viscid matter, which is deposited in a pulverulent form, is soluble in alkalies when dried, and when examined by the microscope, presents all the ap- pearances of globular pus. A large proportion of this last-mentioned matter is formed in violent in- flammation, giving the effused fluid a well-marked purulent appearance, and a quantity of pus is sometimes deposited, as pure and genuine as that coming from an abscess. The inflammation of all serous membranes is followed by similar results. In the inflammation of synovial membranes the viscid, oily, albuminous synovia is likewise con- verted into coagulable lymph or pus, according to the intensity of the inflammatory action. The fluid secreted by mucous membranes con- sists, in health, of animal mucus held in solution by an aqueous fluid, and containing a small quan- tity of saline matter ; the proportion of these in- gredients varies in the different mucous membranes, and other elements are added to them in some, such as muriatic acid in that of the stomach, a sebaceous matter in that of the ear, &c. In active congestion or commencing inflammation, there is generally more or less increase of the natural se- cretion ; it has in ophthalmia the appearance of thin viscid yellow mucus; in coryza it is more fluid and of a yellow white ; in bronchitis it is transparent and viscid, like the white of an egg mixed with water ; in diarrhcea it is very watery and copious, with white flakes floating in it; it is also more or less tinged with bile. In inflammation of the vagina and urethra it is thin, white, and transpa- rent ; in inflammation of the urinary bladder it is mixed with the urine, in which it floats in the form of viscid flakes. In all these cases the mucus has been found slightly alkaline, except that of the digestive tube, which remains acid. This alkaline property is owing to the presence of a small quan- tity of soda. These copious secretions of thin mucus often prove critical, in relieving attacks of congestion or slight inflammation. In more acute inflammation there is excreted in the beginning a very acrid sero-mucous fluid, which excoriates the lips in coryza, the cheeks in ophthal- mia, the anus in diarrhcea, and the internal surface of the thighs in leucorrhcea; this thin acrid mucus is sometimes streaked with blood, as in bronchitis ind dysentery. It differs from the mucus of con- gestion or mild inflammation by coagulating in boiling water and containing albumen ; its acridity is due to the presence of alkali (soda); the quan- tity of albumen is sometimes so considerable that it floats in the thinner part of the fluid in white lumps, differing in no respect from the albumen contained in the serum of the blood, but that there is mucus incorporated with it. At this period of the inflammation there is sometimes an exudation of fibrine as well as of albumen, and this leads to the formation of the false membranes frequently found in the larynx, the trachea, or in some por- tions of the alimentary canal. As the inflamma- tion advances, the secretion lessens in quantity, and it becomes completely suppressed when the inflam- mation has reached its height; there is only then exhaled a very small quantify of a thin viscid fluid, frequently more or less tinged with blood. When the inflammation begins to abate, the secretion returns, becomes very copious, and as- sumes new characters and properties, having a striking analogy with the favourite hypothesis of coction of the ancients. In ophthalmia it is effused in considerable quantities on the surface of the conjunctiva under the appearance of a yellow opaque viscid fluid, distinctly globular, and still a little acrid; il presents nearly the same characters in coryza. In acute bronchitis the expectoration, which consisted first of a thin mucus mixed with some albumen, now assumes the appearance of opaque, yellow, conglomerated masses,-surrounded with some mucus, and constituting well-formed sputa, such as was termed by the ancients well concocted. In diarrhcea there is a greyish, yellow, viscid fluid, containing small portions of coagu- lated albumen ; in blenorrhagia a profuse secretion of a viscid opaque fluid of a yellow colour, inclin- ing sometimes to green. All these secretions, when analyzed, separate into two principal fluids; one, of a milky colour and transparent, floats on the surface of water, or is suspended in it in small flakes; the other, which is of a greyish yellow, and presents all the characters of genuine pus, sinks to the bottom of the vessel. Puriform mucus floats on the surface of water, if the mucus pre- ponderates; but if the pus be in larger quantity, it sinks to the bottom. In very severe inflamma- tion the secretion consists of very liitle mucus, but almost entirely of pus, and the viscidity of the expectoration diminishes with the increase of the latter. In chronic inflammations of mucous membranes, and especially in old catarrhs, if the inflammation is very moderate, the secretion is often purely mu- cous and not purulent, it separates into two parts, one transparent, slightly viscid, and chiefly serous; the other more opaque, greyish, flaky, grumous, and consisting of pure mucus: it is sometimes streaked with black from the secretion of the bron- chial glands. If an acute inflammation supervenes on the chronic, the expectoration becomes more thin, abundant, acrid, or frequently purulent, and does not resume its usual qualities until the inflam- mation abates. These exacerbations of old catarrhs are generally attended with great irritation. Pro- fuse mucous or sero-mucous secretions of long standing must not be supposed always to indicate chronic inflammation, as they sometimes occur spontaneously by a mere increased activity of se- cretion. When, however, the secretion is both purulent and mucous, it is always a sure sign of the presence of inflammation either acute or chro- nic : profuse purulo-mucous discharges of this description occur sometimes in coryza, bronchitis, and colliquative diarrhcea, and are attended with considerable debility. The alterations of the bronchial secretions in pneumonia are also striking and important. In the first stage of inflammation there is expecto- rated a white viscid frothy fluid, containing a good deal of saliva ; it gradually acquires a yellow and then a green tint; its viscidity increases so much that it separates into two parts, the one a thin 712 INFLAMMATION. frothy fluid, the other a thick viscid ropy sub- stance, which sinks and adheres to the vessel. About the third or fourth day the expectoration is often slightly tinged with blood, either uniformly or in streaks, and of a bright red or iron dusky colour; it has generally a saltish taste ; the blood is, however, closely incorporated with the sputa, and not free, as in hemoptysis. The expectora- tion at this stage is found to contain mucus, albu- men, and a certain proportion of fibrine, united with some of the colouring matter of the blood ; it is the combination of albumen and fibrine with the mucus that renders the expectoration so plastic, adhesive, and ropy. In the second stage of pneumonia, or that of red hepatization, the expectoration presents the same characters, only that the thinner fluid be- comes also tinged with blood, which gives the whole expectoration a dirty pale-red colour; there is, however, a considerable decrease in its quan- tity. In partial and interlobular pneumonia the expectoration may continue purely catarrhal, or be only very slightly coloured. In the third stage, or that of the grey hepatiza- tion, the secretions being suspended, there is for some time little, or no expectoration ; but as soon as the inflammation, having reached its height, begins to decrease, the expectoration returns. From being viscid, adhesive, and sanguineous, as described in the second stage, it becomes yellow, opaque, less tenacious, and also less tinged with blood ; it sinks in water, and possesses all the characteristics of pus. As the resolution ad- vances, the expectoration gradually becomes less purulent, and assumes again the plastic, viscid, sanguineous appearances of the second stage of inflammation ; it then passes from this state to that of pure mucus, until, on the complete restoration of the pulmonary function, it finally disappears. The transition of the tenacious bloody expecto- ration into purulent can be very distinctly traced by dissection in the bronchial tubes of an inflamed lung. If the inflammation be arrested in the second stage by active treatment, the expectora- tion, instead of assuming a purulent character, loses its viscidity, becomes more sanguineous and very frothy : this change is favourable, as it indi- cates a more free admission of the air into the in- flamed pulmonary texture, and an exudation of blood on the surface of the mucous membrane—a kind of bronchial hemorrhage which tends to re- lieve the pulmonary congestion and inflammation. It is evident, therefore, that the formation of pus requires that the inflammation should have at- tained a certain height, and the blood have been submitted to a certain elaboration ; this corresponds exactly with the notion of coction entertained by the ancients, which, however ridiculed by some, was founded on a correct observation of nature. In chronic pneumonia the expectoration con- sists of thin transparent mucous fluid, and of a yellow purulent matter, which sinks to the bottom. In chronic catarrh and bronchitis we have already seen that the expectoration is sometimes purulent, tiut consists in other instances of mucus, more or less viscid or diluted. Purulent sputae always rink in water; mucous sputae sink in water when rery thick and viscid, hut float on the surface when thin and flaky, and pure pus floats on water when mixed with a large proportion of mucus. It has thus been seen that in the inflammation of mucous membranes, the component parts of the blood undergo distinct changes, by which all the morbid phenomena can be explained as satisfac- torily as in phlegmon. The serous portion of the blood, which has acquired increased coagulability, is exhaled with some of the fibrine, and frequently tinged with the colouring matter; the albumen of the serum, and the fibrine, supply the materials for the secretion of pus; and all these fluids are mixed in various proportions with the natural se- cretions of the membrane, which have themselves undergone certain changes both in quantity and quality. The secretions of the skin experience corre- sponding alterations in inflammation. The skin, when inflamed, secretes at first a serous fluid ana- logous to the serum of the blood, but containing an increased quantity of albumen, which gives it a gelatinous appearance ; as the inflammation ad- vances, a portion of fibrine is added, increasing the tenacity of the secretion, and forming some- times a plastic membrane. These changes may be observed in the bullae arising from blisters, sina- pisms, burns, &c. When the inflammation has reached its acme, the gelatinous layer becomes more dense and friable, acquiring a yellow opaque colour, and all the properties of pus. In chronic erythematic affections the pus is sometimes green- ish, tinged or mixed with pure blood. The secre- tions of the inflamed sebaceous glands are some- times incorporated with the sero-albuminous or purulent fluid, giving it a peculiar fetid odour, varying in different parts of the body. It is by the concretion of these various fluids that the scales and crusts of cutaneous diseases are formed, as observed in herpes, tinea, psoriasis, &c, and it is also from the sebaceous matter that these crusts derive their peculiar odour. The changes which the blood undergoes in in- flammation, and its mode of conversion into pus, are the same in all textures; the intimate compo- sition of the pus is also identical in all, presenting only such modifications as necessarily arise from the character and degree of intensity of the inflam- mation, and from the intermixture with other fluids. As the composition of the pus and its various modifications will be more fully considered iw the section Suppuration, we shall only remark that its globular appearance, and its being composed chiefly of albumen and fibrine, are striking proofs, in ad- dition to those already advanced, of its beirfg de- rived immediately from the blood. The exudation, in the inflamed part, of coagu- lated blood or lymph, and of other materials more or less concrete, proves sometimes so completely critical, that the inflammation subsides, leaving the swelling behind it. The inflammatory products may then remain in the part for a considerable time without undergoing any change, constituting vari- ous forms of induration and infiltration. These swellings may at a later period terminate by ab- sorption or suppuration, or else take on some form of specific and unhealthy inflammation, such as the cancerous, syphilitic, scrofulous, &c. The dispersion of the inflammatory deposits without suppuration is partly accomplished by the impetus INFLAMMATION. 713 of the current of the blood gradually removing the cause of obstruction from the clogged vessels, and partly by interstitial absorption, as already stated in describing the phenomena of resolution. It is important to remark that, besides the tume- faction resulting from the deposit of morbid pro- ducts, inflammation, when much prolonged or often repeated, causes sometimes an enlargement of purls, by exciting an exuberant action of the nu- iritive powers, and a consequent excessive nourish- ment termed hypertrophy,- there is in this case merely an increased activity of the healthy func- tions, and a preternatural enlargement of the healthy structure, without the occurrence of any morbid process, or the production of morbid de- posits. Hypertrophy is more frequently induced by chronic than hy acute inflammation. On the other hand, one of the frequent effects of inflam- mation, as already stated, is to interrupt the healthy functions of a part; it may cause in this manner a waste of parts from deficient nourishment, and reduce them to a state of atrophy; this is more generally a consequence of acute inflammation. These opposite results of inflammation are some- times observed in parts composed of different struc- tures ; an exuberant nourishment of one tissue is generally attended with a deficient nourishment of the other tissues of the same organ. We some- times see a considerable thickening of the investing membrane of an organ, and a wasting of the sub- stance of the organ itself. The nutritive powers may not only deviate from the healthy standard by being increased or dimi- nished, but are sometimes also perverted ; and this leads to transformations of texture. One tissue may thus be changed by a mere aberration of nu- trition into a structure corresponding exactly with some of the tissues already in existence in the body, such as bone or cartilage ; and these trans- formations are called analogous. But parts that have been long exposed to chronic inflammation frequently acquire a new structure in consequence of a vitiated nutrition, totally different from any in the healthy body; and these transformations are called non-analogous. They give origin to a va- riety of tumours, simple or compound, hard or soft, benign or of a malignant nature. Acute in- flammation generally lessens the cohesion of tissues, and often reduces thein to a remarkably pulpy state, by a peculiar process termed softening. Chronic inflammation, on the other hand, has a greater tendency to cause parts to become indurated.— There are many exceptions, however, to these rules. Softening and induration are sometimes combined in the different textures of the same, or- gan ; but we must refer to the articles Indura- tion, Softening, Hxpertrophy, Athopht, for fuller details of these important changes. When the sensibility and vascular action of a part are so completely destroyed that all vital mo- tion ceases, the dead animal tissues are soon affected with putrefaction, and this constitutes what is termed mortification. When this occurs as the direct effect of inflammation, it is to be attributed either to its excessive violence causing the rupture of a great many vessels and a considerable extra- vasation of blood, or to the nature of the exciting cause, or to some obstruction of the circulation. We shall not, however, enlarge here upon this and Vol.. II. —90 oK some other effects of inflammation, such as ulce- ration, effusion, &c, as our only object in this section is to describe those morbid changes which are best calculated to illustrate the theory of inflam- mation, so as to enable us to define it accurately from all other morbid actions. We must, there- fore, refer the reader for further details to the arti- cles Mortification, Ulceration, &c. Although the preceding changes of structure are frequently the consequence of inflammation, it is necessary to remember that they may occur without any inflammation: the preternatural growth of a part presupposes some increased action of its vessels, but this may take place within the limits of healthy action, and the increase of growth does not at all require that it should be carried to such an extent as to become morbid. It is obvious that atrophy is more likely to be the effect of deficient than of increased action; and both induration and softening are frequently seen to take place under the influence of debility rather than of irritation. A perverted state of the nutritive functions will sufficiently account for all transformations of tex- ture, without the necessity of admitting any in- crease of action; when they are attended with inflammation, this is much more generally to be considered as an ultimate effect of the irritation they have excited in the surrounding parts, than as an exciting cause; there is, however, no doubt that a state of long-continued irritation is one of the most powerful predisposing causes of these changes of structure. It is important also to observe that many of the other common effects of inflammation sometimes occur without any inflammatory action: that in- creased secretions, effusions, hemorrhages, adhe- sions, suppuration, ulceration, and mortification may be the result of a state even opposite to in- flammation, is a fact fully established by nume- rous pathological observations. There are nume- rous examples of large adhesions in the pleura in persons who had never experienced inflammation of the thoracic organs. Ulceration occasionally occurs in the skin and in the mucous membranes of the alimentary canal and of the throat, without any perceptible inflammation, and when the parts, on the contrary, are quite pale : 1° 'he course of a few hours all the symptoms of congestion, such as quickened circulation, increased redness, and slight tumefac- tion, are not only observed in the part first sub- jected to the irritation, but nearly to an equal ex- tent also in the web of the other extremity. The irritation has, therefore, spread by sympathy to the whole circulating system, producing an in- creased redness and coagulability in the entire mass of blood, an increased activity and turges- cence of all the vessels, analogous to that observed in the original point of irritation. In fact, a spe- cies of general congestion has taken place, con- stituting fever; this sympathetic fever subsides with the local congestion. If a very acrid and poisonous stimulant, such as a solution of muriate of mercury, be used, the following remarkable re- sults occur:—signs of severe pain; great accele- ration of the circulation in the webs of both feet; the globules of the blood, instead of a vivid red, assume a dark brownish colour, and the blood shows a tendency to decomposition; the texture of the webs is tumefied, but rather pale ; the skin of the whole body is pallid and covered with a thin mucus; after some time the vessels become less turgid ; they contain but a small column of blood and are relaxed, their contractions con- tinuing rapid but feeble. Small ulcers appear on different parts of the body, and the animal finally dies. [In repeating these experiments, however, we have not been able to distinguish the ulcers alluded to.] In this instance we first see a local inflam- mation followed by sympathetic fever, and next the fever itself becoming the cause of secondary inflammation in various other parts of the body. The essential characters of fever are, therefore, increased quickness of the circulation, alterations in the quality and quantity of the blood, general turgescence of the blood-vessels, and, as aptly re- marked by Kaltenbrunner, a species of inflamma- tory erethism. In secondary fever the local effects of stimulants are propagated to the whole vascu- lar system, whilst primary fever itself may become the exciting cause of local inflammation. The character of the fever may vary according to the previous state of the constitution, and the activity and nature of the stimulant. If a pow- erful stimulus be applied to a constitution in which there is a redundancy of rich blood and great ac- tivity in all the functions of life, the reaction will be strong, and the fever of a highly inflammatory nature. If, on the contrary, the mass of the blood be deficient in fibrine and red matter, and the vital powers low and little excitable, there will be less tendency to symptomatic fever. It has been ob- served that the lower animals are less subject to fever than the higher, but sink more rapidly under it. If there be a predominance of the nervous system, a great mobility of fibre and spare habit of body, the fever will be characterized rather by nervous irritability than great vascular action. If the irritating cause be of such a nature as to act chiefly on the nervous system, by first exciting and then depressing it, as is the case with various K.nimal and other poisons, the fever will also assume an essentially nervous character. If a ritiated state of the blood and fluids be combined with an exhausted and irritable nervous power, we shall have the most formidable and pernicious kind of fever, characterized by an alarming com- bination of nervous and inflammatory symptoms: this is still more likely to occur if the exciting cause itself be of a depressing nature, such as animal and other poisons, the putrid matter of dis- section, over-exertion of mind ; depressing pas- sions, &c. Finally, the exciting cause may ope- rate on constitutions characterized by a specific morbid diathesis, such as the scrofulous, rheuma- tic, gouty, cancerous, &c.; in which cases the fever assumes a variety of well-defined modifica- tions ; all these varieties of constitutional fever will be more particularly considered in their pro- per place. (See Constitutional Symptoms.) General Inflammatory Appearances of the Blood.— Besides the various alterations in the composition of the blood that have been described as occurring in local inflammation, the qualities of the entire mass of the blood are liable also to be affected in certain states of the constitution, which either predispose to, or are consequent upon local inflammation; there is, it may be said, a general inflammatory condition of all the fluids of the animal economy, and this is especially true with regard to the blood, the inflammatory charac- ters of which we shall proceed to describe. When blood is drawn from an individual affect- ed with an inflammatory disease sufficiently se- vere to disturb the constitution, the nature and appearance of the coagulum differ very materially from those of healthy blood; it contains a larger proportion of fibrine than healthy blood, and the fibrine at the top of the coagulum forms a layer of a yellowish white or slightly greenish colour, varying in thickness from less than a line to one or two inches ; this layer has received the name of size, buff, or buffy coat,- the surface of the coagulum is also frequently contracted, puckered up at the edges, and concave in the centre; the blood is then said to be cupped. According to the researches of Hewson, Dowler, (On the products of acute inflammation, by M. Dowler, Med. Chir. Trans., vol. xii.), Gendrin (Histoire Anatomique des Inflammations, vol. ii.) and others, the buffy coat consists of pure fibrine, deprived of the colouring matter, and mixed with a certain quantity of serum, which is found to contain much more albumen than the serum of the rest of the blood. There is a great analogy, therefore, both in appearance and in chemical composition, between the buffy coat of the blood, and the coagulable lymph that constitutes false membranes. Besides the buffed and cupped ap- pearances just described, the coagulum is in gene- ral of a greater density than in health, and less easily broken ; it is firmly contracted and dry, in consequence of the serum being more completely pressed out of it, and it appears for this reason smaller in proportion to the quantity of serum; it has an ovoid truncated shape, and is frequently found floating in the centre of the vessel on a level with the serum. The cupped appearance, however, and the firmness both of the buffy coat and of the entire coagulum, are usually propor- tionate to the strength of the patient and severity of the inflammation, and are also greater in the inflammation of certain textures than of others, such as serous membranes, aponeuroses, tendons, INFLAMMATION. 715 ligaments, and other fibrous tissues. But it should be remembered that there is sometimes considera- ble firmness of the coagulum without any buff or cupping- When the buffy coat is soft, the coagulum is less cupped, softer and larger, adheres to the bot- tom of the vessel, and contains more serum; the layer of buff is also thinner, and there is in reality a larger proportion of serum, although this may not be apparent at first, in consequence of its not being so completely separated from the coagulum: the blood is then sometimes described as being sizy. Whenever there is an excess of the serous portion of the blood, the coagulum will be found soft. The serum of inflammatory blood is also proved, by the researchesof Drs. Traill and Gendrin, to be altered in quality, and to contain nearly twice as much albumen as in the healthy state. Gendrin has sometimes observed, especially in cases of chronic and suppurative inflammation, a mucous layer, either at the bottom of the serum, or sus- pended in it like a cloud ; the buffy coat in these cases was also of a more obscure white, less trans- parent, and softer. The following are the appearances presented by the blood under different degrees of inflamma- tion, according to numerous experiments made by Gendrin. (Op. cit. vol. ii. p. 430.) In cases of very severe inflammation the blood coagulates rapidly. The buffy coat is thick, greatly cupped, firm, and elastic; the coagulum has the form of an oval, truncated at both extre- mities ; it is dense and elastic (containing little serum), and floats on the surface of the serum, to which it bears the proportion, in point of volume, of one to one and a half, and sometimes two. The serum is viscid, colourless, and a little turbid at the bottom, but contains no colouring matter. In some rare cases of extreme inflammation, the proportion of serum is less than that of coagulum ; the buff is very thick and dense, the coagulum adheres to the bottom of the vessel, where it is broader than at the top, having the shape of a truncated cone. In cases of moderate inflammation the buffy coat is not so thick; there is little or no cupping; the coagulum is firm, cylindrical, and floats in a yellowish serum, equal in quantity to twice the volume of the coagulum; there is also a slight layer of colouring matter at the bottom of the vessel. In sub-acute inflammation the coagulum may be slightly buffed, but more generally presents on its surface a layer of a bright red colour, and one or two lines in thickness; it is dense, slightly ovoid, and floats in the serum, although it some- times either adheres to the vessel, or sinks to the bottom. The serum is viscid and limpid, but of a reddish colour at the bottom of the vessel, in consequence ol the precipitation of some of the colouring matter ; the serum equals in quantity at least twice the volume of the coagulum. There may occur, of course, many modifications in degree between each of the preceding divisions; but this general outline will be sufficient to guide us in estimating the character of the inflammation, as far as we can depend upon the appearances of the blood. It is important to notice that the blood may present all the inflammatory appearances just described, without the actual existence of any inflammation. Ratier and Belhomme ascertained by numerous experiments, that the blood of indi- viduals in a state of sanguineous plethora was often buffed and cupped ; this circumstance affords an additional proof, if any were wanting, that the general state of the blood may become a primary cause either of inflammatory fever or of local in- flammation. The same inflammatory appearances are frequently observed also in pregnancy; the constitution of a pregnant woman bearing the closest analogy to the inflammatory diathesis, for the extraordinary increased activity of the circu lation in the uterus borders on inflammation, and the general circulation of the mother is in a state approaching to symptomatic fever. The buffy coat has also been found in individuals who were in the habit of being bled, as a measure of pre- caution, at certain periods of the year. The buffy coat and cupped-like form have been observed in the arterial blood during inflammation. Dr. Tweedie has seen it on two occasions ; one was a case of inflammation of the chest, in which the temporal artery was opened in consequence of failure to procure blood from the veins ; the other was a case of cerebral fever, in which blood was also taken from the temporal artery. Gendrin says that, on the only two occasions in which he opened the temporal artery, he observed a thin layer of buff, slightly coloured, on the surface of the blood. The presence of the buffy coat may generally be considered as a correct indication either of the actual existence of inflammation, or of a strong predisposition to it; and when the obscurity of the other symptoms leaves any doubt respecting the inflammatory nature of a case, a buffed and cupped appearance of the blood will tend greatly to con- firm us in the opinion of the disease being inflam- matory. The degree of buffiness is not, however, in proportion to the danger of the inflammation ; for, as already stated, in the inflammation of fibrous tissues, the blood is in general more in- tensely buffed and cupped than in that of vital organs. The absence of the buffy coat is not, on the other hand, to be taken as conclusive evidence of the non-existence of inflammation. We have seen that in sub-acute inflammation the buffed and cupped appearances are often wanting, and that they accompany the inflammation of certain tissues more constantly than that of others. In some in- flammations of the mucous membranes, for in- stance, such as bronchitis, the blood frequently exhibits no buffiness or cupping. In weak or phlegmatic subjects also, whose blood is impover- ished and whose constitutions are not very sus- ceptible of sympathetic irritation, an important organ may be affected with dangerous inflamma- tion, although the blood exhibits no indication of such a state of disease, and has, on the contrary a dark red, jelly-like, and decomposed appearance. This has been observed in cases in which the in- flammation has run rapidly to gangrene, or when the fever was of a typhoid character. It has also sometimes occurred in these cases, that when tht typhoid symptoms have subsided, and the fever has assumed a more acute character, the blood 716 INFLAMMATION. has then become buffy. Whenever, therefore, there are other well-marked symptoms of inflam- mation, we are not to attach much weight to the fact of the blood not exhibiting the usual inflam- matory appearances. The immediate cause of the formation of the buffy coat is obviously the circumstance of the colouring matter of the blood beginning to subside before the coagulation is complete, so that the upper part of the coagulum loses its redness. There have been numerous speculations respect- ing the remote cause of the buffiness, none of which, however, can be considered as satisfactory. Hewson, Dowler, and some others, thought that the fibrine of inflamed blood became lighter ; the latter states that he found the fibrine of the buffy coat to contain a larger proportion of serum, which, by diminishing its viscidity, facilitated the precipitation of the red matter. Hunter took an opposite view of the subject, conceiving that the red matter was squeezed out by the firmer coagu- lation of the fibrine : this is probably in part cor- rect, as we find the coagulum of inflamed blood much firmer than in its healthy state. Hewson and other writers have also affirmed that inflamed blood coagulates more slowly than healthy blood, and that more time is thus allowed for the subsi- dence of the red particles. This opinion, how- ever, is controverted by Drs. Davy and Gendrin ; the latter maintains, as the result of many experi- ments, that the coagulation of inflamed blood commences sooner, and is completed more quickly than that of healthy blood. That the slow coagu- lation of the blood is not sufficient to account for the formation of the buffy coat is clearly proved, moreover, by some experiments related by Dr. Stokes, in his Pathological Observations. He made twenty-seven experiments, in fifteen of which a buffy coat was formed, and in the re- mainder it was wanting. No coagulation took place in three of the latter class of cases, in less than from twenty to forty minutes, and in four there was no coagulation for eight minutes; there was, therefore, ample time for the red particles to have separated from the fibrine ; while in twelve out of the fifteen, in which there appeared a buffy coat, coagulation took place in five minutes, and was only delayed for fourteen minutes in the three others. Although the comparatively slower coagulation of inflamed than of healthy blood cannot be ad- mitted as the cause of its buffy appearance, it is nevertheless certain that every circumstance favour- able to an unusually rapid coagulation of the blood has the effect of preventing altogether the formation of a buffy coat. These circumstances are principally the following : a narrow opening of the vein, so that the blood trickles down slowly in a small stream ; being thus exposed to the cool- ing influence of the air, it coagulates almost in- stantly on reaching the vessel, so that there is necessarily no time for the separation of any of its constituent parts. We may sometimes account in this manner for the first cup not exhibiting any buffiness, while, if the blood is made to flow after- wards more freely, the buff may form in the second cup, in consequence of its coagulating more slowly. The formation of the buffy coat may also be pre- vented or very much lessened by the blood being received in a flat vessel, and especially if cold ; for by warming the same vessel so as to delay the coagulation, the buff has made its appearance. It is likewise prevented by letting the blood fall into the vessel from a height of three or four feet, or by keeping the blood for some time in a state of agitation, or by adding a solution of caustic potash. The formation of the buff is, on the contrary, favoured by making the blood flow from the vein in a full stream, and by receiving it in a deep and narrow vessel. A narrow vessel is also the most favourable to the blood assuming the cupped ap- pearance, which it very seldom does in broad and shallow vessels. Some have advanced that the mere acceleration of the circulation was sufficient to impart to the blood its inflammatory characters; but this is denied by others, and Sir Charles Scudamore says that he has never observed any buff' in cases of simple fever, or after violent ex- ercise. (Elliotson's Lectures, Med. Gaz. Dec. 3, 1831.) It is evident, therefore, that although the buffi- ness and cupped-like form peculiar to inflamed blood may be influenced in a certain degree by the various accidental circumstances just men- tioned, these are wholly insufficient to account for this remarkable property, and that it must depend on some other cause with which we aTe unac- quainted. The following remarkable facts would tend, however, to show that this property is im- mediately connected with some peculiar influence exercised by the vital powers of the system over the mass of the blood. The first cup of blood is often buffy, when the second is much less so, and the last one not at all. Now bleeding is frequently attended with an immediate diminution of the violence of the inflammatory symptoms, even while the blood is flowing; and the rapid change in the appearance of the blood may therefore be justly attributed to the amendment in the state of the patient. If at the end of some hours the inflam- matory symptoms increase, and blood be again drawn, it will be found to have re-assumed the buffy appearance. Gendrin has observed on se- veral occasions, that if blood was taken immedi- ately after recovery induced by syncope, it not only had lost its inflammatory character, but that the clot was much softer ; and the effect of syn- cope in rapidly subduing the inflammatory dia- thesis is well known. We have already stated that the fibrine is more abundant in inflamed than in healthy blood; it has been found, moreover, that the quantity of fibrine varies with the buffy appearance in the different cups, the blood of the first cup containing more fibrine than that of the second, so that the relief afforded by the bleeding is attended also with an immediate change in the proportions of the constituent parts of the blood. In some diseases of debility in which the blood and other fluids are greatly vitiated, the blood is often extremely deficient in colouring matter, and the coagulum appears of a dirty yellow or greenish colour. This must not be mistaken for the buf- finess of inflammation, from which it will easily be distinguished, by the great softness of the co agulum, turbidness of the serum, and general dis solved appearance of the blood. [The state of the blood in inflammation has INFLAM been long attended to, so far as regards the buffy coat, and the shape and character of the crassa- mentum. The causes of the buffy coat in in- flamed blood are presumed to be its slow coagula- tion, and the increased quantity of fibrin. We can thus understand, that in anaemia, in which the proportion of the red globules to the fibrin is diminished, the buffy coat may exist; and it is not uncommonly seen in chlorotic cases. The cupped form of inflammatory blood is owing to inequality of contraction. The upper surface being freer from intervening red particles con- tracts more powerfully than the under, and a con- cavity of the upper surface is the consequence. When, however, the contraction is weaker, the weight of the subjacent red clot, which forms a part of the same mass with the upper colourless portion, weighs this down, and keeps it in a hori- zontal position. (B. Babington, art. Blood, Mor- bid Conditions of the, in Cyclop, of Anat. and Physiol, i. 415.) The condition of the blood, which gives occa- sion to the buffy coat, when it occurs in inflam- matory diseases, has been considered by M. Piorry (Traite de Diagnostique, &c, § 781, Bruxelles, 1838) an inflammatory one of the fluid itself, and has received the name Hemite. Positive haema- tological experiments have shown, that inflamma- tory blood contains an increase of its fibrinous ele- ment. The experiments of various observers have been detailed elsewhere. (Practice of Medicine, 2d edit. ii. 534, Philad. 1844.) It will be neces- sary here to refer only to the recent investigations of MM. Andral and Gavarret. (Archiv. General. serie 3, tom. viii., p. 501; and Andral, Hematolo- gic Pathologique, Paris, 1843 ; or Amer. Trans- lation, Philad. 1844.) In another article, (Blood, Morbid States of the,) it is stated by the writer, that healthy blood consists, on the average, in 1000 parts,—of fibrin, 3; red corpuscles, 127; solid matter of serum, 80 ; and water, 790 ;—the proportion of fibrin probably varying, within the limits of health, from 2£ to 3£ in the thousand. In acute inflammatory affections, M. Andral inva- riably found an increase in the proportion of fibrin, the increase being proportional to the inten- sity of the inflammation, and the degree of symp- tomatic fever accompanying it; and he affirms, that if we find more than five parts of fibrin in 1000, in the course of any disease, we may assert positively, that some local inflammation exists. The average augmentation of fibrin in inflam- mation he estimates at 7; the lowest at 5 ; and the maximum at 10^. Pneumonia and acute rheumatism are the only diseases in which he has found the proportion of fibrin rise as high as 10. M. Andral hence approves of Meckel's definition of inflammation—" congestion with tendency to new production" — the new production being, according to M. Andral, an excess in the quantity of fibrin. He found, however, considerable differ- ence in the increase of fibrin according to the seat of the inflammation. In inflammation of the cellular tissue, it did not exceed 5 ; in pneumonia, it rose occasionally to 10 and more. In inflam- mations of the mucous membranes, when slight, and unaccompanied by fever, it remained in the usual quantity ; but when they attained a certain degree of intensity, and were accompanied by NATION. 717 febrile reaction, the fibrin invariably rose in amount. In inflammation of the serous membranes, the in- crease was marked ; and in acute rheumatism it rose as high as in pneumonia. The increase in the proportion of fibrin appears in the blood from the time the inflammation commences. In no case was it perceived before the modification of the solid that characterizes the phlegmasia was present. He properly, however, considers the question yet unsettled as to which of the two phe- nomena is primary, or whether they do not arise simultaneously. In the case of a burn, the blood clearly becomes affected secondarily, and analogy might lead to the belief, that the same may be the case with other inflammations. Dr. C. J. B. Williams (Principles of Medi- cine, Amer. edit., by Dr. Clymer, p. 227, Philad. 1844) thinks it is pretty clear, that the increase of fibrin, and its more contractile and separating quality, originate in the vessels of the inflamed part, and must be regarded as an augmentation of the vital process of nutrition developed by in- flammation. If oleaginous or finely-powdered substances be injected into the blood-vessels, they may circulate freely until they reach the extreme vessels; but there they become the source of obstruction and consequent inflammation. Viscidity of, the blood may likewise arise spontaneously from disease, and in all such cases some serious lesion of the lungs has to be apprehended. On the other hand, experiments have shown, that if blood be deprived of its fibrin, and be in- jected into the vessels, death speedily results ; and in such case, the blood has been found to have become so utterly unfit for circulation in the capil- lary vessels, that it was extravasated into the various tissues, and especially into the parenchyma of the lung. If the fibrin of the blood be removed in small portions, local lesions are induced, the origin of which cannot be mistaken. (Magendie, Lectures on the Blood, Amer. edit., Philad. 1839.) It would appear, consequently, that whenever the blood becomes much thinner than in health, it ceases to be adapted for the vessels in which it circulates, and transudation takes place through their parietes. In this mode—as the writer has repeatedly remarked—bleeding in many cases of hemorrhage proves detrimental, especially if wa- tery fluid be freely allowed at the same time.] Uses of Inflammation.—Inflammation may generally be considered as a salutary process, in- stituted by the powers of the constitution, or the vis medicatrix naturx, for the purpose of pre- venting, repairing, or removing the consequences of injury and disease ; but, like all other salutary efforts of the system, it not unfrequently becomes a source of serious injury, and leads to fatal re- sults, in consequence either of its excessive vio- lence, or of the importance of the part affected. The salutary effects of inflammation in pre- venting more serious disease are well illustrated by the process of adhesion. When an opening is made in any of the hollow viscera, either by ul- ceration or violence, the escape of their contents into the surrounding cavities is likely to prove fatal by exciting violent and very extensive in- flammation. This, however, is frequently pre vented by a slight inflammation set up spontane 718 INFLAMMATION. ously on the outside of the organs, and near the edge of the ulcer or wound ; coagulable lymph is effused, and firm adhesions are thus contracted between the opening and the surrounding parts. Adhesive inflammation is often useful in prevent- ing the spreading of disease, as, for instance, of suppuration or ulceration. Both adhesive and ulcerative inflammation assist materially in the re- moval of foreign substances or collections of mat- ter, which are deeply seated ; thus, in cases of hepatic abscess, there are sometimes firm adhesions first contracted between the liver and the large intestine, or the stomach, and then a passage is opened for the pus, by a process of ulceration, into either of these organs, and its escape into the cavity of the abdomen, which would inevitably prove fatal, is thus effectually prevented. A si- milar process attends the pointing of all abscesses of internal organs towards the parietes of the cavities in which they are contained, and the pas- sage also of foreign substances through important parts of the body. The advantages of inflammation in repairing the effects of injury or disease are illustrated by the reunion of divided parts, and the restoration or reproduction of some which have been partially destroyed, as is the case with bone, skin, cellular membranes, and vessels; there are structures, however, such as the nervous, muscular, and fibrous, which are not susceptible of being repro- duced. When the consequences of injury or disease are to be removed, this is effected either by sup- puration, ulceration, or increased secretions. When a part of the body has become useless and inju- rious in consequence of mortification, and when the mortification has a tendency to spread, this is prevented, and the separation of the living from the dead parts effected by a circle of inflammation being excited at their point of contact, which is followed by a gradual process of ulceration, where- by the dead parts are completely cast off. When, after severe injuries, parts have been so much lacerated and contused that reparation be- comes impossible, they are removed by suppura- tive inflammation. Suppuration is also some- times of use in the removal of noxious substances and of foreign bodies; this may likewise be ef- fected by increased secretions, or by the effusion of lymph, which afford relief, moreover, by sheath- ing and protecting the parts from the action of the irritating cause. Inflammation is sometimes excited spontane- ously in various parts of the" animal economy, in- dependently of any external cause, for the purpose of getting rid of some noxious or infectious mat- ter which irritates, oppresses, or otherwise disturbs the operations of life ; as is exemplified in the exanthemata, in several forms of fever, &c. We see, therefore, that various modes of inflammation are excited, according to the particular object that is to be obtained. It is evident from the preceding considerations that inflammation is the most frequent of all dis- rases ; it may exist singly, but is often combined with other diseases. When excited for a benefi- cial purpose, it is always susceptible of assuming a dangerous degree of violence, and this often .h.-pends on the state of the constitution. It fre- quently, however, occurs as a morbid process, not intended to answer any salutary end; and when it affects certain parts, such as vital organs, it is the most dangerous of all diseases. Congestions.—The morbid phenomena of the second stage of the inflammatory process, which we have described under the name of active con- gestion, occur in a variety of important diseases which run their course without passing into in- flammation, for which, however, they have not unfrequently been mistaken. Some melancholy instances of the injury done by the adoption of a violent course of treatment in congestive affec- tions, in consequence of their having been errone- ously considered as inflammatory, have come under our observation. We think it, therefore, desirable to devote a separate section to the con- sideration of congestive diseases. The important distinction between inflammation and congestion was clearly defined by the cele- brated Laennec in his admirable discourses on the practice of physic, 'delivered at the College de France, in which he devoted several lectures to the consideration of congestive affections. This distinction has also been kept prominently in view by Andral in his excellent Pathological An- atomy, and especially in the section hyperxmia, to which we have been indebted for material as- sistance in this division of our subject. Between the slightest increase of vascular action and that which constitutes decided inflammation, there are many intermediate degrees. Some of these are so slight and momentary that they do not interrupt the healthy actions of the part, and may be considered as physiological; such as the flushing of the cheek produced by moral emo- tions, &c. But in many diseases characterized by disturbance of the functions of nutrition, se- cretion, or innervation, there is a state of conges- tion more or less active, which is truly pathologi- cal. A congested state of the liver, lungs, or any of the secreting surfaces, may be attended either with a suspension or excessive flow of their secretions. Congestion at the origin of the nerves, in the brain or spinal marrow, is frequently the cause of a variety of nervous affections; it may also be induced by long-continued nervous irrita- tion of the brain itself. A sudden congestion in some organs may be the cause of instantaneous death, as in sanguineous apoplexy and spontane- ous hemorrhages. Many of these diseases, al- though attended with very serious disturbance of the general health and considerable suffering, leave behind them no trace whatever of any change of structure, or else appearances only of an increase of vascularity, quite inadequate to account for the severity of the symptoms. It is evident, therefore, that there is a state of increased activity of the cir- culation, not amounting to inflammation, which may become an extensive source of disease; and we think this state may be appropriately distin- guished from true inflammation by the name of congestive irritation. The study of this morbid condition is of considerable importance ; for be- sides constituting of itself an important class of diseases chiefly functional, it may lead to inflam- mation, and lay a foundation for the development of many organic diseases ; so that it may almost be laid down as an axiom in medicine, that, di*- IN F L A M M A T10 N. 719 cases of function always precede diseases of struc- ture. It should be remembered, however, that these morbid actions are closely linked together, passing, by imperceptible gradations into each other ; and that it is often as difficult to draw the exact line of demarcation between the healthy and pathological species of congestion, as between the latter and inflammation. Congestive irritation may be more particularly limited to the arteries, the veins, or the lympha- tics. Arterial congestion occurs most frequently in children, and venous congestion in old people. The scrofulous diathesis is peculiarly subject to congestive irritation of the vessels and glands of the lymphatic system. The vessels carrying only the colourless or serous portions of the blood, and those destined to the function of secretion, may be affected with congestive irritation as well as the vessels containing red blood, as is seen in sudden attacks of diarrhcea, cholera, &c. Congestions, however, may also occur without previous irrita- tion, depending on debility of the vessels, me- chanical obstructions to the circulation, or some alteration in the qualities of the blood. Con- gestions may, therefore, be divided into active, passive, and serous. Active congestions.—These may be the effect, as already stated, of a primary irritation either of the nervous or vascular system, or of both con- jointly : they are characterized by various degrees of increased activity of the circulation ; injection and enlargement of the minute vessels; slight tumefaction, and in certain textures, redness, pain, and heat. Or when the congestion is very con- siderable, there is a languid oppressed circulation from over-distension. Active congestions differ, however, from inflammation, as already stated, by the circumstance of there being no rupture of the vessels or extravasation of blood, no ex- exudation of blood, coagulable lymph, forma- tion of new products, or decided change of struc- ture. Almost every part of the body may be af- fected with active congestion, but it is of most frequent occurrence in organs of a highly vascu- lar structure, or having numerous direct commu- nications with the heart and large vessels. We shall briefly notice the effects of active congestion in some of the principal organs. In the brain, which it is obvious must be great- ly predisposed to active congestion, it may occa- sion severe headach, delirium, drowsiness, vertigo, convulsive and other nervous affections; and it may lead to apoplexy, meningitis,%or encephalitis: these symptoms are the result either of the stimu- lus of an excessive quantity of blood, or of its pressure on the cerebral mass and origin of the nerves. The cause of the congestion may not be seated in the brain, but depend on its morbid sympathy with some other organ, or on the gene- ral state of the circulation. The lungs are perhaps more liable than any ether organ to be affected with active congestion, either of their parenchyma or mucous membrane. This is a frequent source of embarrassed breath- ing, and of a variety of other symptoms of pul- monic irritation ; as, for instance, the dyspnoea at- tending asthma, chronic suffocative catarrh, and diseases of the heart. There are many other cir- cumstances capable of causing a sudden determi- nation of blood to the lungs ; it sometimes hap- pens that while portions of the lung are engaged in chronic inflammation, the rest of the organ i9 in a state of congestive irritation. Active con- gestion is one of the frequent causes of hemop- tysis. Congestion of the heart and adjoining large vessels is of frequent occurrence; any obstruction to the circulation from organic disease in the lungs, brain, or large vessels in the neighbourhood of the heart, or any circumstance repelling the blood from the surface and extremities of the body towards the centre, must necessarily cause it to accumulate in the heart; and this may induct either symptoms of quickened and irregular, o\ slow and oppressed action. Organic disease of the heart is also a frequent consequence of a long continued state of congestion. There are many hepatic affections depending on a state of congestion of the liver, not amounting to inflammation. The great vascularity of this organ, and the peculiarities of its vascular system, consisting of a large proportion of veins in which the blood circulates slowly, greatly predispose it to congestion. The majority of hepatic diseases in this climate are functional, the liver not being so subject to active inflammation as in tropical re- gions. A congested state of the liver sometimes causes sudden jaundice by obstructing the biliary canals; at others it gives rise to an excessive flow of bile, which is ejected by vomiting or diarrhcea, as in cholera ; in some cases it has been followed by ascites, an unusual quantity of blood being thrown into the vessels of the peritoneum, in con- sequence of the obstruction of the branches of the vena portae. Some remarkable cases of this de- scription have fallen under our observation, and they have in general yielded readily to an appro- priate treatment. The great extent of the mucous surface of the alimentary canal, its high vascularity, and nume- rous sources of irritation, sufficiently account for its being frequently the seat of active congestion. The pathology of these viscera, which was for a long period almost entirely overlooked, has been diligently investigated of late years, and its gene- ral importance fully established. The influence of a partial congestion and inflammation of this membrane in many diseases, and especially as the proximate cause of continued fevers, has, how- ever, been much overrated. It is particularly with respect to these organs that some pathologists have frequently described appearances as inflam- matory, which belonged only to the increased vascularity of active or passive congestion. We have sometimes seen, whilst on the continent, patches of mere redness and injection found in the stomach or intestines, noted down as decided inflammation by disciples of Broussais. Continued and intermittent fevers, and some of the exanthemata, are generally attended with congestive irritation of several of the internal organs, which sometimes assumes the character of sub-acute, and more rarely of active inflamma- tion. Various degrees of vascular injection and redness are often found in patches in the stomach and intestinal canal of patients who die of fever In the yellow and some low forms of fever, cha- racterized by violent and irregular determination* 720 INFLAMMATION. of blood, large portions of the mucous membrane present sometimes a uniform dark injection, and the patients in the last stage of these fevers fre- quently discharge blood by the mouth and anus. The hemorrhagic affections of the alimentary canal, such as hematemesis, melaena, the hemor- rhoidal flux, are usually preceded by some degree of congestive irritation, which seldom amounts to inflammation. In melaena the congestion, how- ever, is in general rather passive than active. There is often an unusual quantity of blood forced into the vessels of the alimentary canal in diseases of the heart and liver, giving its mucous coat a highly injected and uniform red appearance : the same may occur when the last struggles of life are violent and much prolonged, but in these cases the congestion is also frequently passive. The uterus is always in a state of congestion at the approach of the menstrual period. This organ is peculiarly subject to congestive as well as nervous irritation, which sometimes leads to pro- fuse hemorrhage. The morbid irritations of the uterus exercise a most powerful influence over all the other functions; and especially those of the nervous system. The kidneys are affected with congestive irritation in some cases of hematuria, especially after scarlatina: the only morbid ap- pearance these organs present in diabetes is a di- lated and injected state of their blood-vessels. The spleen is frequently found excessively dis- tended with dark blood after continued and inter- mittent fevers. We have well-characterized instances of active congestion of the skin in a variety of cutaneous diseases. Erythema and erysipelas may be con- sidered as holding a middle station between active congestion and inflammation, presenting the cha- racters of the former when mild, and of the latter when severe. Petechiae sometimes depend on congestive irritation, though they seem more gen- erally connected with a passive condition of the vet-sels. The mucous membrane of the nose, mouth, and pharynx is often affected with active congestion : and there is in some individuals an habitual congested state of the pharynx and ton- sils, that greatly predisposes them to reiterated at- tacks of cynanche. Sudden congestion of the pharynx occurs also sometimes in hysteria. Sev- eral diseases of the bones, such as necrosis, exten- sive caries, spina ventosa, are occasionally attended with great vascular congestion and profuse hemor- rhage. This is also the case with cancer, fungus haematodes, erectile, and other tumours. The preceding general, though imperfect, sketch of some of the principal varieties of active con- gestion is sufficient to show that it is a pathologi- cal condition of extremely frequent occurrence, and that it includes a number of most important diseases. Considerable vigour in the powers of life, a great development and activity of the vascular system, with a large proportion of rich blood, will no doubt strongly predispose to active conges- lions. They, however, frequently occur also in an opposite state of the constitution—one of great general debility. The irritability of both the ner- vous and vascular systems being considerably in- ^reased by weakness, very slight causes are then efficient to induce severe local congestions. The nervous sympathy existing between the different organs has a remarkable and important influence in the formation of active congestions ; the mor- bid irritation which attracts the blood to one organ is often transferred through the medium of the nervous system to other organs, and disturbs their functions. The occurrence of any considerable change in the circulation of one organ, either in excess or deficiency, frequently tends also to de- stroy the balance of the circulation in others, con- stituting in this manner a species of sanguineous sympathy; we accordingly find that a primary congestion is sometimes followed by secondary congestions in other organs, whilst it sometimes has a contrary effect in depriving other organs of their usual quantity of blood. Thus, in conges- tions of the mucous membrane of the alimentary canal, the skin may be either hot and red, or pale and cold ; the brain either violently congested, or in the opposite condition. The occurrence of these secondary congestions depends of course on the extent of sympathy existing between the seve- ral organs, and this accounts for many of the im- portant combinations of symptoms in disease ; as, for instance, the cerebral symptoms accompanying active congestions of the stomach and intestinal canal; the occurrence from a similar cause of pa- roxysms of asthma, or of disordered action of the heart. The morbid irritability of the uterus, either with or without congestion, is a most prolific source of active congestion in either the digestive, the respiratory, the circulating, or the cerebral or- gans, and gives rise to an endless variety of anom- alous and distressing symptoms. A diminution in the usual quantity of blood, and a deficiency in the vitality of one organ, may also become, as before stated, the immediate cause of congestion in others ; as, for example, the sudden suppres- sion of the perspiration, or an habitually torpid action of the skin from long-continued exposure to cold and damp ; the suppression of the cata- menia ; of the urinary or alvine excretions; the application of cold and wet to the extremities, &c. If any one organ is in a state of disease, or has previously been so, that organ has the greatest . disposition to be affected with either primary or secondary congestion. When congestion exists in several vital organs at the same time, there is often a combination of most dangerous and alarming symptoms, many 01 them, however, of a purely nervous character, and leaving no morbid appearances beyond very slight traces of increased vascularity in some of the organs. A secondary congestion has sometimes the effect of aggravating the primary disease, at others it supersedes it; and in some cases there are singular alternations of disease called metastases, as is often observed between the brain and the stomach, or the brain and the lungs. These irre- gular determinations of blood may be traced in a great measure to the influence of the nervous over the vascular system, and especially over the func- tions of the minute and capillary vessels, for they occur particularly in debilitated subjects, whose nervous system is highly susceptible, and endowed with great mobility: the just balance and harmony of the circulation is easily destroyed under this feeble and unsteady action of the nervous power; points of irritation are excited in various organ? INFLAMMATION. 721 from the influence of slight causes, inducing a I sudden, unequal, and temporary flow of blood to- wards these organs, and a consequent train of anomalous symptoms, frequently of a formidable description. It is remarkable how trifling a de- gree of local irritation and congestion is often sufficient under this state of weakness and irrita- bility to cause violent pain, delirium, convulsions, or syncope ; this class of patients, moreover, very frequently exaggerate their symptoms. An in- cautious perseverance in very active remedies in such cases is only calculated to aggravate their condition, and it is often necessary to combine, in their treatment, moderate local depletion with the administration of tonics, and to depend sometimes altogether on the restoration of the general strength. This important principle did not es- cape the attention of the great Hunter, for in the treatment of severe ophthalmia, in highly irritable constitutions, he often found bark and a generous diet more successful than depletion and purga- tives. It should be observed, however, that long- continued disturbance in the nervous action of an organ has a great tendency to induce active con- gestion, and lay the foundation of organic disease ; and this important consideration should never be overlooked in the regulation of the treatment. The state of the mass of the blood, both as to quantity and quality, is a very frequent cause of active congestion. There is sometimes a greater quantity of blood formed than is required for the purposes of life, and this creates a state of over- distension of the whole vascular system, a sort of general congestion called plethora. There is a tendency in some constitutions to make blood more rapidly and in greater quantity than in others; this is favoured by high living and little exertion either of body or mind. There is also a much greater natural development of the vascular system in some individuals, constituting the san- guineous temperament; and the blood is then generally rich in fibrine and red matter. This excess in the quantity and nutritive quality of the blood keeps the solids in a state of permanent ex- citement highly favourable to the development of active congestion and inflammation. When this excitement is carried to a considerable extent, it ceases to be healthy; every portion of the animal economy is stimulated into inordinate action ; the functions both of the nervous and vascular system become generally disordered; the pulse increases in strength and frequency ; the temperature of the body is raised ; the secretions are variously modi- fied ; and all the symptoms of general fever, with- out any marked local affection, are developed. This fever from plethora may be mild and soon subside, or else there may be a strong general re- action, giving rise to a variety of alarming symp- toms, and sometimes to an apparent prostration of strength from oppression of the powers of life. When this form of fever terminates in death, the only morbid appearance to be discovered is a cer- tain degree of congestion in the minute vessels of the different organs, without any one being more particularly affected than the rest. It has been remarked by Andral, that since wherever the blood is distributed, derangement of function is fDund, the first cause of the disease resides indis- outably in the blood, the lesion of the solids being Vol II 91 only secondary. That cases of fevei exactly cor- responding with the preceding description do some- times occur, is a fact as well established by the concurrent testimony of many experienced patho- logists, as any in medicine. We have had the opportunity of examining several hundred bodies of persons wtho have died of fever, and in some of these, although certainly but a small proportion, we have been unable to detect any morbid appear- ance worth noticing; the assertion, therefore, of Broussais and his followers, that fever is always the effect of a sympathetic irritation of the heart depending on the irritation or inflammation of some other part of the body, and that essential or idiopathic fever has no existence but in the ima- gination of some pathologists, is directly opposed to general experience. There are few, we believe, who would venture to deny that all the organs are sometimes found perfectly healthy in other acute diseases which have come unexpectedly to a fatal termination; and it may well be asked, why should not the same occur in fever ? A plethoric condition of the system is, however, most generally combined with a great tendency to accumulation of blood and active congestion in the different organs. When the brain is thus affected, a variety of cerebral symptoms, such as have already been described, may manifest them- selves, and even a fatal termination be the result, without leaving any other trace of disease than a highly injected state of the vessels. The conges- tion may more particularly affect the thoracic organs, and occasion distressing symptoms of dyspnoea, cough, palpitations, &c. The digestive and hepatic viscera are frequently the seat of active congestion from plethora, in which case the diges- tion may be impaired, the secretions increased or vitiated, and indirect debility induced by the op- pressed action of the different organs. It is justly- observed by Dr. Barlow, in the article Congi.s- tion of Blood, that this condition of the system has often been mistaken for common dyspepsia, and a more formidable and permanent disease been excited by the adoption of a tonic course of treatment; whereas, if the mass of the blood be diminished, and the vessels unloaded by means of venesection, by remedies tending to increase the secretions, and by abstinence, the oppressed or- gans soon recover their free action. The kidneys, uterus, and cutaneous surfaces may be similarly affected, and a natural cure sometimes takes place by spontaneous hemorrhage. The ancients were well acquainted with this state of the system, and were by no means in error when they laid it down as an established pathological principle, that many acute and chronic diseases, especially of the digestive, hepatic, and excretory organs, were to be considered as critical efforts of the constitution tending to rid it of various sources of oppressio. i or irritation, and to re-establish the just balance of the functions. The late Mr. Abernethy bat accurately pointed out the great importance ol attending to this principle in the treatment of sui- gical diseases, and he is on this account justly entitled to the merit of having introduced a new era in this department of pathology. A state of great obesity induces sometimes :• form of plethora more dangerous, perhaps, thai.' any other in its consequences, and more difficul 3l MATION, 722 IN F L A M to obviate. When a great quantity of fat is deposited under the skin and round important viscera, the small vessels become so compressed, that the blood necessarily accumulates in the heart and larger vessels, in which case those or- gans destitute of fat, such as the lungs and brain, are often oppressed by excessive plethora, and strongly predisposed to active congestion; the action of the heart itself is frequently impeded by the mass of adipose substance surrounding it, and its muscular tissue is even sometimes partly con- verted into fat: this condition of the system is generally characterized by an extremely embar- rassed, slow, and irregular circulation, and great disorder in the functions of the brain, lungs, and heart; in one instance we observed the pulse fre- quently so low as 28 in a minute, and it never rose to 40. There may be an habitual excess of blood in one organ, a state of local plethora, whilst the other parts of the body have even less than their natural quantity. This may be the effect of na- tural conformation. When the thorax is narrow or deformed, the lungs are compressed, and the circulation through them is so impeded, that a slight acceleration of the action of the heart will be sufficient to cause an accumulation of blood in their texture. The same may occur in the brain when the head is small in proportion to the size of the trunk, and especially of the thorax. Large men with a small head and short neck often suffer severely from cephalic affections, especially when the heart is large and its action naturally vigorous; on the other hand a very large head and contract- ed chest may be attended with the very same result, especially in children : in fact, any great disproportion in the natural development of dif- ferent parts of the body, must necessarily predis- pose to unequal distributions of blood, and this is one source of those peculiarities of constitution termed idiosyncrasies. Plethora may exist more exclusively either in the veins or arteries; and this difference is in a great measure connected with the period of life. The arterial system being most developed and in greater activity in childhood and youth, active arterial congestion is most common at these ages. As the rigidity of the solids augments with age, the arteries in particular acquire a greater degree of density, and a greater number of the minute arteries become obliterated; a larger quantity of blood is consequently thrown into the veins, whose coats offer less resistance than those of the urteries; and the venous system becomes in this manner gradually more distended with blood towards the decline of life, and more liable to be the seat of congestion. (See the Physiological Speculations of Sir Clifton Wintringham ; Cul- len's Nosology, book iv. chap. 1.) The different periods of life are characterized also by a greater tendency to plethora and active congestion in cer- tain organs than in others ; thus, in childhood and youth the brain and thoracic viscera are prin- cipally affected, the abdominal viscera in adults, and the brain and abdominal viscera in old age. Local plethora may be the result of habits of fUe and modes of employment. Intense study ueates habitual plethora in the brain ; occupa- tions requiring a low position of the head and great straining of the sight produce a similar effect. The people employed in Italy in the manufacture of mosaics suffer greatly on this account from congestive and inflammatory affections of the brain and eyes; and the same is observed in a variety of other trades. The seasons and climates exercise a considerable influence over the distribu- tion of the blood. Heat stimulates the activity of the circulation, and creates a tendency to ple- thora in the skin and superficial parts of the body during spring and summer, as is shown by the prevalence of the exanthemata and other cutane- ous affections: this is likewise the case in tropical climates, where some cutaneous affections assume a highly inveterate character. Excessive heat is known also to create a strong predisposition to hepatic congestions and disordered biliary secre- tions. The application of cold to the surface lowers the activity of the circulation, and repels the blood towards the centre ; and hence the great tendency to congestions in the lungs, brain, and mucous surface of the alimentary canal, during winter and in cold climates. The sudden expo- sure to intense cold has often been instantaneously followed by an attack of apoplexy: the influence of variations of temperature is greatly increased by their occurring suddenly. These changes in the circulation are not the effect merely of the heat of the atmosphere, but also of the different degrees of pressure it exercises on the body ac- cording to the variations in its density. Thus, a condensed, pure, and cold atmosphere adds by its pressure to the power of the solids to resist the impulse and distension of the fluids ; and the quantity of blood on the surface of the body being thereby lessened, a certain degree of internal ple- thora is the result: whilst in a heated, rarefied, damp, and impure atmosphere, the vessels of the surface being subjected to less pressure, are more relaxed, admit a larger quantity of fluids, and there is a consequent tendency to external ple- thora. Some ancient pathologists conceived that there were certain conditions of the body independent of the effect of heat and cold, which give rise to alternate states of condensation and rarefication of the fluids, and which they referred to some particular influence of the nervous system. They explained in this way various sudden congestions whose occurrence could not be traced to any irri- tation or mechanical cause ; they accounted in the same manner for the great extrication of gaseous fluids observed in some nervous diseases, such as hysteria. The motions of the fluids, and their degrees of rarefaction and density, have been sup- posed by some modern pathologists to be partly regulated by electricity ; but these speculations, however interesting, do not yet appear to rest on sufficient evidence to be applied to practical pur- poses.* The last of the causes of local plethora to which we shall allude, is of a mechanical nature,— that arising from tight bandages habitually worn over different parts of the body. Every medical * See the researches of Dr. Reiiss of Moscow, pub- lished some years ago ; the more recent experiment, also, of Dutrochet in France, and Faust and Mitchell in America, on the endosmosis and exosmosis of iluids and gases. INFLAMMATION. 723 man must have had numerous opportunities of witnessing the highly injurious consequences of this pernicious practice, especially in women; they are too obvious to require further illustration! The introduction into the animal economy of a contagious virus, or of any other deleterious prin- ciple, such as putrid miasmata, &c. has generally the effect of exciting congestions more or less ac- tive in several organs at the same time, as is ob- served in a number of infectious diseases, such as measles and scarlatina, typhoid and malignant fevers ; or after the administration of poisons. These deleterious principles vitiate the quantities of the blood, disturb the whole nervous system by either irritating or depressing it, and thus create active congestions in the brain and alimentary canal. One of the frequent terminations of congestive irritation of the blood-vessels is hemorrhage, either within the texture of the part affected, or on its surface. When there are no means of escape for the blood, the consequences are often extremely dangerous; as in apoplexy, and likewise in he- moptysis, when the blood is only partially expec- torated, and a portion retained within the pulmo- nary texture. Where, however, the blood can issue freely, the hemorrhage frequently relieves the congestion, as in epistaxis, hematemesis, monor- rhagia, &c. This timely hemorrhage often pre- vents the congestion from passing into inflamma- tion ; whilst the repression of the hemorrhage, whether spontaneously or by artificial means, has been sometimes immediately followed by formida- ble symptoms of inflammation. Hemoptysis has in this way been converted into pneumonia; he- matemesis into gastritis; metrorrhagia into me- tritis. The hemorrhage may also prove hurtful by causing an excessive loss of blood, either in one or successive attacks ; there is a great tendency to hemorrhagic action in certain constitutions, de- pending most probably on some condition of the blood-vessels leading to congestive irritation ; other constitutions being more predisposed to serous effusions. It should be observed, however, that hemorrhage may occur without any previous con- gestion of the blood-vessels, either active or pas- sive, the parts after death not presenting the slightest morbid appearance ; this must be owing to some modification in the texture of the parietes of the vessels, or to some peculiarity in the quali- ties of the blood ; as, for instance, when reduced to a thin watery state, so that it escapes from the vessels as fast as it arrives. This species of he- morrhage is observed in scorbutus and in the he- maturia of old age. Inflammation is one of the most natural and important consequences of congestive irritation. The development of many formidable diseases may be prevented if the congestive stage of the inflammatory process can be removed by the timely application of appropriate remedies. Active con- gestions are sometimes only temporary, and quick- ly subside: when of long duration, they frequently occasion various alterations in the nutrition and secretions of the part, which they either increase, diminish, or vitiate. They sometimes assume an intermittent and periodical character, as in some forms of cephalalgia, dyspnoea, &c. Passive Congestions. —It has been already stated that congestions are frequently formed without any previous irritation or increased activity of the circulation, and that they may be the effect of a relaxed state and deficient activity of the vessels, of a vitiated condition of the blood, or of some mechanical obstruction to its course: in these cases the congestion is termed passive. Pas- sive congestion is characterized by various degrees of redness and sometimes tumefaction, but is distinguished from active congestion by the ab- sence of pain and heat. The accumulation of blood in the passive con- gestion sometimes becomes a source of irritation, and the congestion then assumes an active cha- racter. On the other hand, a congestion, which was at first active, may after some time become passive. There are, therefore, two forms of pas- sive congestion, the one primary, and the other secondary. The principal causes of passive congestion, viz. relaxation of the small vessels, languor of the general circulation, and a thin vitiated state of the blood, are combined in the scorbutic constitution ; there is consequently a remarkable tendency in scorbutus to passive congestions and extravasa- tions of blood in all vascular textures. In cases of general debility of the powers of life, and de- ficient energy of the capillary system, the blood has the greatest tendency to accumulate in tho^i portions of the vascular system the, most remotr from the propelling influence of the heart, and in which the circulation is chiefly carried on by the contractility of the extreme vessels ; and this is still more likely to occur where the blood in it.' passage from the capillaries into the veins has to overcome the force of gravitation. The lower extremities of old people are sometimes affected, owing to the operation of these causes, with spots presenting an injected, dark-red, marbled appear- ance, sometimes varicose or in a state of ecchy/- mosis. (Andral, Op. cit. vol. i. p. 50.) In some cases there is a complete stoppage of the circula- tion, stagnation and coagulation of the blood; the vitality of the part is destroyed ; it becomes cold and insensible ; assumes a dark livid colour; and a form of gangrene frequently supervenes, called the gangrene senilis. A similar affection is of frequent occurrence in certain forms of fever, and other diseases attended with great nervous debility and a vitiated stale of the blood ; the application of any slight irritation to the skin, especially in the dependent parts of the body on which the patient lies, such as the back, sacrum, and nates, is followed by the appearance of red patches of congestion ; these, at first acute, soon become pas- sive, and assume a gangrenous appearance. All the internal organs are subject to passive congestion. When death is attended with violent struggles, as is the case from the convulsions of tetanus, of asphyxia, by strangulation, or from the effects of certain poisons, many of the internal organs, and particularly the brain, are found loaded with blood, and more or less injScted. When after protracted diseases death occurs very gradu- ally, the lungs are sometimes found gorged with blood and serum, although there was no previous symptom of pulmonic affection. These changes occur more particularly in the posterior portion of the organ, when the patient lies constantly on 724 INFLAMMATION. the back. They can only be referred to debility of the capillaries and passive congestion, as they were not preceded by irritation. After the in- flammation has been subdued in acute pneumo- nia, and convalescence is established, there re- mains in some cases a certain degree of dyspnoea and crepitating rhoncus, although the thorax has recovered its natural sound on percussion, and these symptoms resist the continuation of anti- phlogistic remedies, whilst they yield readily to the employment of tonics. The congestion of the bronchial membrane in chronic catarrh frequently requires a tonic plan of treatment, and it may be fairly concluded in both these cases that the ves- sels are in a relaxed and passive condition. There is a great predisposition to passive con- gestion in the mucous membrane of the alimentary canal. This is not surprising when we consider how largely it is supplied with blood-vessels, their subdivision into numerous arches supported only by a loose membrane, and, above all, the peculiari- ties of its venous circulation ; for the venous blood of the alimentary canal being distributed to the liver by veins deprived of valves, the slightest obstruction to the circulation of that organ, which is naturally slow, must have the effect of retard- ing the return of blood from the intestines, and creating an accumulation in their venous system. This accounts for the frequency of hemorrhoidaJ affections, diarrhoea, and dysentery, in chronic af- fections of the liver. In fevers of a low, nervous, and malignant type, the mucous membrane of the intestines, and chiefly of the colon, is sometimes found of a uniform dark-red colour, turgid and soft, in consequence of an intense venous injec- tion of a passive character, the black pitchy secre- tions of the membrane resembling decomposed genous blood. (Dr. Armstrong made these con- vestions the foundation of one of his divisions of fever, which he termed congestive.) In a case of this description the mesentery was covered with large dark-red blotches, giving it the appear- ance of a leopard's skin, and arising from a state of intense injection of the mesenteric veins with extravasation of blood, the congestion having fall- en on the mesentery instead of the coats of the intestines. The mucous membrane presents fre- quently similar appearances in melaena ; and in a case of recent occurrence we found it impossible to discover the least difference between the black sanguineous fluid contained in the intestines, and the blood taken from the vena portae. Mechanical compression or obliteration of any portion of the venous system, is necessarily fol- lowed by passive congestion in all the parts whose blood is returned to the heart by the obstructed vessels. When this obstruction occurs either in the lungs oV heart, it produces passive congestion in all the organs of the body. This is particularly well exemplified in asphyxia, in which the face becomes livid and swollen, the lips purple, the tongue tumid, the eyes red and staring, and the whole surface of the body injected with dark blood. The lungs, right cavities of the heart, and entir° venous system are found distended with venous blood, whilst the left cavities of the heart are nearly empty; the mucous membranes of the lungs and alimentary canal are also deeply inject- ed. Wnen the obstruction in the pulmonary cir- culation takes place gradually, as in pulmonary consumption, the same general congestion is not observed, because the absolute quantity of blood in the whole system is diminished by long-con- tinued imperfect sanguification, deficient nutrition, and increased excretions. A nearly similar state of general passive congestion is sometimes pro- duced by diseases of the heart, whether congeni- tal, as in the morbus cceruleus, or acquired. Serous congestions. — The order of vessels which convey only the colourless or serous por- tion of the blood, are liable also, as before stated, to be affected with congestive irritation. These vessels exhale in health a sero-albuminous fluid or vapour, which constantly lubricates the areolae of the cellular tissue, the cavities lined with serous membranes, the mucous and cutaneous surfaces, and, in fact, every part of the body. It can be satisfactorily shown, by a variety of experiments, that this fluid is supplied by the serum of the blood. If, for instance, a solution of prussiate of potash be injected into the veins, it can be imme- diately detected in the fluid of the serous mem- branes by means of sulphate of iron. (Andral, Op. cit. vol. i. p. 379.) Serous and sanguineous congestions are not unfrequently combined ; the former may, like the latter, occur without previous irritation, and be passive. Congestive irritation of the colourless vessels is generally followed by an increased exhalation of serous fluid, which is either retained in the areolae of tissues and closed cavities of membranes, con- stituting different forms of effusion, or, when poured out on the mucous and cutaneous surfaces, is carried off in the form of increased excretions. Those portions of the cellular tissue, the tex- ture of which is loose and the position dependent, are the most frequently the seat of serous effu- sions. The dense cellular tissue lining mucous membranes is not, however, exempt from serous infiltration ; the membrane is then raised, loose, and flaccid, as is well exemplified in that fatal dis- ease, oedema of the glottis. When serous effu- sions occur in the membranes investing vital or- gans, they often give origin to various formidable and fatal diseases. The investigation of their causes is, therefore, deserving of some considera- tion. These causes may be divided into increased action of the vessels, debility of the vessels, alter- ation in the qualities of the blood, and mechanical obstructions to its circulation. Serous effusions may take place from irritation and increased activity of the secreting vessels, without the cellular tissue or serous membrane undergoing any alteration of texture, or presenting even the slightest appearance of sanguineous con- gestion. If the irritation be slight, the effused fluid corresponds exactly in its composition with the serum of the blood, consisting of a large pro- portion of water (900 in 1000 parts), a small quantity of albumen (80 in 1000), and the remain- der made up of soda, various salts, and an animal matter analogous to mucus. (Andral, Op. cit. vol. i. p. 389.) Under certain circumstances nol connected with irritation, the effusion contains also a substance called extracto-mucus, either uniformly combined and giving it a slight turbid appearance, or floating in the midst of the fluid in small fila- ments or flocculi. As, however, the irritation in- INFLAM MATION. 725 creases, the proportion of albumen becomes con- siderably greater, and this substance is therefore a good test of the violence of the irritation. When the congestive irritation reaches the point of true inflammation, the disease is characterized by other morbid changes ; there is an exudation of coagu- lable lymph and pus, which, being mixed with the serous fluid, gives it a turbid appearance ; the surface of the membrane itself is lined with layers of lymph; its blood-vessels and those of the sub- serous cellular tissue are deeply injected, and blood is sometimes extravasated by their rupture. The absence, however, of any trace of vascular injec- tion in a serous membrane, after effusion has taken place, must not always be considered as a sure proof that it never existed; for there may have been considerable sanguineous congestion in the first period of the disease, which has disappeared after the turgidity of the vessels has been relieved by the exhalation of the distending fluid. We accordingly often observe the symptoms of local and general irritation in acute affections of the cellular tissue and serous membranes, completely subside the moment the effusion has taken place ; and we may frequently predict an accession of effusion by the return of these symptoms. It may, therefore, be received as a general rule that a state of congestive irritation, both of the sanguineous and serous vessels, especially when long-continued, is more favourable to acute dropsical effusions than active inflammation; that active inflammation is attended with a greater disposition to the formation of adhesions and false membranes, or to the ex- udation of pus and blood, than to copious serous effusions, the function of secretion being rather suspended than accelerated during the inflamma- tory process. The fever and other constitutional symptoms which precede effusions into the cavities of the head, chest, and abdomen, are accordingly, in the majority of cases, rather of a sub-acute than highly inflammatory character; and it is extremely important to keep this circumstance in mind, as the mild and insidious nature of the symptoms has frequently concealed the real danger of the disease. Serous effusions take place also, no doubt, in the course of severe attacks of inflammation ; but effusion is then almost always combined with suppuration and the formation of pseudo-mem- branes, and it generally occurs when the inflam- matory action is on the decline. We have exam- ples of this in pleurisy and peritonitis. In recent cases the texture of the serous mem- branes is generally unaltered ; but when serous congestion has been of long standing or frequent recurrence, the membrane becomes thickened and of an opaque white, in consequence of the infil- tration of the serous fluid between its layers. A similar infiltration takes place into the subjacent cellular tissue, which on this account adheres to the membrane when raised, and increases its thick- ness; this happens more especially where the sub- . serous cellular tissue is loose and abundant, as, for instance, between the arachnoid and pia mater. The free surface of the membrane loses also its smoothness and polish, becoming rough and gra- nulated. In some severe and very protracted cases, the membrane is thickened and even cartilaginous, in consequence of vitiated nutrition. The serous fluid may be either colourless or of a green, yellow, or reddish tint, owing to the presence of a portion of the colouring matter of the blood; it is some- times mixed with a yellow colouring matter ana- logous to that of the bile, and has in some cases been found to contain uric acid. The effusion may be occasioned by a primary irritation of the tissue in which it is formed, or a secondary irritation propagated from a neighbour- ing part. (Andral, Op. cit. vol. i. p. 393.) Hy- drocephalus is in most cases to be attributed to irritation in the brain ; ascites is sometimes con- secutive to peritonitis ; erysipelas, phlegmon, and all extensive and deep-seated inflammations, are attended with oedema of the adjacent cellular tissue. Effusions depending on congestive irritation are characterized by local and constitutional symptoms more or less acute; when they occur in the sub- cutaneous cellular membrane, as in oedema and anasarca, there is swelling and some degree of heat, pain, and tension ; this corresponds with the diffuse inflammation described by the late Dr Duncan. When the effusion takes place within any of the splanchnic cavities, or in the texture of important organs, there are a variety of local symptoms more or less severe according to the impediment occasioned in the functions of the organ. The constitutional symptoms vary con- siderably, being sometimes violent, at others mild, obscure, and insidious; this depends very much on the suddenness of the affection, as well as on idiosyncrasy, and other circumstances. A slight degree of congestion and effusion occurring sud- denly may give rise to very violent symptoms and prove rapidly fatal; whilst a higher degree of con- gestion, and the effusion of a larger quantity of fluid, if it only takes place gradually, is sometimes attended with comparatively little inconvenience, there being time for the parts to accommodate themselves to the distension occasioned by the fluid. The following enumeration of the diseases in which effusion occurs as a consequence of conges- tive irritation of the serous vessels, will show the importance of attending to this species of diseased action. It affects both sides of the arachnoid, the pia mater, the lining membrane of the ventricles of the brain, and the medulla spinalis, in arach- nitis, hydrocephalus, and hydro-rachitis; the pleura in pleurisy and hydrothorax; the pericardium in pericarditis and hydrops pericardii; the peritoneum in ascites; the ovaries in hydrops ovarii; the tu- nica vaginalis in hydrocele ; the joints and sur- rounding parts in hydrops articulorum, and also the bursae mucosae of tendons ; the cellular tissue in oedema and anasarca; the globe of the eye in hydrops oculi. The parenchyma of several organs may also be the seat of serous congestion and ef- fusion ; the white softening of the brain seems to depend on a species of serous infiltration, there is a serous congestion of a sub-acute character called oedema of the lungs, which is in general very . obscure and intractable, and a frequent, though unheeded, cause of anasarcous swellings in differ- ent parts of the body. Serous congestion and effusion depenu some- times, as already stated, on debility of the vessels without previous irritation, being what is termde passive. In order to give a connected view ol the pathology of these affections, we shall offer a few observations on this and some other causes of 726 INFLAMMATION serous congestion, although not immediately con- nected with inflammation. When the powers of the constitution have been considerably reduced after protracted diseases, excessive evacuations of blood, or in old age, especially in temperaments naturally leucophlegmatic, serous effusions some- times occur, to all appearance, from mere debility; the lower extremities, where the blood has to over- come the greatest degree of gravitation, are most commonly first affected. Effusions from mere vascular debility are, however, by no means so frequent as was formerly imagined. It more gene- rally happens that there is combined with debility some other cause, such as alterations in the quan- tity or qualities of the blood, or obstruction to its circulation. Since the fact of absorption being actively car- ried on by the veins as well as the absorbents has been fully established by the experiments of Ma- gendie, nothing can be more obvious than that the distension of the venous system by an excess of blood must have a special influence in the produc- tion of serous congestions and effusion, by retard- ing the current of the blood, causing an accumu- lation in the minute vessels, and lessening the .activity of absorption. There are cases of oedema and anasarca which can be attributed to no other cause than extreme plethora; a remarkable one, which terminated fatally, is related by Andral. That effusion may occur from this cause is clearly proved by the fact of our being able to produce it at will by injecting into the veins a large quantity of water, so as to create a state of artificial plethora. That, the absorption of the veins is greatly accele- rated when in a condition opposite to that of ple- thora is also satisfactorily proved; for if in the same animal we remove the plethora by abstracting blood from the veins, the serous effusions soon disappear: this explains the good effects that follow venesection in acute dropsical affections. A diminution in the proportion of fibrine and red matter, and a corresponding increase in that of the serosity of the blood, greatly favours serbus congestions and effusions : this state of the blood is induced by copious and repeated venesections, which are sometimes followed by dropsical effu- sions. The long-continued use of a poor and watery diet produces similar results, although the mass of the blood may be diminished in quantity. The coagulating property of the blood is destroyed also by some poisons, especially those of reptiles; its fluidity is thus increased, and it assumes a de- composed appearance; the unhealthy malignant inflammation excited by these poisons is accord- ingly combined with serous infiltrations. Any obstruction to the venous circulation has a tendency, for the reasons already stated, to in- duce sanguineous congestions and serous effusions. The obliteration of the principal veins of a limb from inflammation, the pressure of a tumour, or other causes, is generally followed by oedema of the limb below the obstruction. The obliteration el the inferior vena cava causes dropsy of the lower extremities: obstacles to the circulation of the vena portae, arising from diseases of the liver, are among the most frequent causes of ascites. Several dis- eases of the kidneys, which have been well de- f- in the vessels of one particular organ. The different parts of the body may, however, assume also various degrees of redness and injec- tion after death, which it would be a serious mis- take to attribute to the effects of disease. The formation of these congestions can easily be proved by experiment; for if the colour and degree of injection of different organs be noted immediately after death, and the same organs be examined ugain at different successive periods, parts natu- rally white will be observed to become red, ves- »els and patches of ecchymosis become apparent where none could previously be seen. It is possi- ble, indeed, to produce at pleasure a red congested appearance of the lung in any one of its surfaces, by letting the body lie for some time on its back, side, or face, and to bring about a similar result in any portion of the intestines by suffering it to hang in a dependent position. Numerous experi- ments were made on this subject by Rigot and Trousseau; and the blood sometimes oozes in such quantity as to accumulate in the cavity the form of a hemorrhage. These sanguineon-j congestions are formed not only when the mass of the blood is considerable, but also after pro- tracted diseases.* These congestions are principally observed on the exterior of the body in the most dependent parts of the skin, such as the back and calves of the legs, which present a uniform livid red colour, disposed in stripes or patches. Red streaks, either parallel or intersecting each other, are also some- times seen on the arms, thighs, thorax, and abdo- men, and not confined to the dependent parts of the body ; the vessels of all these parts, especially the veins, are found minutely injected with black blood ; the streaks occur in the course of large veins, and seem to be the effect of the transudation of their blood staining the surrounding tissues. During the last moments of life, owing to the weakened action of the heart, there is not so much blood propelled to the surface, and it has a tendency to accumulate in the internal organs; the internal cadaveric congestions present a uni- form red tint, disposed also in isolated spott, stripes, or patches; the blood escaping from its vessels forms effusions, and stains the neighbour- ing tissues; if there exist previously serous effu- sions, they become tinged with the colouring mat- ter of the blood ; there is also extravasation of the serous fluids; and effusions take place into the cavities of serous membranes or in the cellular tissue; the bile likewise transudes through the gall-bladder, and stains the surrounding parts. All these appearances are more particularly found in the membranes of the brain lining the posterior part of the skull, and in the posterior part of the spinal canal; in the lobes of the cerebellum, and posterior lobes of the cerebrum ; in the posterior portion of the lung ; the most dependent portions of the stomach and intestines, and in the kidneys. These parts present sometimes a uniform deep red colour, resembling the most intense congestion. At a later period, when putrefaction commences, various gases are disengaged, and particularly sul- phuretted hydrogen, which penetrate the coats of the blood-vessels as well as all other tissues, change the colour of the blood, and produce the various tints of brown, livid, and green, that cha- racterize putrefaction. These changes of colour are first noticed on the concave surface of the liver, in consequence of its vicinity to the trans- verse arch of the colon ; they next manifest them- selves in the abdominal muscles, and subsequently in the integuments. Congestions after death are formed, therefore, in three different ways: by the gravitation of the fluids within their vessels; by transudation of the fluids through the parietes of the vessels and imbibition of the neighbouring tissues; and by chemical affinities. The nature of the first species of cadaveric congestion is sufficiently obvious not to require any explanation. The fact of the transudation of fluids through the membranous parietes of vessels, and of all animal tissues having in a cer- tain degree the property of imbibition even during life, has been clearly established by the experi- * Andral. Op. cit. vol. i. p. 83. This chapter contains a very full and interesting account of the occurrence of congestions and effusions after death. INFLAMI mental researches of Magendie, Fodere, and Du- trochet : the functions of exhalation and absorp- tion seem to be, partly at least, carried on by transudation and imbibition. The vessels and serous membranes are, however, considerably less permeable to the fluids they contain during life than after death, which is partly attributed by Magendie to the current of circulation constantly conveying away the fluids before they can accu- mulate in any part; the solids are also endowed by their vital principle with a greater degree of density and power of resistance during life, whilst after death the physical laws acquire their full in- fluence. The patches and stripes of uniform red are the effect of this property of transudation and imbibi- tion ; the tissues appear as if soaked in blood and stained with it. This uniform red tint is fre- quently observed on the internal coat of the blood- vessels and of the heart; it is of a vermilion red in the arteries, and of a darker red in the veins : the redness penetrates all the coats of the smaller and thinner vessels, and extends sometimes to the adjacent tissues : the vasa vasorum of the large vessels are minutely injected. These appearances in the blood-vessels are almost constantly found at the end of twenty-four hours in the bodies of persons who have died from an obstructed state of the circulation, or from diseases in which the blood is preternaturally fluid. The small quantity of colourless or reddish serous effusion found in almost every body in the arachnoid of the brain and spinal marrow, in the pericardium, pleura, and peritoneum, thirty-six hours after death, is to be attributed also to transudation. Congestions and effusions from transudation occur most frequently in those diseases in which the blood is thin, and retains its fluidity after death, such as scorbutus, purpura hemorrhagica, and all diseases usually called putrid: they are seldom observed in the neighbourhood of large veins and arteries on ac- count of the thickness of their coats ; they are greatly facilitated by the rapidity of putrefaction, and therefore materially influenced by the heat and moisture of the atmosphere. With regard to the effects of chemical affinities, it is important to remark that, when a portion of lung, intestine, or brain, presenting little or no vascularity, has been exposed for a short time to the atmosphere, it assumes a bright scarlet ap- pearance, resulting from the arterialization of its blood, which, being thus more highly coloured, is apparently increased in quantity. We have al- ready stated that the gases evolved by putrefaction give the blood a brown, livid, or green hue ; the texture of the part becomes more friable and flac- cid, and these appearances have, we apprehend, been sometimes mistaken for gangrene. Further details of the cadaveric appearances will be found in Andral's Pathological Anatomy, (vol. i. article 4, p. 70,) and in the works on Medical Jurispru- dence by Fodere, Paris, and Beck, [Devergie, Guy, and A. Taylor.] We have thought it desirable to describe at some length these cadaveric appearances, feeling the great importance of their not being mistaken for the effects of disease, especially with respect to forensic medicine. There is, perhaps, no point n pathological anatomy which has given rise to Vol. IL —92 A TION. 729 greater diversity of opinion, has proved a more fer tile source of error, and remains yet more undeter mined, than the exact nature of the morbid appear ances which separately characterize congestions both active and passive, and inflammation. This is in fact a subject often surrounded with many difficulties, an ignorance of which has led to the erroneous practice of pronouncing hastily and in- discriminately as inflammatory, appearances of redness, injection and turgescence, belonging per- haps only to either active, passive, or cadaveric congestion. We shall therefore point out, as far as we are enabled in the present state of patholo- gical knowledge, the characteristic signs by which we can establish a line of demarcation in the dead body between these various morbid appear- ances. 1. The existence of various degrees of redness in any tissue, depending on minute vascular in- jection, is not alone sufficient to indicate inflam- mation, as redness is produced also by several forms of congestion. An increase of volume like- wise is not always characteristic of inflammation; it may arise from the distended state of the vessels, or the slight serous effusions that occur in con- gestions both active and passive. Increase of volume may depend, moreover, on a morbid acti- vity of the functions of nutrition and secretion, causing a diseased growth of texture without the necessity of an inflammatory action. Congested tissues become also more soft and friable in con- sequence of the greater quantity of fluids they contain. The redness and increased thickness of a membrane and softening of its texture cannot, therefore, be always considered unequivocal marks of inflammation. The following are the only sure signs of genu ine inflammation: considerable increase of vascu larity with extravasation of blood or coagulable lymph, and the formation of pus or other morbid products, leading to a decided change in the struc- ture of the part affected. The presence of all these signs at the same time is not, however, re- quired : there are variations in this respect, accord- ing to the texture of the part, the intensity and duration of the inflammation. A very minute in- jection, chiefly of the small arterial branches; a vivid red colour, disposed in dots or striae occupying the whole thickness of the tissue, and not removable by pressure or ablution ; spots of ecchymosis, occa- sioned by the rupture of some of the small vessels; effusion of blood on the surface, or its infiltration within the texture of the part, are all character- istic of recent inflammation. The exudation of coagulable lymph, the secretion of pus, and the formation of ulcers, indicate a more, advanced period of inflammation. This, however, is not constant, as both lymph and pus are sometimes poured out, and ulcers very rapidly formed in cer- tain soft tissues, as, for instance, in mucous mem- branes. The organization of lymph and conver sion into new tissues, the complete organization of abscesses, and the formation of purulent sinuses, point out inflammation of longer standing : the minute vascularity and redness have in this lattei case generally disappeared. 2. Injection, redness, and patches of ecchymo sis exist also in passive congestion ; but the injec tion then is seated principally in the veins. Thf 730 INFLAMMATION. redness is of a dark-brown hue rather than florid ; the blood extravasated is thin and fluid, and the red colour is easily removed by ablution : the tex- ture of the solids is soft, flabby, and easily torn, and the condition of the whole body usually indi- cates a state of cachexia. Active congestions are distinguished from passive by the vascular injec- tion occupying chiefly both the large and small arteries, the net-works formed by their extreme ramifications being so minutely filled with blood as to impart to the tissue an intensely bright red colour; the blood is generally very viscid, and the texture firmer than in passive congestion. This is a condition of parts bordering on active inflam- mation, although no distinct change of structure has yet taken place. It is often described as in- flammation, and the mistake is not perhaps of much practical importance, since they both fre- quently give rise to the same local and constitu- tional symptoms, and require the same mode of treatairnt; the morbid appearances belonging to inflammation and active congestion are, moreover, often united in the same organ ; active congestion is most frequently attended with serous effusions or hemorrhage ; inflammation, more generally with the effusion of coagulable lymph and pus, or ulcer- ation. It must, however, be acknowledged that the distinction between active and passive conges- tion is often extremely difficult, if not impossible; and it will be necessary in general to attend to other circumstances besides tl e morbid appear- ances; such, for instance, as the mode of death, whether it has been sudden and rapid, or linger- ing ; attended with violent struggles, or tranquil: also the nature of the preceding disease, and the state of the other organs of the body. We may thus ascertain whether the venous system is gene- rally congested or not; and it should be remem- bered that the parenchymatous and membranous organs are usually found gorged with blood after disease of the heart and asphyxia, in consequence of the mechanical obstruction to the return of blood to the heart. It is important, however, to remark that the morbid appearances indicating active or passive congestion, such as redness, injection, turges- cence, and even slight effusions, which existed during life, sometimes completely disappear after death. There can be no doubt that this may happen, because there are instances in which, although the skin or the eye presented some of these appearances during life, they have been found quite pale after death. When, therefore, •here have been well-marked symptoms of con- gestive disease during life, the absence of the usual morbid appearances after death is not always sufficient to destroy our belief in their existence. We know that nothing may be found in the brain after apoplexy from simple congestion, though such cases are not of frequent occurrence. The changps of structure induced by true inflamma- tion, such as suppuration, ulceration, &c, are free from this source of deception. 3. A little attention will be sufficient to distin- guish the cadaveric congestions arising from mere gravitation of the fluids, from those produced by disease ; the vascular injection and redness is con- fined to the most dependent parts of organs, and ;s found in a number of organs at the same time, varying of course according to the position of the entire body, or of certain regions only ; this should always be a subject of particular inquiry. A con- siderable degree of injection, therefore, confined to one organ, and especially not occupying its most dependent part, may fairly be attributed to disease. The redness, injection, and sanguineous or serous infiltrations resulting from transudation, occur at a later period after death ; the tissues are of a uni- form red, as if dyed with blood ; the blood can sometimes be washed away by repeated ablution, or by maceration for some hours in water; but this will not be the case four or five days after death. If a considerable degree of sanguineous infiltration is observed in one organ only, some days after death, and if it be accompanied par- ticularly with much injection of both its large and small blood-vessels, there is little doubt but that it is the effect of disease ; but if similar appearances exist also in different other parts of the body, it is much more probable that they originate in the cadaveric transudation that attends putrefaction. There is frequently, however, great difficulty in forming a right judgment in such cases, and it is necessary to exercise the utmost caution and dis- cretion on this subject when called upon to give evidence before a court of justice. The various appearances depending on the action of chemical affinities in a more advanced state of putrefaction, are too well characterized to deceive any well-in- formed observer. In judging of the morbid appearances, it will be necessary to take into consideration :—1. the period at which the body is examined; 2. the position of the part; 3. whether there existed any mechanical obstruction to the circulation during life ; 4. the mode of death ; 5. whether there were any symptoms of acute vascular disease during life. Local Symptoms of Inflammation.—Inflam- mation has been described both by ancient and modern writers as characterized by four local symptoms. These have been accurately noticed by Celsus : notx vero inflammationis sunt, quatuor— rubor et tremor cum colore et dolore (Lib. iii. cap. 10.) These symptoms may not all exist in every case, but the greater number of them are usually present; they may assume also various respective degrees of intensity. In some tissues there is generally very little redness or swelling, but in- tense pain. The pain may be intense, although the inflammation is moderate, or the pain be slight and the swelling considerable. The heat also varies in the same manner, the inflammation being sometimes attended with little increase of heat, while the swelling is great. These four symptoms exist in a moderate degree in the first stage of the inflammatory process, sometimes described as sub- acute, and which we have distinguished from per- fectly developed inflammation by the term active congestive or congestive irritation. It is only when these symptoms have acquired a certain de- gree of intensity, leading to morbid changes of structure, that they constitute, according to the view we have adopted, true inflammation. Redness.—Some tissues are naturally red ; their redness, therefore, must be preterimturally in- creased to become morbid. A quickened circula- tion may cause a temporary increase of redness, INFLAMMATION. 731 heat, and even swelling, which soon subsides, and is in this case only physiological; the increase of redness must therefore be permanent to be ac- counted morbid. The redness is manifestly owing to the increased quantity of blood in the diseased part distending the vessels, and penetrating into the minute vascular ramifications which previously conveyed only colourless blood. Mr. Hunter froze the ear of a rabbit and thawed it again; this occa- sioned considerable inflammation, an increased heat and thickening of the part: this rabbit was killed when the ear was in the height of inflam- mation, and the head being injected, the two ears were removed and dried ; the uninflamed ear dried clear and transparent, the vessels were distinctly seen ramifying through its substance ; but the in- flamed ear dried thicker and more opaque, and its arteries were considerably larger. The redness sometimes partly depends also on the formation of new vessels, but this of course can only happen in advanced stages of inflammation. Preternatural redness alone is not sufficient to constitute inflam- mation ; it must be accompanied with a certain degree of pain, heat, and swelling; for we have seen that it is a common attendant of congestions, active, passive, and cadaveric. Its intensity is very variable ; some dense fibrous tissues, such as tendons and ligaments, exhibit very little redness when inflamed, having but few vessels; whilst in more vascular textures the redness is bright and florid, constituting one of the mos't prominent symptoms; as, for example, in some cases of cynanche maligna, in which the pharynx and ton- sils are of an intense fiery red with burning heat and pain, in consequence of the extreme injection and distension of the minute vessels; when the blood, however, stagnates, the redness changes to a dark purple, indicating mortification. The same appearances are observed in gangrenous erysipelas. The redness may assume various tints, from a bright scarlet to a dark livid purple, with every intermediate shade. It may also appear in patches, stripes, streaks, or be uniformly diffused; it is generally greatest in one point, decreasing gradu- ally as it extends, until it becomes imperceptible, or sometimes terminating abruptly. It may be made to disappear by pressure, but returns as soon as the pressure is removed. Swelling.—The swelling is produced in the first stage of inflammation by the greater influx of blood ; at a later period it is increased by the effusion of serum, the extravasation of blood, and the deposition of coagulable lymph or pus; the interruption of the absorption may also be noticed as one of its causes. The swelling often remains after the inflammation has disappeared, particu- larly when it has induced much change of struc- ture. Swelling alone does not constitute inflam- mation ; although one of its symptoms, it may be occasioned by many other causes, such as the displacement^ a part, as in hernia, and the dis- location of a bone, by the effusion of blood or water, the accumulation of air, morbid growths, Arc. To be inflammatory, it must be conjoined with pain or redness. The degree of swelling depends partly on the violence of the inflamma- tion, and partly on the structure of the parts affected ; there sometimes exists very little swell- ing, as in ophthalmia, and superficial inflammation of the mucous and serous membranes, and also of the skin; the swelling is then irregularly dif- fused over a large surface ; in other textures it may be considerable and circumscribed. Excessive swelling and redness in a part, without much heat or pain, is very likely to terminate in gangrene. It is sometimes not easy to ascertain the exist- ence and exact seat of swellings of the internal organs, particularly in the abdomen ; and a con- siderable degree of habit and tact is generally re- quired to avoid mistakes. The swelling may be fixed or movable, pulsatile or not; it may be necessary to make the patient vary his position, or to lessen the fulness of the abdomen by empty- ing the bowels ; the exact seat of the swelling also is to be considered, whether connected with the liver, stomach, bowels or kidneys; situated in the mesentery, or merely in the abdominal parietes. A solid tumour sometimes pulsates in consequence of being in contact with the aorta ; this must not be mistaken for aneurism. It is very important to remember accurately the natural relative posi- tion of the different organs; the same.rule applies to the protrusion of tumours through the parietes of the thorax. Whilst on the subject of swelling, we must notice the accompanying changes in the consist- ence or density of the part. Some pathologists have advanced as a general proposition, that in- flammation has the effect of hardening soft and softening hard textures, giving as an instance the increased firmness of hepatized lung, and the soft- ening of inflamed bone. We conceive, however, that there is some inaccuracy in this statement, owing to the ideas attached to the terms in which it is expressed not being well defined. Almost all soft parts of the body feel harder to the touch at the commencement of inflammation, in conse- quence of the distension produced by a greater influx of fluids; but this increased firmness of the part is far from indicating any increase in the force of cohesion of its particles, or a real aug- mentation of density. A portion of hepatized is much more friable and easily broken down by pressure than sound lung, which, although more yielding to the touch, has a greater degree of elas- ticity and power of resistance. It is more correct, therefore, to say that recent inflammation has the effect of lessening the force of cohesion of all parts of the body, both hard and soft. This remarkable property of inflammation will be fully considered in the article Softening. When soft parts have been exposed to chronic inflammation, they often become hardened in consequence of new concrete products being deposited in their texture, or of its undergoing some change of structure by a slow and vitiated process of nutrition and secretion, as is exemplified in a variety of indurated tumours and morbid growths; in phlegmasia dolens ; a peculiar form of hardening of the subcutaneous cellular tissue, and elephantiasis. Heat.—The application of the hand to an in- flamed part is sufficient to prove that its tempera- ture is increased; the air expired, when the nos- trils, throat, or bronchial membrane are inflamed, is so heated by passing over the inflamed parts as to feel burning. The sensations of the patieni also indicate an increase of heat, although this is generally exaggerated, in consequence of the moi 732 INFLAM? bidly increased state of the sensibility ; in some nervous affections the patient complains of a sen- sation of burning heat, whilst the temperature of the part remains natural or is even diminished; there is sometimes a sensation of burning heat in gangrene, when the part is quite cold. The na- tural temperature of the body varies from 98° to 100° at the heart and on the trunk, but it gradu- ally decreases as we proceed further from the heart, and as the parts become smaller and more exposed to the influence of the surrounding atmo- sphere; it is thus only 92° at the extremities of the body: this is a fact it will be important to re- member in forming any estimate of the increase of heat in inflammation. Mr. Hunter concluded, from experiments he made, that the temperature of inflamed parts is but little augmented ; he ex- cited artificially inflammation in the chest, the abdomen, the rectum, and the vagina, without being able to discover any great increase of tem- perature, the thermometer rising only to 101°; in one case, however, it was as high as 104° in the abdomen; and in a case of hydrocele the heat of the tunica vaginalis, which was 92° at the time of performing the usual operation, rose to 98° after inflammation had come on. There must, we think, have been some source of error in these experiments, for in numerous experiments made since those of Hunter, the thermometer, when applied to inflamed parts in cases of erysipelas, phlegmonous swellings, &c. has been observed to rise as high even as 107° of Fahrenheit. It is well known also that the general temperature of the body may be very considerably increased in various states of disease, not always inflammatory. When making observations to ascertain the varia- tions of temperature in fever, we have not unfre- quently seen a thermometer placed in the axilla, or under the tongue, rise as high as from 105° to 107°: a similar elevation of temperature has been noticed in acute rheumatism, and during the con- vulsions of tetanus. There is generally a rise of temperature with any great local increased acti- vity of the circulation. Sir E. Home observed the oviduct of a frog, when about to spawn, two degrees higher than the temperature of the heart. Dr. Granville states that, during parturition, he has occasionally found the temperature of the vagina rise to 120°, the elevation appearing to bear a proportion to the degree of action in the organ. (Phil. Trans, for 1825, p. 262.) Every preternatural increase of heat is not therefore to be considered as inflammatory. In cases of fever, and especially of hectic fever, the whole body, or certain regions, such as the cheeks and the extre- mities, may be of a burning heat for a considera- ble time, in consequence of a state of active vascu- lar congestion, without any inflammation. There must be a certain degree of intensity and a certain duration of morbid heat, united with other symp- toms, to constitute inflammation. Redness and swelling may also exist with very little heat or pain, and pass on to suppuration, as is the case in abscesses by congestion and other forms of chronic inflammation. We can scarcely expect that any satisfactory Hxplanalion of the increase of heat in inflamma- tion will be given as long as there are points in the theory of animal heat that remain involved IATION. in obscurity. As the variations of animal tempe- rature constitute one of the most important mor- bid phenomena of inflammation, and of many other diseases, the consideration of the various opinions that have prevailed respecting the source of animal heat, and the causes which regulate its variations in disease as well as in health, is a sub- ject of peculiar interest to the pathologist. The chemical theory of animal heat proposed first by Dr. Black, and greatly improved subse- quently by Dr. Crawford, (Experiments and Ob- servations on Animal Heat, &c. by Adair Craw- ford, M.D., F.R.S., L.&E., &c.,) was long considered to account in a perfectly satisfactory manner for all the varied phenomena of animal temperature, both in health and disease. The accuracy of this theory has, however, been called in question of late years by several able physiolo- gists, who have drawn conclusions from their ex- periments tending to subvert every one of its main positions. The chemical theory assumed as fundamental facts, 1st, That the generation of heat in animals is the immediate effect of the chemical action of the air upon the blood in the lungs, leading to results strictly analagous to those of ordinary combustion : 2d, That oxygen and arterial blood have much greater capacities for caloric than carbonic acid and venous blood ; 3d, That the temperature of the blood is the same on both sides of the heart, and in the large trunks of the pulmonic system; and that the evolution of heat throughout the body is the result of the capacity of the arterial blood for caloric becoming lessened when it is changed into venous, by which a portion of its latent caloric is set free. The important fact of oxygen having a much greater capacity for caloric than carbonic acid has been denied by Delaroche and Berard ; and the fact of the capacity for caloric of arterial blood being greater than that of venous has been dis- puted also by Dr. Davy. The experiments, how- ever, for estimating the capacities of gases and fluids for caloric are of so delicate a nature, and liable to so many sources of error, that the con- clusions of these two gentlemen are by no means considered as fully proved. It has been asserted also, as the result of numerous experiments, that the heat of the blood on both sides of the heart is not uniform, but that the arterial blood is warmer than the venous by one or two degrees : it must be acknowledged that this opinion seems to have a great weight of evidence in its favour. The experiments, however, which would have most completely overthrown the chemical theory, if their conclusions had been confirmed, were those of Mr. Brodie; they ted to the conclusion, by maintaining artificial respiration in decapitated animals, that the generation of heat has no con- nection whatever with the changes the air and blood undergo in the lungs, but is entirely de- pendent on the influence of the brain and nervous system. (Phil. Trans, for 1811, p. 37; also Phil. Trans, for 1812.) Legallois having, how- ever, performed experiments of a similar descrip- tion, arrived at conclusions directly opposed to those of Mr. Brodie, and tending strongly to con- firm the opinion of the evolution of heat always bearing a relation to the consumption of oxygen. (Ann. de Chim. et Phys. tom. iv. p. 5. U3.) INFLAMMATION. 733 The inaccuracy of Mr. Brodie's conclusions was further clearly established by the investigations of Dr. W. Philip, who pointed out several impor- tant sources of error in his experiments. While, however, it is admitted by Dr. W. Philip that the action of the air upon the blood in the lungs is the great source of animal heat, he has been led to conclude by some ingenious experiments, that its extrication from the blood throughout the sys- tem depends on the direct action of the nervous influence on the blood, and that the generation of heat may therefore be regarded as a kind of se- cretion.* The advocates of the chemical theory have dif- fered with respect to the part of the animal eco- nomy in which the combination of the oxygen of the air with the carbon of the blood takes place. Dr. Crawford maintained that the carbonic acid is formed in the lungs ; that the heat evolved by its production is absorbed and becomes latent in consequence, as before mentioned, of the great capacity for caloric of arterial blood ; and that it is again set free on the blood being changed into venous. Legrange and Hassenfratz conceived that the air is absorbed by the blood in the lungs, and that the combination of its oxygen with the carbon of the blood takes place in the course of circulation, leading in this way to a gradual evo- lution of heat. Dr. Edwards has adopted this opinion, and supported it by experiments which appear extremely conclusive. Mitchell and Faust, however, having lately made in America some highly interesting experiments on the endosmosis of gases, consider that they have ascertained, be- yond all doubt, that the carbonic acid is generated in the lungs. (American Journal of Med. Sciences, vol. vii. Philad. Nov. 1830.) If it be true, as stated by some able chemists, that the most deli- cate analysis can detect no carbonic acid in venous blood, this would at once prove fatal to the opinion of Legrange.-f- On the whole the weight of evidence seems to be still greatly in favour of Dr. Crawford's theory; and although doubts may have been thrown out on the accuracy of some of his fundamental con- clusions, none of them have yet been successfully controverted. It appears highly probable that no theory can ever be established without a due refer- ence to the connection which respiration has with the production of animal heat. It must, in the mean time, be admitted that the temperature of a part is not always in proportion to the strength and rapidity of its circulation, and that there are other circumstances, not hitherto well understood, by which the phenomena must to a certain extent be influenced : this is particularly the case with respect to the circumstances that influence the extrication of heat, and regulate the ever-varying changes of temperature in different parts of the * It has been ascertained by Prevost and Dumas, from some very valuable experiments upon the propor- tional quantity of globules contained in the blood of different kinds of animals, and of different parts of the sanguiferous system in the same animals, that there exists an exact ratio between these globules and the temperature of the animal, which is highest in those whose blood contains the largest proportion of globules. t A good account of the various opinions brought for- ward on the subject of animal heat, and of their respec- tive merits, will be found in Dr. Bostock's valuable Ele- mentary System of Thysiology, vol. 11. p. 243. 3 M body. In some cases, for instance, of gouty in- flammation, the heat of the part feels extremely pungent to another person, although there is not the least symptom of any increased influx of blood ; the heat of the surface of the body is very high in some nervous fevers in which the vascular action is only moderately increased. Dr. Hastings states that he has seen several cases of fever in which the circulation was even remarkably slow, the pulse being only 45, when the temperature of the body was 105° ; and that the heat has also been 100° in cases of hydrocephalus, with a pulse at 60 or 70. (Hastings on Inflammation, p. 110.) There is great reason to believe that the influence of the nervous system over the evolution of heat throughout the body is very considerable, espe- cially in some states of disease; and if this be a well-founded conjecture, it would enable us to ex- plain in a perfectly satisfactory manner several of the phenomena of this interesting process, whicb cannot so well be accounted for on chemical prin- ciples. There is one circumstance, besides chemical ac- tion, which must, we conceive, have a considerable degree of influence in modifying the animal tem- perature, and which appears to us to have been hitherto too much overlooked. The various mate- rials of which the body is composed are undergo- ing, during the process of assimilation, disassimi- lation, and secretion, an incessant change of state; some passing from the gaseous to the fluid, and from the fluid to the solid state, whilst others experience similar changes in an inverse order. These variations of density must necessarily be attended with both a considerable extrication and absorption of caloric, partly, no doubt, under the influence of chemical and electro-galvanic agency. It is, therefore, reasonable to suppose that the dif- fusion of animal heat throughout the body is in some measure connected with the operations, phy- sical, vital, and chemical, constantly going on in the extreme vessels ; and we shall probably never be able to construct any perfect theory of animal heat until we are better acquainted with the func- tions of these vessels. It is well known that every material disorder of the functions of nutri- tion and secretion modifies the temperature of the body : when the powers of assimilation exceed those of disassimilation, and the function of nutri- tion is in great activity, the faculty of producing heat is considerably increased ; while, when the waste of the body surpasses its nutrition, the faculty of producing heat is weaker. Thus, in healthy individuals in the prime of life this faculty is greater than in old and sickly people ; this is likewise exemplified by the cooling effects of the evaporation of the cutaneous perspiration, and, in dogs, of the pulmonary exhalation. In inflam- mation there is a great accession of nutritive fluids, which, becoming condensed, necessarily give out heat, whilst absorption and disassimila tion are completely suspended ; this must inevi tably create a considerable preponderance in the extrication of heat over its absorption, and con tribute to raise the temperature of the part. Dr. Edwards has adopted the conclusion, from his beautiful experiments On the Influence of Physical Agents, that the production of animal heat is to be referred to a special power possessed 734 INFLAM by the living body, a kind of calorific function, which varies according to age, states of health or disease, and climate; that this power of generating heat is intimately connected with the respiratory, circulating, and secreting functions, and that it cannot suddenly undergo any permanent alteration during health. Dr. Edwards' interesting experi- ments admit of some important applications in pathology. The power of generating heat is dis- tinctly proved to be less in children than in adults by nearly five degrees of Fahrenheit, and their temperature can, therefore, only be maintained at the standard of health by artificial heat, contrary to the commonly received pernicious opinion that children resist cold better than adults: this is fully confirmed by the great tendency observed in chil- dren to become cold and pallid, and to be affected with other symptoms of exhaustion, from the in- cautious use of bleeding and purging. The faculty of producing heat diminishes as the heat from ex- ternal agents increases, and vice versa,- so that this faculty is greater in the inhabitants of cold than in those of hot climates. But the power of generating heat is not capable of being either in- creased or diminished Suddenly during health ; hence the injury sustained by all sudden changes of the atmospheric temperature. When an in- habitant of the north removes to the south, his faculty of producing heat being too great in rela- tion to the climate, there is an excess of heat in his system, by which he is greatly predisposed to inflammatory affections ; and this will continue to be the case until his power of generating heat has been gradually lowered, so as to become adjusted to the climate : a change of this description is found to require in general about two years. Recent experiments, made with great accuracy, prove that animal temperature is not, as was sup- posed, equalized all over the globe. Dr. John Davy ascertained that the inhabitants of Ceylon have a higher temperature than Europeans by nearly two degrees ; this is the effect of the heated atmosphere in which they live, and would be still greater were it not counterbalanced by the circumstance of their generating much less heat than Europeans.* Di. Edwards observes, also, that the faculty of producing heat is considerably modified by disease. In all inflammatory diseases it is greatly increased ; in chronic and organic diseases, especially of the organs of respiration and circulation, it is often much lowered. Individuals labouring under such diseases are consequently observed to suffer severely from cold, and to be in general benefited by emi- gration to a warmer climate, where a diminished power of generating heat is more compatible with the enjoymenf of good health. [See on all this subject the physiological works of Mulier, Car- penter, or Dunglison.] Pain.—Pain has a highly important influence in inflammation; it varies from the slightest in- crease of sensibility to the most violent suffering. It may be induced by an irritation of the nervous system without any corresponding increased action in the vascular system; severe spasm causes in- tense pain, as is seen in cramps. There are ex- * Pome observations having been made recently by one Of our medical officers on the coast of Africa on the comparative heat of Negroes and Europeans, it was found that the temperature of the former was several degrees fci-jher than that of the latter. 1ATION. cruciating neuralgic pains of long continuance, as in tic douloureux, without any accompanying in- flammation. In consequence, however, of the intimate connection between the functions of the nervous and vascular systems, and especially those of the minute vessels, nervous irritation is gene- rally attended with increased vascular action. We have already seen that the first effect of the appli- cation of irritants to the living body is the excite- ment of pain, and that this is soon followed by an accelerated circulation and increased flow ol blood to the part. It is not easy to explain why the action of irritants is sometimes confined to the nervous system, unless we can suppose that there is some state of disease affecting exclusively the structure or function of the nerves. The pain in inflammation is either to be attri- buted to the direct irritation of the nerves by the exciting cause, or to their compression in conse- quence of the over-distension of the vessels, or the stretching of the fibres of the part; the pain is often increased with each dilatation of the arteries, constituting what is called pulsatile pain. There are great variations in the degree and nature of the pain, depending on the texture of the part, the number of its nerves, the violence of the inflam- mation, nature of the irritating cause, &c: it must be acknowledged, however, that until we are better acquainted with the structure of the nerves and nature of the nervous principle, we can scarcely hope to account for all the varieties of their morbid excitement. It is generally very acute in parts largely pro- vided with nerves, and especially when they are delicate and pulpy; for the degree of pain is rather in proportion to the number of nerves terminating in a part, than to the size of the nerves passing through it. In parts of a dense and unyielding texture the pain is also generally very severe, al. though they have but few nerves, and are not naturally endowed with much sensibility; this is owing to the great compression of the nerves by the distended vessels. We see this exemplified in bone, tendon, ligament, all fibrous textures, and even the hard cartilaginous surfaces of joints, which become red and extremely painful under inflam- mation: the same takes place in soft parts when- ever surrounded by fibrous bindings. When there is great tension, the pain is often so excruciating as to disturb the whole nervous system and bring on delirium; hence the good effects of relieving the tension by practising incisions even in the early stages of inflammation before the formation of matter: they are often followed by the instan- taneous remission of fever and delirium. This is probably the reason of the inflammation of serous membranes, which are generally spread out tightly, being attended with much more violent pain than that of mucous membranes. Mucous membranes are also much less sensitive than the skin, and their inflammation is often not attended with much pain: this is one reason for the inflammatory af- fections ot the mucous membrane of the alimen- tary canal having been so often overlooked. The degree of pain is not always therefore in propor- tion to the original sensibility of the part, but de- pends also on its tense and unyielding character. The pain is usually pruriginous, pricking, and burning in the skin ; acute and shooting in serous INFLAMMATION. 735 membranes -, dull and throbbing in cellular and parenchymatous organs; lancinating in cancer and malignant tumours ; obtuse and heavy in glands and bones. A sense of weight and throb- bing generally indicates a tendency to suppuration, and the pain usually subsides on the formation of matter, particularly if it has a free issue. The pain is in some instances continued, in others periodical; the sensibility of some of the organs of sense, such as the nose and mouth, is dimin- ished during inflammation, whilst the eye and the ear, when inflamed, become exquisitely sensible. The pain is sometimes so slight, that it amounts only to a morbid soreness or tenderness on pres- sure. Besides pain, the sensibility of the part is morbidly increased to all external impressions, so that those which before gave pleasure become pain- fully exciting. Most of the internal organs per- form their functions during health without trans- mitting any perceptible impression to the senso- rium ; but when inflamed, we become immedi- ately conscious of their various actions, in conse- quence of these being attended with uneasiness and pain : we can then distinctly feel that we have a stomach, heart, lungs, &c. : these sensa- tions are always sure signs of a state of disease, and intended no doubt as warnings that we may avoid persisting in the use of what might prove injurious. The pain arising from mere spasm is generally lessened by pressure, as is observed in colic ; and this forms a good distinction from inflammatory pain, which pressure aggravates. The pain of inflammation is, however, chiefly increased by sudden and partial pressure; for frequently a gentle pressure of the whole of the inflamed part gradually increased, can be endured without pain, and even mitigates it.* One of the effects of gen- eral pressure is to diminish the influx of blood, and lessen in this way the swelling, the heat, and all the other symptoms of inflammation. Gene- ral and graduated pressure has on this account been recommended, and sometimes successfully applied as a remedy ; it has been used to this effect by Dr. Balfour in rheumatism, by Mr. Car- michael in cancer, and Mr. Velpeau in erysipelas. We have witnessed good effects from it in some cases, but have seen it aggravate the symptoms in others. The sudden disappearance of intense pain in a highly inflamed part often indicates the approach of gangrene. Very severe pain has a great influ- ence in inflammation by the morbid sympathies and constitutional disturbance it excites. Some caution is frequently required in ascer- taining the existence of pain. Under certain states of general nervous irritability, the patient com- plains of tenderness in whatever part of the body pressure is applied ; this tenderness is sometimes greater, or perhaps entirely confined to certain re- gions, and more particularly to the epigastrium and the hypochondria. There are in some ner- vous persons at all times a great intolerance of pressure in the epigastrium. hasty and superficial examination in such cases lead most erroneously to the conclusion of mflam- *Dr. Emotion's Lectures on 'nfla,mmati^^fveGd,e. Nov.20 iy:il in which a clear and comprehensive de- •cription vs given of the local symptoms. mation being present, and to the consequent adop- tion of active remedies, where there was no actual disease. Mistakes of this kind are by no means of rare occurrence in the present times, since the minds of practitioners have been so exclusively occupied with the idea of the great prevalence of inflammatory diseases over all others, and espe- cially of gastro-enteritis ; and persons have in this manner not unfrequently been subjected, without the least occasion, to long courses of bleeding, purging, and mercurial treatment. The presence of pain or tenderness alone, with- out any of the concomitant symptoms, is never sufficient to constitute inflammation ; by diverting a little the patient's attention, and then gradually repeating the pressure, it will often be found that his first complaints were greatly exaggerated.— There is in general much difficulty in ascertaining the seat of pain in infants, as they merely exhibit general signs of suffering, without being able to describe their sensations. It will be necessary in such cases to watch carefully the expression of the countenance for the ordinary indications of pain, when pressing the different parts of the body : in- fants are sometimes observed to carry frequently their hands to the part of the body that is affected. Pain, even of the most intense description, may also become latent in consequence of the sensi- bility of the sensorium being impaired by disease. This not unfrequently happens in febrile affec- tions when the head is much affected ; local in- flammations, which at first complicated the fever, may thus be supposed to have subsided, while in reality they are only masked, and are proceeding in their destructive course: it is necessary, in or- der to guard against this deception, to make daily in such cases, a minute and careful examination of the condition of the principal viscera. There is another source of delusion with respect to pain: it is sometimes felt at a distance from the seat of the inflammation in a greater degree than in the diseased part. In such cases the pain is generally conveyed by nerves passing through the inflamed part to other remote parts, in which they termi- nate. We have familiar instances of this pecu- liarity in the morbus coxarius, in which the only pain complained of is frequently in the knee, and sometimes likewise in sciatica. There is a particular expression of countenance characteristic of the existence of pain in each of the different viscera ; the contraction of the fore- head and eye-brows, combined with a wild, staring, or heavy expression of the eyes, are the usual in- dications of pain in the head. The distension of the alae nasi, contraction upwards of the commis- sures of the lips and of the cheeks, and protrusion of the eyes united to heaving of the shoulders, point out pain in the thoracic viscera. A falling in of the cheeks, contraction downwards of the angles of the mouth, an elongated and pinched appearance of the features, with sunk eyes and pallidness, indicate abdominal disease. There is an expression of great dejection in all chronic dis- We have known a eases of the urinary organs. Besides the local symptoms just described, there are others which have reference to the disturbance of the functions of the organs affected. Thus, in- flammation of the brain is attended with delirium, vertigo, coma, convulsions, and paralysis • inflaro- 736 IN F L A M : matio.i of the larynx with a shrill, crowing, hoarse, or feeble voice, and difficulty of breathing; that of the pharynx with difficult deglutition; that of the lungs with dyspnoea, cough, and various kinds of expectoration; hepatitis with pain in the shoulder and larynx, besides pain, heat, and ful- ness in the right hypochondrium ; gastritis with nausea and vomiting, besides fulness, heat, pain, and great tenderness in the epigastric region; nephritis with retraction of the testicle and vomit- ing ; panaris with swelling of the glands of the axilla, &c. When the inflammation affects ex- haling and secreting organs, there is a change in the quantity and quality of the secretions; they are at first diminished, or even suspended ; they then return altered perhaps in colour, thickness, or smell. In the inflammation of internal organs these functional and sympathetic symptoms are often of the greatest value, as the more ordinary local symptoms are mostly beyond the reach of our observation. When the inflammation is extensive and severe, the functions of other organs are also disturbed: the whole constitution may become more or less affected; and this affords another class of symptoms called constitutional, from which we often derive considerable assistance in our diagnosis. These form the next subject of consideration. [From the whole consideration of the subject, we are justified in embracing the views of a recent able writer, (Alison, in Tweedie's Library of Medicine, 2d edit. vol. i., Philad. 1843; see, also, his Outlines of Pathology and Practice of Medicine, Amer. edit., Philad. 1844): "In order," he re- marks, "to give the requisite precision to the general notion of inflammation, as a local change of the condition of any part of the body, it seems only necessary to include in it, besides the pain, swelling, heat and redness, the tendency always observed, even when the changes in question are of short duration, to effusion from the blood-ves- sels of some new products, speedily assuming, in most instances, the form either of coagulable lymph or pus. It is true, that there may be in- flammation either of so slight intensity, or short duration, as never to show these, its usual conse- quences ; but we shall escape a great deal of use- less verbal discussion and misapprehension if we lay it down as a rule, never to apply the term except in cases where we are satisfied, that the tendency to these effusions exists, and that, if they do not appear, it is only because of the minute scale, or the rapid abatement of the diseased action. A peculiar perversion of nutrition or of secretion, we hold to be essential to the very exist- ence of inflammation; and all descriptions, and all attempts at explanation of the changes to which the term is applied, if they do not include this, their most essential peculiarity, we must regard as necessarily and fundamentally defective."] Constitutional Symptoms of Inflammation.— It has already been stated in the experimental in- quiry into the nature of inflammation, that the action of stimuli on the living body was not always limited to the part to which they were ap- plied, but extended frequently to the whole animal economy, exciting various degrees of disturbance '.'l its several functions. The existence and nature 1ATION. of this constitutional derangement were demon- strated by several experiments. Inflammation may extend in several ways be- yond its original seat. By continuity :—when it extends along the surface or throughout the sub- stance of the same tissue: thus there is a great tendency to the rapid diffusion of inflammation along the surface of the skin in erysipelas; and the same is observed in the inflammation of mu- cous, serous, and fibrous membranes. By con- tiguity :—when it is communicated to adjacent tissues of a different nature : the inflammation often extends in this manner from serous mem- branes to the organs they invest. The facility with which inflammation spreads by contiguity depends, in a great measure, on the disposition of the connecting cellular membrane : when loose, it transmits the inflammation rapidly from one part to the other ; but when dense, it appears to oppose strongly the propagation of the disease. It was a remark of Laennec, that congestions and gangrene had a greater disposition to spread by contiguity, and acute inflammation by continuity. The local extension of inflammation is, on the other hand, checked by differences in the texture, the vital properties, and in the functions of the various organs and tissues of the body; and we may add, that general tendency in all living mat- ter to resist the destructive effects of disease. One of the means by which this is effected is the effu- sion of coagulable lymph, and contraction of ad- hesions around the seat of the inflammation ; so that the continuity of the parts is interrupted, and the disease circumscribed. The communication of inflammation to parts of the body remote from its original seat takes place in two different ways, either through the medium of the circulation, or that of the nervous system. It has been satisfactorily proved, by di- rect experiment, that when deleterious substances are inserted into any part of the body, they are sometimes absorbed into the blood-vessels, and conveyed by the blood to remote parts, where they excite various diseased actions. (Magendie's Physiology, p. 347, Milligan's translation.) We have further demonstration of this being the case from numerous pathological facts, as in the morbid effects of various animal and other poisons, which it would be difficult to explain in any other man- ner than by the absorption of the morbid matter. It is, therefore, very generally admitted that the blood is the vehicle of a great many morbid prin- ciples ; and that the deterioration of its qualities is to be placed among the most frequent causes of disease. In inflammation it is easy to conceive, when it is either of an unhealthy character or the result of a specific cause, how the morbid products of the local affection, being absorbed into the blood and circulated with it throughout the body, should sometimes excite inflammation in distant organs and disturb the general health. Morbid impressions are, however, transmitted also from one part to another by the nervous system ; and nervous sympathy is therefore another great cause of the constitution being so frequently and va- riously affected by local inflammation. We think it, therefore, desirable to offer here a few observa- tions on the influence of sympathy. The structure of the human body is very com- INFLAMMATION. 737 plicated, its elementary materials being so arranged as to constitute an assemblage of tissues and or- gans having distinct physical and vital properties; these tissues and organs act reciprocally on each other, producing by their combined operations the complex phenomena of life. Every living part of the body has a general sympathy with the whole system, or a particular sympathy with certain parts of it; and the functions of each part are more or less essential to the healthy action of the whole. The influence of these reciprocal sympa- thies is, therefore, very considerable, especially in disease. It is through the medium of the brain and nerves that sympathies are established between all parts of the system ; receiving morbid impres- sions from diseased parts, the nerves transmit them to the other organs of the body, and in this man- ner become the source of an infinite variety of both local and constitutional morbid phenomena.* Inflammation in one part of the body may also disturb the functions of the others by its direct in- fluence on their circulation, independently of any- nervous sympathy. The great accumulation of blood in an inflamed part may be the means of depriving another of its usual supply of blood; thus the inflammation of internal organs attracts sometimes the blood from the surface towards the centre of the body, creating coldness and pallid- ness of the skin ; the lower extremities are like- wise cold in cases of determination of blood to the head; on the other hand, if the regular return of the blood to the heart be prevented by the inflam- mation of any of the central organs, such as the lungs, heart, large vessels, &c, this will cause it to accumulate in remote organs, and impede their functions. These unequal distributions of blood from the mere mechanical derangement of the balance of the circulation are of frequent occur- rence, and a much greater source of constitutional derangement than has generally been supposed: they may be looked upon as a species of sanguin- eous sympathy. There exists a strong sympathy also between the different organs engaged in the same function : when the stomach, for instance, is in a state of disease, all the other organs belonging to the di- gestive function are more particularly predisposed to sympathize with it. One eye has also been known to become inflamed through mere sympa- thy with inflammation that existed previously in the other. This kind of sympathetic influence has been called sympathy of function. It has been advanced by Bichat that similarity of struc- ture chiefly is a great source of sympathy, and that, for example, when a serous or fibrous mem- brane or a muscular organ was inflamed in one part of the body, there was a strong tendency to inflammation of the same texture in every other part of the body. The various morbid sympathies and constitu- tional symptoms to which they give rise, are con- siderably modified by those peculiarities of consti- tution which have been termed temperaments and idiosyncrasies. The temperaments are formed by * See Dr. Thomson's account °f Pa'tic"'f^P^e,9 in his Lectures on Inflammation and also some, „m lent remarks on the influence of local and general sym pathies in the work on inflammation by Mr. James, se cond edition. Vor,. II. — 93. 3 M a preponderance in the development and activity of certain tissues over others in the same body ; they may be divided, to suit practical purposes, chiefly into four—the sanguineous, bilious, phleg- matic, and nervous; there are, however, various combinations of these, forming a number of sub- divisions. By idiosyncrasies are meant peculiari- ties of constitution belonging only to one or a few individuals ; these are innumerable, often disco- vered only by accident, and in general difficult to explain. Thus certain alimentary and medicinal substances affect some individuals in a manner totally opposite to their general mode of action. There are also predispositions of the constitution to certain forms of disease, which are called dia- theses. Having premised these general observa- tions on the different modes of extension of in- flammation on sympathetics and temperaments, we shall proceed to the important consideration of, 1st, the influence of the constitution on local in- flammation ; and, 2dly. if the various forms of con- stitutional derangement induced by inflammation. Influence of different states of the Con- stitution on local Inflammation.—We have already had occasion to remark, that every living part seems to be endowed with an inherent faculty of resisting, to a certain extent, the effect of dis- ease. We are unacquainted with the nature of this faculty: it cannot be satisfactorily accounted for by structure, and is to be referred most probably to the immediate influence of the vital principle ; it has been designated accordingly by the ancients vis medicatrix naturx. It is in consequence of this faculty of resistance, that whenever a living part has sustained any injury, either from external or internal causes, an increased activity is soon observed to take place in most of its vital actions, and a process essentially vital is set up, by which the effects of the injury are often prevented, re- moved, or repaired. The faculty of resisting disease is observed to exist in different degrees in different individuals, and in the various parts of the same body. It is generally greater or less in proportion to the strength and soundness, or weakness and unsound- ness, of the constitution. In strong and healthy constitutions, there is in general only moderate predisposition to inflammation, even after the se verest injuries, which are repaired by a mild though efficient degree of inflammatory action But in individuals whose constitutions are either originally weak, irritable, or unsound, or havi been rendered so by long-continued disease, the tendency to resist inflammation is much weaker, and when excited, it is generally more violent, spreads more rapidly, and is less easily removed It is also well known that parts of the body having a low vitality, such as tendons, ligaments, bones, &c, resist inflammation much less effectually than those more highly organized. It is highly import- ant, therefore, in a practical point of view, to re member that there are circumstances in which thi: violence and spreading of inflammation may bu greatly increased by a state of general debility. A disordered state of the constitution operates not only in favouring the increase of inflammation, but opposes also a formidable obstacle to the es- tablishment of those restorative processes by which it is brought to a favourable termination. The 738 INFLAMMATION. principal sources of disorder in the constitution by which local inflammation is liable to be affected, may be referred to the following : a state of gene- ral plethora combined with an over-degree of ac- tivity in all the functions of life—an opposite con- dition of the system arising from deficient nourish- ment, and attended with general languor and de- bility—the vitiation of the qualities of the blood and other animal fluids, the effect either of bad food and air, or of the introduction into the ani- mal economy of morbid and other deleterious substances—a disturbed and irritable condition of the nervous system—a disordered state of the di- gestive function, and that in general of any of the vital functions—organic disease of an important organ—and, lastly, a predisposition to some form of specific disease, such as scrofula, gout, cancer, &c. Innumerable examples of the influence of all these morbid conditions of the constitution upon local inflammation might easily be adduced, were it not incompatible with the limits of this article ; but we shall have occasion to enlarge upon this view of our subject when treating of the constitutional effects of inflammation. There is one highly important practical rule to be deduced from the preceding considerations, namely, that from whatever cause the disorder of the constitution may proceed, the attention of the practitioner must be first directed to the amend- ment of the general health before he can hope to succeed in removing the local disease; this latter must in fact be treated by constitutional remedies; for if local applications only be relied upon, they will seldom be treated by constitutional remedies ; for if local applications only upon, they will sel- dom be found of much avail. The merit of having called the attention of the profession to this im- portant principle in pathology, is due, as already observed, to the late Mr. Abernethy, who directed more especially his inquiries to the influence of the state of the digestive organs over local diseases: we must refer the reader for fuller details on this impor- tant subject to Mr. Abernethy's valuable writings. (On the Constitutional Origin of Local Disease.) Various Forms of Constitutional Dis- turbance Induced by Inflammation^ — In- flammation of any parts of the body, whenever it is very intense, excites a disturbance in the func- tions of the heart, brain, and stomach, charac- terized by a series of morbid phenomena which have received the name of symptomatic or sym- pathetic fever. This morbid state of the consti- tution reacts, however, powerfully in its turn on the local inflammation by which it has been ex- cited, so that there exists the most intimate con- nection between the local affection and constitu- tional reaction. This is a circumstance leading to highly important consequences, for the sympa- thy of the constitution is generally the result of a salutary effort of the powers of life to assist in anesting the progress or removing the effects of the local disease, and the accomplishment of this desirable end depends in great measure on the local and constitutional morbid actions being duly balanced. Many proofs can be adduced in support of this mutual dependence of the local and constitutional affection upon each other. The reaction of the constitution corresponds generally in degree with the strength of the local inflammation, the former being aggravated or diminished in the same pro- portion as the latter increases or lessens. When the reaction is excessive, it tends to aggravate the local disease: when, on the contrary, the reaction is deficient, the local affection may either remain stationary and assume a chronic character, or it may increase rapidly, and affect by sympathy re- mote parts of the body, as sometimes happens in the unhealthy inflammation excited by morbid effluvia or animal poisons. It is well known that if the constitution becomes much disordered, or if its powers happen to fail during the progress to- wards restoration of any wound, the inflammation of the wound, which was before perfectly healthy, either assumes immediately an unhealthy charac- ter, or entirely disappears, leaving the part even sometimes in a state of mortification. The dis- charge from a wound, moreover, is generally scanty, and never of a healthy character as long as the symptomatic fever continues high ; but as soon as the fever abates and the general secretions are restored, the discharge becomes more copious and healthy. If, on the other hand, an individual reduced to a state of extreme debility from severe local disease, be seized with inflammation of a vital organ, he will sometimes bear with impunity a degree of general depletion which would have been previously sufficient to destroy him. (James on Inflammation, p. 46.) The preceding instances, to which many others could easily be added, will be sufficient to establish the fact of the existence of the closest sympathy between the local and constitutional morbid actions. The constitutional reaction not only varies as already stated, in degree, but also in its nature; and the correspondence is likewise maintained in this respect between the local and constitutional affection. The character or type of the sympto- matic fever is influenced chiefly by the following circumstances in the temperament and previous state of health of the individual,—the seat and ex- tent of the local affection, and the nature of the exciting cause. In individuals of a sanguineous temperament there is generally a strong reaction of the vascular system, and the type of the fever is essentially inflammatory, and seldom attended with much danger. In those of a nervous and irritable temperament, or whose constitutions have been weakened by disease, the fever is chiefly cha- racterized by considerable disturbance of the ner- vous system, and by a variety of anomalous and untoward symptoms ; there is frequently in this form of fever a degree of ofer-excitement followed by rapid collapse. The character of the reaction, however, may be entirely derived from the seat and extent of the inflammation, or the nature of the exciting cause: thus the inflammation of fibrous tissues, that consequent upon extensive injuries, or poisoned wounds, &c, generally in- duces very great disturbance of the nervous sys- tem, and the most dangerous forms of sympathetic fever, even in robust and healthy subjects. It is worthy of remark in these cases, that whenever we can change the character of the local disease by substituting healthy for unhealthy inflamma- tion, the character of the constitutional affection becomes also immediately impaired. There is another important form of constitu- INFLAMMATION. 739 tional affection that differs widely from the prece- ding ; it is characterized by the total absence of all reaction, and by a state of direct prostration and rapid sinking of the powers of life ; this dan- gerous affection may also depend either on the temperament and previous state of health, the seat and extent of the local affection, or nature of the exciting cause. The constitutional symptoms present other va- riations with respect to their character or the order of their appearance; they may be remittent or in- termittent ; precede the appearance of the local symptoms, occur simultaneously, and sometimes only after them. The character of the fever may be modified by the inflammatory and nervous types being combined in an almost infinite variety of degrees. It would be impossible, however, to describe every shade of difference ; and we think it sufficient therefore for practical purposes, to adopt the division of the constitutional affections into, 1st, inflammatory reaction ,- 2d, nervous re- action ,- and 3d, the state of direct prostration and rapid sinking without reaction. We must be understood not to use the terms inflammatory and nervous in an exclusive sense, but as only implying that such is in each case the predomi- nant nature of the reaction. 1. The appearance of the constitutional as well as of the local symptoms does not always imme- diately follow the introduction of a morbid agent into the system ; a period of variable duration often intervenes, which may be considered as one of incubation. This important period is some- times characterized by a certain degree of consti- tutional derangement; the symptoms of this de- rangement being, however, obscure, have not hitherto obtained the attention they perhaps de- serve, and are often unnoticed both by the patient and the practitioner. There may be a feeling of general uneasiness and lassitude ; pains in the limbs, disturbed sleep, sometimes headach, de- pression of spirits, slight alternations of chill and heat, a decrease of appetite, a bitter taste, clammy and furred tongue, a tendency to con- stipation, and turbid urine: other symptoms, be- sides the preceding, might no doubt be some- times detected by close observation ; they all in- dicate the latent influence of some morbific cause, acting on the entire system, and depressing more especially the functions of the circulation and in- nervation. After the period of incubation has lasted a vari- able interval of time, the local symptoms of in- flammation generally make their appearance ; and these are followed sooner or later by a more marked degree of constitutional disturbance. The patient is seized with rigor, nausea, or vomiting; the face is pate, the skin cold and rough, the pulse small and frequent : to this depression succeeds a general reaction, characterized by a dry burning heat of the skin, headach, flushing of the face, pain in the loins, restlessness, great general anxi- ety, soreness of the whole body, and sometimes delirium. The pulse is full, hard, and frequent; the breathing hurried ; the secretions become di- minished and altered ; the tongue is furred, dry, and red, especially at the edges and point; there is loss of appetite and great thirst; the bowels are confined ; the urine is scanty and high-coloured, but it remains clear and emits a strong animal smell. The blood drawn from the veins is buffed and cupped, a state of the blood which has already been fully described. These symptoms vary in severity and duration according to the seat and intensity of the inflammation. In all inflammatory affections there are also daily variations in the acuteness of the symptoms, constituting paroxysms of exacerbation and re- mission. The exacerbations generally occur to- wards night, when there is an increase of the pain, heat, and swelling, and an exasperation of all the febrile symptoms. As the morning ap- proaches, the symptoms lessen in severity, and there is either a partial or complete remission of fever, characterized by an abatement of the pain, and frequency of the pulse, and by the breaking out of moisture on the skin. Besides these daily variations, the course of in- flammatory affections may be divided into three periods—one of invasion, one of increase, and one of decline. The febrile symptoms already de- scribed persist, varying only in intensity, until the inflammation has reached its height. During the period of decline they are variously modified ac- cording to the mode of termination of the local disease: if by resolution, there is a gradual abate- ment of the fever, attended usually with a resto- ration of the diminished secretions and critical evacuations from some of the excretory organs. Thus, as the local symptoms decrease, the fre- quency of pulse and heat of the skin gradually subside ; the tongue becomes moist and clean ; the thirst, restlessness, general pains, and delirium disappear; there is a variety of critical evacua- tions, by profuse sweat or a copious flow of urine, by diarrhcea, expectoration, ptyalism ; or by spon- taneous hemorrhage from the nose, stomach, bowels, kidneys, or uterus. These critical dis- charges occur either singly or are variously com- bined ; they are frequently preceded by a severe general rigor and exacerbation of all the constitu- tional symptoms, exacerbatio critica, which is sometimes mistaken for an aggravation of disease, but is soon followed by profuse sweat and other evacuations, which lead to a complete remission of the fever. The variations in the state of the urine deserve particular attention ; a full account of them will be found under the section Resolu- tion. The ancients attributed these critical evac- uations to the expulsion of the morbific matter, by which blood and humours were deprived of their inflammatory and other deleterious properties; and they considered them as being strictly analo- gous to the suppuration of phlegmon. When, however, the inflammation terminates in suppuration, there is during the period of de- cline an imperfect remission only of the constitu- tional symptoms ; the fever returns after a de- ceitful suspension or partial abatement of its symptoms for a few days. It assumes a more de- cidedly remittent character ; slight paroxysms of rigor are experienced towards evening or after the meals, followed by flushes of heat, particu- larly in the cheeks, hands, and feet: also thirst, restlessness, and frequency of pulse; the exa cerbation increases until towards morning, when it is relieved by profuse perspiration, and there is a well-marked remission of fever during th«i 740 INFLAMMATION. forenoon; this constitutes hectic fever, which has been fully described in the article Fever. The sudden cessation of violent pain attended with prostration of strength, increased rapidity, weakness and irregularity of the pulse, cold clam- my sweat and delirium, denote the fatal termina- tion by gangrene. It is important to observe, that when the period of increase of the inflammation has been attended with high general excitement, that of decline is sometimes marked by a great and dangerous col- lapse of the powers of life, particularly in old peo- ple and young children. The probability of such an occurrence should be carefully kept in view, in prescribing active remedies during the violence of the disease in such subjects ; for otherwise a state of fatal sinking or dropsical effusion may be brought on by too active a treatment, although it may perhaps have appeared justified at the time by the immediate relief it afforded. If old people were formerly stimulated to death under the mis- taken notion that they are not subject to inflam- mation, we suspect that some in the present day may have sunk under the indirect effects of ex- cessive bleeding, owing to a disregard of the practical precept just alluded to. The series of constitutional symptoms we have just described are those of the simplest form of inflammatory fever. This fever is generally in- duced by the development of common acute in- flammation from either accidental or constitutional causes ; it affects most commonly robust healthy individuals, of a sanguine temperament, in whom there is a redundancy of rich blood—a condition of the system which has received the name of in- flammatory diathesis. The simple inflammatory fever may be considered as a salutary effort, by which the general powers of the constitution are brought into action, in order to assist in relieving some part of the body from a state of disease, by which the harmony of the functions, essential to health, is more or less disturbed. The fever may itself become a source of danger, when too violent, by aggravating the primary disease, or by exciting inflammation in other parts of the body; or when, from deficiency of the powers of life, the fever of reaction is too weak, the local disease is sometimes only partially removed, and passes into a chronic state : a deficient reaction is thus frequently the cause of inflammation being followed by changes of structure, such as indurations and effusions. 2. There is a form of constitution directly op- posed to the sanguineous: it is chiefly character- ized by weakness and irritability of the nervous system, and called the nervous temperament. This condition of the system is very obnoxious to in- flammation, which, when developed, runs a much more irregular and unpropitious course than in the sanguine temperament. The constitutional symp- toms of inflammation in this temperament are, as already stated, rather characterized by disturbance in the nervous system than by strongly increased vascular action, and the fever generally assumes a nervous, typhoid, or ataxic type. Another pecu- liarity of constitution which often accompanies the former, is a vitiated state of the blood, whose qualities have become altered, in consequence, probably, of some disorder in the functions of nu- trition or sanguification. The combination of these two conditions of the system gives origin to the very worst forms of symptomatic fevers, called adynamic or putrid, in which to the most formidable nervous symptoms are united an extremely vitiated state of the secretions, and a great tendency of the blood and other fluids to rapid decomposition. There is sometimes a combination of the inflam- matory and typhoid or adynamic forms of fever, exhibiting symptoms of high vascular excitement with great deficiency of nervous power; this is a complication of disease attended with extreme danger, and requiring considerable tact and cau- tion in its treatment. The essential character of the irritability of temperament which predisposes to the preceding forms of constitutional derangement, is over-acti- vity of the nervous system, combined with defi- ciency of the power of resistance. Irritability may be induced by deficiency as well as by excess of stimulus : a certain degree of stimulus is ne- cessary to preserve the healthy tone of every living part: thus, if the retina be deprived of its natural stimulus by the long-continued exclusion of light, it becomes weak and irritable, and intolerant to that degree of light which was previously endured without inconvenience. An excess of stimulus, as in inflammation, produces exactly the same re- sult. The stomach in the same way becomes weak and irritable by long abstinence from the use of meat and wine, and can only be brought back by slow degrees to tolerate even moderate quanti- ties of stimulating food, as we see exemplified in convalescence after protracted acute diseases, and in all cases of long-continued starvation. When the privation of stimulus is carried beyond certain limits, instead of increased irritability, the sensibility becomes gradually weakened, until it is at last completely extinguished, and a state of torpoi succeeds ; the effect of long-continued over-stimu- lus is likewise to induce torpor, both extremes thus leading to exactly the same result. These illustrations of the opposite causes which may give rise to irritability, are susceptible of some impor- tant practical applications in the pathology of in- flammatory diseases. There is no state of the constitution attended with so many complicated, obscure, and varied morbid phenomena, and so difficult to manage, as that which is characterized by either local or general irritability. The irritability may be confined to one organ or to one function; it may be justly said that there is in every constitution some weak part more pre- disposed to disease than others; and this may be the result of original structure, or have been ac- quired by habits of life or previous disease. In consequence of the great excitability of the nervous system in irritable habits, and want of power to sustain action, the sympathetic fever of inflammation is frequently characterized by a state of great over-excitement, followed by collapse. For example, the first effects of any serious injury or of the spontaneous development of inflammation in an irritable constitution may be a momentary state of depression, languor, or stupor. This, however, is, after a variable interval of time, suc- ceeded by one or several paroxysms of rigor, some- times very severe, which usher in the variable train of symptoms: nausea, vomiting, and great irrita- bility of the stomach; a dry brown tongue, parch- INFLAMMATION. 741 ing thirst, obstinate constipation, scanty and high- •oloured urine; praecordial anxiety and great rest- lessness; rapid pulse, either bounding or small, contracted, and irregular; burning dry heat of the skin; oppressed hurried breathing with frequent sighing; flushed countenance; severe headach; contracted pupils and wild expression of the eyes; incoherence, amounting sometimes to fierce mania- cal delirium, requiring restraint; convulsive pa- roxysm, with great distortion of the features, not unlike epilepsy. This state is followed by one of considerable exhaustion, characterized by somno- lency ; sunk, haggard, and livid aspect of the countenance; profuse chilly and clammy sweats ; small, irregular, fluttering pulse, rapid sometimes beyond reckoning; panting respiration ; passive convulsions; hiccup and subsultus ; coma and stertor, terminating in death. The symptoms do not, however, always present this extreme degree of violence, nor lead so rapidly to a fatal result; they frequently assume the form of mild typhous or adynamic fever, characterized at one period by restlessness, anxiety, some head- ach, occasional low muttering delirium, moderate heat of skin, and frequency of pulse ; the skin is covered with petechiae, the tongue black and dry, the alvine evacuations vitiated and fetid ; whilst at another period there are stupor, chilliness, slight convulsions and subsultus, and the usual symp- toms of collapse. These various forms of consti- tutional derangement are especially distinguished by a rapid alternation of symptoms denoting con- trary states of the system, and they derive their essential character, as before observed, from a state of excitement not supported by sufficient vital power to maintain and carry it through. In this general state of morbid irritability, very slight causes of irritation give rise sometimes to the most violent constitutional disturbance, so that the general symptoms are not always proportionate to the extent of the local inflammation, nor a sure criterion of the degree of danger; the pulse may rise to 160, the heat of the skin be very high, and all the other symptoms usually indicating dangerous inflammation of some important organ, may be occasioned by only a trifling wound or furuncle, slight inflammation of the tonsils, or rheumatism of a joint. It is necessary, therefore, in forming a prognosis, not to be guided entirely by the general symptoms, but to take also into account the seat and extent of the inflammation. At other times, however, the local affection takes upon itself the impress, as it were, of the consti- tution ; the inflammation is either exasperated and spreads rapidly, or it is partially suspended, or there is a complete cessation of vital action in the inflamed part, which becomes cold, livid, flabby, and sometimes gangrenous: these unfavourable changes have been frequently observed in exten- sive wounds after injuries or operations ; in which cases no restoring process can be established so long as this disturbed state of the nervous function continues. When, in the course of the salutary fever in- duced by common inflammation, any circumstance occurs to create severe disordered action of the nervous system, the regular course of the fever is immediately arrested and completely changed and a new train of symptoms, chiefly nervous, and of a more dangerous and destructive character, make their appearance. This circumstance has led some pathologists to consider constitutional nervous ir- ritation as a morbid condition of the system, to- tally distinct from that which has received the name of fever. There appears, however, to be no good foundation for such a distinction, for the fever has merely assumed a new character, which corre- sponds exactly with that of the nervous, irritative, or typhoid fevers, that have been frequently de- scribed by nosological writers. The description of fevers under consideration attend some of the worst forms of inflammation, such as confluent small-pox, the malignant varieties of scarlatina and rubeola, several species of gan- grenous inflammation, and especially hospital gan- grene : this combination of local inflammation with constitutional typhoid symptoms is often ex- tremely perplexing, presenting to the practitioner at the same moment the most opposite and contra- dictory therapeutic indications. We have already stated that the nervous and irritative class of fevers are to be attributed either to constitutional causes, or to the seat, extent, and nature of the local inflammation. The following are some of the principal constitutional causes, which are extremely numerous:—great mental de- pression, arising from anxiety, grief, or the appre- hension of death; exhaustion from over-exertion of mind, and particularly from excessive study and loss of steep ; or that consequent upon large evacuations, either by spontaneous hemorrhage, or copious bleeding and purging : an impure atmo- sphere ; certain natural states of the body, such as that of pregnancy and lactation; the long con- tinuance of organic disease, especially in the uterus, testicle, stomach, urinary bladder, or any of the large joints. One of the most common and active causes, however, is the abuse of spirit- uous liquors ; the constitution of those who in- dulge to excess in the use of malt liquors, (as, for instance, brewers' servants,) is distinguished by a state of extreme plethora, combined with nervous debility; and although apparently robust, they bear very ill the loss of blood, being soon affected with low delirium, partial convulsions, coma, and other symptoms of prostration. In habitual gin- drinkers the nervous system is so weakened by constant over-excitement, that they sink rapidly under a similar train of symptoms, from even slight inflammatory attacks. Over-activity and weakness of the nervous and vascular systems are predominant features of the constitution of infants and young children, and inflammatory symptoms rapidly attain in them a high degree of intensity which is soon followed by an opposite state of collapse and sinking. Individuals endowed with great nervous irrita- bility, and particularly puerperal women, are sometimes subject to sudden attacks of acute pain in the head, chest, or abdomen, accompanied with considerable constitutional disturbance, bearing so strong a resemblance in several of its symptoms to active inflammation, that the affection has often been mistaken for either arachnitis, pleurisy, or peritonitis; it is a form of disease uepending, however, entirely on nervous irritation, combined at times with some degree of active congestion The disease sets in with rigor, generally more 742 INFLAMMATION. severe and lasting than in cases of inflammation; the reaction is proportionally violent, and charac- terized by considerable nervous disorder and great irregularity in the course of the symptoms ; there are frequent alternations from one extreme to another, differing in this respect from inflamma- tory reaction, which pursues its course more steadily. The general symptoms correspond with the description already given of the nervous and irritative forms of sympathetic fever, but it may be useful to offer a few observations on the local symptoms, for the purpose of defining more accu- rately the diagnosis of this affection from true in- flammation, as it is sometimes rather obscure. The affection of the head is characterized by acute general pain, great intolerance of light and sound, contraction of the pupils, vertigo, wake- fulness, and delirium, sometimes even maniacal. This differs from arachnitis by the disease coming on more suddenly without any premonitory symp- toms, and acquiring at once an extreme degree of violence ; besides, in the latter the symptoms are less acute, and increase only gradually. When the chest is affected, there is acute pain in some part, so severe as to check a deep inspira- tion ; but the pain shifts its situation, shooting from one side to another, or towards the back ; and if the patient be made to repeat the inspiration several times, the increase of pain becomes less and less; there is no cough or crepitus in making a deep inspiration, and the absence of all the signs of inflammation usually detected by the stetho- scope will afford every information that can be desired for a correct diagnosis. There are, some- times, severe attacks of palpitation and violent throbbing of the carotids, abdominal aorta, and all the large arteries. The affection of the abdomen is denoted by acute pain and great tenderness on pressure, either confined to one part, or more or less dif- fused. There is as great an intolerance of pres- sure in some cases as exists in peritonitis, the more local pain resembling that of gall-stones. The distinction, however, from inflammation is established, by the suddenness of the attack, the violence and irregularity of the general symptoms, and the severe sympathetic affection of the head, which very seldom occurs in peritonitis or enteritis. The effects of the treatment will afford addi- tional sources of diagnosis. The loss of blood is not well tolerated in this form of disease, deple- tion to a few ounces causing syncope ; whilst, in the inflammatory affections alluded to, the patient can bear the abstraction of forty or fifty ounces of blood before fainting is induced. Bleeding may sometimes appear to afford complete relief at the moment in cases of nervous irritation ; but the paroxy-m of pain soon recurs with equal if not greater violence; and it has persisted in some instances with unabated or increasing urgency, notwithstanding an enormous loss of blood. The symptoms on the other hand gradually yield to the use of purgatives and opiates, and of a light nutri- tive diet. In patients who have died of this affec- tion no traces of inflammation have been disco- vered in any part of the body, and no other morbid appearance than at times a slight vascular injec- tion of some of the organs. This important form of disease had not been hitherto well understood ; the profession is in- debted for a good account of it to Dr. Gooch, and more especially to Dr. M. Hall.* It is attributed by the latter gentleman to intestinal irritation. This, no doubt, is very frequently the case, but we have traced it also to uterine irritation; and it may in some instances be referred to primary irritation of the brain, particularly in persons re- duced to a state of great nervous exhaustion by any of the causes already mentioned. When excessive loss of blood by hemorrhage or blood- letting does not prove fatal through immediate sinking, it is sometimes followed by an excessive reaction resembling that we have just been con- sidering, excepting only that the principal local affection is confined to the head, and there is a more marked tendency to subsequent exhaustion. We must refer for an excellent account of this latter affection to the article Bloodletting. When inflammation occurs in constitutions in which an artificial plethora has been created by indulgence in the pleasures of the table, so that the functions of the different organs are oppressed by excessive repletion, the constitutional reaction is sometimes very feeble, the secretions are gene- rally unhealthy, and the fever may assume a ty- phoid or adynamic character in consequence of this state of indirect debility. It is highly im- portant to discriminate between a fever thus in- duced, and one of exactly the same character originating in direct weakness and nervous irrita- bility. In the former case the debility being indi- rect, and the effect only of the oppression of the powers of life, the fever would be aggravated by the stimulating plan of treatment which in the latter case it may sometimes require ; while, by disregarding the apparent debility, and having re- course to depletion and other active remedies, all the untoward symptoms are speedily removed, the character of the fever is transformed from typhoid to inflammatory, and both the local and constitu- tional affection pursues a more favourable course. It is in such cases that the pulse is found to ac- quire a greater degree of fulness, firmness, and regularity, under the repeated use of the lancet and the free exhibition of purgatives. It was stated that the character of the constitu- tional symptoms was sometimes influenced by the seat, extent, and form of the local disease, inde- pendent of any predisposition of the constitution. Thus, with regard to texture, injuries of parts of little sensibility and low organization frequently induce a higher and more alarming degree of ner- vous irritation, than that of parts more largely endowed with nerves and blood-vessels; inflam- mation of the dense unyielding texture of ten- dons, ligaments, fasciae, and fibrous membranes, especially of the periosteum, has already been mentioned as exciting an intense degree of local pain and tension. This generally gives rise to considerable disorder in the functions of the ner- vous system, while the constitutional excitement induced by the inflammation of mucous and serous membranes, or even of vital organs, more gene- rally assumes the form of simple inflammatory fever. •Commentaries on the Diseases of Females, hy Mar- shall Hall, M. D., Sec; and Morbid and Curative Elfects of Bloodletting, by the same author INFLAMMATION. 743 The lesions of muscular and fibrous tissue, es- pecially when the irritation is kept up by the pre- sence of any extraneous body, are attended with a most severe degree of general irritation fre- quently ending in tetanus. Injuries or erysipe- latous inflammation of the integuments of the head, chest, and abdomen, are followed by greater constitutional disturbance than those of other regions of the body, in consequence probably of contiguous sympathy. The inflammation of veins, which bear some analogy in their structure to flbrous membranes, is particularly characterized by symptoms of nervous and typhoid fever, and spreads rapidly along those vessels to a considera- ble distance. The injuries of nerves bring/on most alarming symptoms of general irritation, being a frequent cause of convulsions and tetanus: this is chiefly owing to the propagation of morbid impressions along their branches, as they are rarely found inflamed. The ganglia of the great sympathetic form perhaps an exception, having been found by Mr. Swan intensely injected in cases in which the system had been strongly im- pregnated with mercury. (Travers, Inquiry con- cerning Constitutional Irritation.) With regard to the form of the local injury, narrow and punctured are followed by more con- stitutional disorder than broad and open wounds; this frequently happens after the injury of some fibrous membrane or the puncture of a nervous filament, the complete division of which would have been of no importance. When the inflam- mation extends beneath a fibrous membrane, and suppuration takes place, the form of the wound not admitting of the discharge of the accumulated fluids, a considerable degree of tension and pain is the inevitable result. There may be for a time no local symptoms of the existence of the disease beyond a slight degree of tension and tenderness. When matter, however, is formed, an uniform diffused cedematous swelling, with erysipelatous inflammation of the skin, is observed round the margin of the wound, but without any distinct fluctuation; and this is accompanied with very violent constitutional disturbance, which can only be relieved by large and free incisions. The symp- toms arising from the puncture of a nerve are more developed in the course of the nerve, and in the constitution generally, than in the wound itself. Contused and lacerated wounds, especially when of considerable magnitude, and attended with great destruction of parts, are necessarily followed by most serious and alarming derangement of the constitution. This is the case with gun-shot wounds, especially when important organs are injured and foreign substances remain within the wound ; from the exposure also of muscles by the tearing away large flaps of skin; the denuding of an extensive surface of the cutis by burns and scalds; the extensive laceration, exposure, and crushing or comminution of the larger joints ; the displacement and protrusion of the ends of frac- tured bones, with partial or complete divisions ol great muscles and blood-vessels. There is con- siderable danger in these cases of the powers of the constitution sinking rapidly under the shock they have received, as will be mentioned hereafter: but a latal termination may likewise take place from the violence of the nervous irritation leading to convulsions and tetanus; or from the gradual exhaustion induced by the erysipelatous, gangren- ous, and sloughing inflammation, which usually precede the reparatory process in all such exten- sive injuries. The constitutional symptoms are also frequently characterized by great nervous irritability and de- pression, low delirium, and convulsions, after severe operations, either for recent injuries or the removal of chronic diseases. Hence the great importance, whenever practicable, of attending carefully to the state of the patient's constitution previous to the performance of any serious opera- tion. Besides the seat, extent, and form of the injury, the nature of the exciting cause has also a power- ful influence over the character of the general symptoms. This is particularly evident in the case of poisoned wounds, whether received in dissection, or from the bites of venomous ani- mals. We have, in this class of cases, very striking and instructive examples of the most dangerous forms of constitutional affection from local disease. The constitutional symptoms correspond with the description already given of the irritative and typhoid forms of fever, varying only in different individuals as to the relative degrees of reaction and collapse, to the combinations of severe ner- vous symptoms, with weak or strong vascular ac- tion, and to the more or less vitiated state of the secretions. In a case described by Dr. Duncan, there was profuse dark-coloured clammy sweat of intolerable fetid and disagreeable smell, so abun- dant as to wet the bed-clothes and stain them of a dark colour. This diaphoresis was critical, and it scarcely ever occurs but in cases that recover. There are considerable differences, however, with respect to the local affection. In some cases the poisoned wound is exempt from external in- flammation, the patient sinking exclusively from the action of the morbid matter on the constitu- tion ; sometimes there is the formation of a vesi- cle or pustule on the wound, followed by pain and inflammation of the cellular membrane of the arm, axilla, and thorax of the same side; or without any reaction in the wound, there may be severe pain and diffused swelling in the axilla and breast on the wounded side, followed by patches of a red diffused swelling and excruciating pain in distant parts of the body. In other cases there is violent reaction in the wound, leading to sup- puration and gangrene in the tendinous sheaths of the finger or hand, accompanied with painful diffused erysipelatous swelling of the arm, axilla, and integuments covering that side of the body. Sometimes numerous vesicles, some of a consid- erable size, have formed on the inflamed parts, containing either a transparent serum or a dark coloured fluid, the erysipelas round these vesicles assuming a dusky hue; and, lastly, the diffused inflammation of the cellular membrane on the arm or trunk has, in some instances, terminated in extensive suppuration and sloughing. The re- markable disposition shown by the inflammation in all these cases to rapid extension, arises, no doubi, from its affecting tissues in which inflammation generally spreads by continuity, such as the ab 744 INFLAMMATION. sorbents, veins, subcutaneous cellular membranes of tendons, and fasciae of muscles. (See Tra- vers, Inquiry concerning Constitutional Irritation.) This is also owing in some measure to the erysi- pelatous character of the inflammation, which in- duced Dr. Good to give it in his nosology the name of erythema anatomicum. The constitutional symptoms are chiefly to be ascribed to the introduction of the poison into the mass of the blood, whose qualities it vitiates and renders deleterious, and to the morbid action of this deteriorated blood on every part of the animal economy, and more especially on the vital organs; poisons have also been conceived to affect the nervous system in a more direct manner by the transmission of morbid impressions along the nerves. We have already stated that there are strong arguments and facts in support of each of these opinions, and that it is probable that the in- fluence of both causes must to a certain extent be admitted. It has been remarked that the constitutional affection is often as severe, and proves as rapidly fatal, in cases attended with scarcely any local affection, as in those in which whole regions of the body are engaged in inflammation. Extensive local disease is not therefore always so serious an aggravation as might at first be supposed; the danger is in proportion to the degree in which the poison has been mixed with the blood and has deteriorated its qualities, and to its paralysing in- fluence on the nervous power. It is generally considered that whenever the action of the poison can be confined either to the wounded or to any of the other inflamed parts of the body, by excit- ing in them inflammation of a healthy character, its pernicious influence on the constitution is con- siderably lessened, if not altogether prevented. Mr. Travers very justly observes, " Inflammation is not necessary to the most virulent and fatal action of the poison, and in general I should be disposed to say of these cases, that the symptoms of local inflammation and constitutional irritation exist in an inverse ratio of severity." A great many interesting cases illustrating the different forms of local and constitutional affection produced by poisoned wounds, are to be found in Mr. Travers' Inquiry concerning Constitutional Irritation—a work the most complete and valua- ble without exception yet published on the highly important subject of which it treats, and reflecting the greatest credit on the author's talent and ob- servation. The form of the disease most analogous to the preceding, is that arising from the bite of the more venomous serpents, and especially of the rattle- snake (crotalus horridus, Lin.), and of the cobra rli capello (coluber naja, Lin.) ; it only destroys life in a shorter time. The iocal and constitu- tional symptoms take place nearly simultaneously; I he bitten limb swells instantaneously, and the in- flammation shoots with great speed up its entire length to the axilla and shoulder; and if life con- tinue long enough, it darts down the side over the pectoral muscle, and produces there the same kind of erythema as in the cases already de- scribed. The vital principle, however, is from the lirst suddenly exhausted, as if by a stroke of light- ning ; the blood ceases to flow in the smaller ves- sels of the swollen part, which feels deadly cold; the action of the heart is so weak that the pulse is scarcely perceptible ; the stomach so irritable that nothing can be retained in it; dejection and horror overpower the mind, and the patient sinks with a low muttering delirium. Very powerful stimulants applied instantly may check the deadly influence of the poison, and sometimes produce a cure; but if life be sustained until the venom has exhausted its malignity, the debility is so extreme, and the sphacelus so extensive, that the unhappy sufferer often falls a victim to the local mischief. Dr. Mason Good, from whose Nosology the fore- going description is taken, gives an interesting account of the case of a man who died in St. George's Hospital, from the bite of a rattle-snake exhibited in London; he remarks that all other serpents have an immunity against each other's bite; but the rattle-snake not only kills every other, and even its own kind, but being so far ir- ritated as to inflict a personal wound, has been found to kill itself. The frightful assemblage of symptoms that characterize hydrophobia afford an example of the highest conceivable degree of over-excitement, and fatal disorder of the whole animal economy. One very remarkable circumstance connected with the action of the rabid virus, is the great length of time during which it has in some cases remained dormant in the constitution before taking effect; it is difficult to account for this long period of in- cubation of a virus that proves so rapidly destruc- tive after it begins to operate. The invasion of the constitutional symptoms is sometimes accom- panied with slight pain and inflammation of the wounded part; but the local affection is never severe, and in some cases completely wanting. In all the preceding cases there have been very few traces of disease found after death, beyond those resulting from the local inflammation ; the only morbid appearances ever observed have been partial vascular injections in some of the internal organs, and this only in a small proportion of cases. A high degree of injection of the medulla oblongata and pharynx is stated to have been found in some cases of hydrophobia. 3. The third modification of the constitutional derangement induced by local irritation or inflam- mation in the irritable temperament, is that of sinking without reaction. The symptoms of this state of sinking are not unlike those of a pro- longed fit of syncope, only more severe. The patient first experiences a degree of vertigo fol- lowed more or less quickly by gradual loss of con- sciousness. This, however, is sometimes only partial, there being rather a tendency to drowsi- ness, from which the patient can be momentarily roused by any strong and sudden impression ; he is also affected with a sensation of shuddering, considerable degree of universal pallor, contraction and coldness of the surface, and particularly of the countenance; the pupils are dilated; the breath- ing is short, at one time almost imperceptible and only carried on by the diaphragm, or at another interrupted by short irregular sighing; the pulse is slow, feeble, or indistinct; the tongue and fauces are dry, the stomach is irritable, and vomiting sometimes procures relief by creating a general reaction. When, however, this is not the case INFLAMMATION. 745 other more formidable symptoms make their ap- pearance ; the pallidness, collapse of the counte- nance, and coldness of the surface, increase; the breathing becomes more oppressed, and is attended with a peculiar crepitating noise; there is restless- ness, jacitation, and delirium, followed by coma, convulsions, relaxation of the sphincters, and ster- torous breathing, ending soon in death. The symptoms offer, however, many variations; in some cases the patient falls so gradually into a state of apparently quiet sleep, as not to excite any suspicion of danger; but this is succeeded by stupor, and he dies without any struggle. In other cases, he is affected with delirium, restlessness, and frightful convulsions. Convulsions, however, may appear without delirium or coma, the latter being of most frequent occurrence in infants. When sinking does not terminate in death, it is followed by either partial, excessive, or healthy re- action. In slight and temporary syncope, return- ing animation is indicated by the gradual restora- tion of warmth on the surface, with occasionally a gentle moisture of the skin ; the breathing be- comes more full and free ; there is deep sighing and sometimes hysterical sobbing; the pulse re- covers its fulness and strength ; and consciousness gradually returns as if the patient were awaking from sleep. In the state of more severe sinking, reaction is generally ushered in by rigor : a state of great depression of the nervous energy has the effect of lowering the action of the heart, and causing a gradual accumulation of blood in the central parts of the body, while the circulation is diminished in the capillaries of the surface and extremities. This unequal distribution of the circulating fluid impedes the action of the two most important vital organs, until the constitution, unable to bear any longer the irksome oppression, is roused to a con- vulsive effort, in order to remove the obstacles opposed to the circulation and respiration. The commencement of this effort at reaction is indi- cated by rigor, and sometimes also by vomiting and hiccup ; the action of the heart is immediately increased, and the reaction becoming general, leads to a restoration of the circulation and heat of the surface, to a relief of the embarrassed breathing, and to a revival of the depressed ener- gies of the brain and nervous system. If these changes take place without violence and are sus- tained for some time, a permanent healthy reac- tion is established ; they may, however, be only momentary, in consequence of the insufficiency of the nervous power to keep up reaction, and the patient sinks again into collapse. Rigor of long continuance without any return of heat, or fre- quently recurring, indicates likewise a want of power in the system. At other times the reaction may be too strong, and lead to a condition of the system opposite to sinking,—that of over-excite- ment. The shudder which accompanies the shock differs from rigor: it is a cerebral affection of short duration, produced by a painful impression of the mind, and it is not necessarily connected with any change in the temperature of the body. (Inquiry concerning Constitutional Irritation, by B. Travers, Esq. p. 138.) It is of great practical importance that the dis- tinction betxr~ri these opposite morbid conditions Vol. IL — 91 3n of the system should be well understood, and the changes from the one state to the other require to be watched with the utmost vigilance; for the treatment which may be the means of restoring life during the period of sinking, might prove destructive during that of reaction. The rule laid down by Mr. Travers, of maintaining action without forcing action, should be constantly borne in mind ; the effect produced by stimulants must also be carefully observed, in order that they may be laid aside as soon a3 reaction has taken place, and opposite measures should then be adopted if required. The state of sinking is brought on by all causes tending to depress considerably the nervous power. Nervous weakness being the chief characteristic of an irritable constitution, it is strongly predis- posed to this form of disease. The effect of sudden and painful emotions on weak and irri- table persons in causing syncope and convulsions is well known, and has even proved fatal in individuals much exhausted by disease. The breathing of putrid and pestilential effluvia has sometimes caused such a degree of faintness and sinking that life has been extinguished before re- action could take place. Individuals have died in the cold stage of the algide fever from a similar cause. Several powerful narcotics, by completely paralyzing the action of the brain and nerves, and probably also that of the heart, prevent all re- action, and destroy life with amazing rapidity. Patients who have been much exhausted by long and painful inflammatory affections, sometimes sink unexpectedly at the moment they were con- sidered convalescent. Some of the cases of sudden and unexpected death that take place without any known cause during attacks of severe illness, may reasonably be accounted for in this manner. Pro- fuse hemorrhage is a frequent cause of sinking, especially in puerperal women, whose vital pow- ers have been much lowered by the sufferings of tedious and painful labour: the sinking in these cases is often attended with frightful convulsions. Among the frequent causes of sinking is to be reckoned the sudden shock the constitution re- ceives from severe injuries, which operate in this way either in consequence of their extent or of the tissues that are affected ; as, for instance, when many textures are implicated in a wound, and ex- tensive portions of skin detached, or when joints and tendinous structures are lacerated, and large bones comminuted. The effect of extensive burns in causing direct prostration is very remarkable ; the great sensi- bility of the skin as the organ of tangible impres- sions, the importance of its functions as a secreting surface, and its numerous sympathies with all the vital organs, will sufficiently account for the sys tern receiving a severe shock when it is extensively injured. The danger is greater when the burn is seated on the integuments of the trunk than on those of other parts, in consequence, probably, of contiguous sympathy. The tendency to sinking may continue for the first three days after the accident; but at the end of this period, reaction is generally established. The situation of the pa- tient is very analogous to that of a person stunned by a fall ; he is in a state of apathy bordering on stupor, without actual loss of consciousness: ther* 746 INFLAMMATION. is an absence of all pain, as if the sensibility had shrunk below the point of pain. The complaint of pain is, therefore, rather a favourable sign : continued shivering is completely the reverse. The shock which the brain receives in concus- sion brings on symptoms of sinking; the stupor resulting from other casualties is the effect only of functional disorder, while that ariring from inju- ries of the head is generally connected with physi- cal derangement of the organ : in the latter case, when reaction takes place, there is much greater reason to apprehend and guard against cerebral infl im'iiation than in the former.* Children are sometimes affected with sinking after excessive evacuations ; this is chiefly indicated by a ten- dency to stupor and coma, which has often been mistaken for hydrocephalus. Full details re- specting the diagnosis and treatment of this im- portant affection will be found in the article Hrimo- cefiialus. The shock inflicted by the pain of a severe operation often brings on sinking, especially if the vital powers have been previously depressed by rerr;,t injury or painful chronic disease, or else if the patient has been under great dread of the operation, or much alarmed at the prospect of death. Severe and intense pain is of itself destructive. Puerperal women have sunk after difficult and protracted labour, from the mere paralysing effect of intense and long-continued pain ; ruptures of the stomach, gall, and urinary bladders are some- times productive of such sudden and excruciating pain as to bring on rapid and fatal syncope. The effects of severe pain are variable : the sudden in- fliction of intense pain may be instantly followed by such a degree of direct general torpor that the individual appears as if completely stunned, and little or no pain is afterwards experienced. When intense pain is long endured, it absorbs every other feeling, and induces a remarkable degree of insensibility to all surrounding impressions. Se- vere jiain at other times brings on delirium, con- vulsions, vomiting, suspension of the secretion of urine, and other symptoms of over-excitement; but this is of short duration, and is soon succeeded by a statu of exhaustion and torpor. Long-con- tinued pain impairs all the operations of life, and gradually exhausts the vital principle itself; so that pain has been justly called the greatest sedative in nature. The sudden remission of intense pain has sometimes been followed by syncope and death. Very intense pain of an unimportant part is sometimes well tolerated ; while slight pain of a vital organ or highly sensitive part, such, for in- stance, as the urethra, may be sufficient to cause syncope. The constitution in some cases be- comes accustomed to the impression of moderate pain, wlun frequently repeated or long-continued; the susceptibility to all impressions, whether plea- surable or painful, being lessened by habit. When the pain of inflammation is so intense as to con- stitute its most prominent symptom, and has not yielded to fill depletion, the inflammation is some- times kept n;i by the continuance solely of the pain. It is of ,'r.) The air-passages are more frequently covered with false membranes than any other mucous surface; and it may be observed that children are more subject to affections of the mucous membrane of the air-passages—the formation of false mem- branes is consequently more common at this than at other periods of life. When they form in the air-passages, they vary in thickness and consist- ence ; some are transparent, and of extreme deli- cacy; others are several lines in thickness, and so consistent, that they can not only be removed entire, but afterwards preserve their moulded form. A viscid fluid is interposed between the inflamed surface and the false membrane, by which their adhesion is prevented : in some instances minute filaments have been observed in these exudations, by which it has become united to the surface on which it has formed. We have already mentioned that the membrane which is formed in diphtheritis sometimes dips into the upper part of the larynx. Inflammation of the mucous membrane of the larynx is, how- ever, seldom followed by membranous exudation, but generally, when intense, the inflamed mem- brane is covered with thick viscid or semi-puriform fluid, which is most abundant in the sacculi of the .arynx. Minute portions of fibrine may be occa- sionally effused, and give a greater degree of con- sistence to the exudation. The pathology of these cases is, however, very different from that of la- ryngitis, in which the inflammation is seated in the submucous cellular tissue by which the mu- cous membrane is united to the cartilages of the larynx. In tracheitis, or croup, the inflammation is fol- lowed by the rapid exudation of a tenacious mem- branous substance, which is moulded to the form of the trachea. This false membrane is generally limited to the trachea and of a tough consistence; when it extends to the bronchia it is much softer, and in the smaller bronchial tubes it becomes quite fluid. The impediment to the respiration in croup is to be attributed in a great measure to the pre- sence of these false membranes, but also to the swelling of the tracheal membrane, and to the bronchitis which very often accompanies the dis- ease. The spasmodic affection of the muscles of the larynx, which occasionally accompanies croup, adds much to the sufferings and danger of the patient: when the disease proves fatal, the death is owing to the mechanical obstruction of the air in the trachea and bronchial tubes by the false membranes. The formation of false membranes is also a consequence of inflammation of the gastro-intes- tinal mucous membrane ; and, as noticed by An- dral, it occurs more frequently in its supra-dia- phragmatic than its infra-diaphragmatic portion. In children, the mouth, pharynx, and oesophagus are occasionally lined with a membraniform exud- ation, which terminates abruptly before it reaches the stomach. After puberty, these formations are equally uncommon, either on the internal surface of the stomach or intestines, Andral having never seen any either in the stomach or small intestines, and in only two instances had he observed false membrane lining the large intestine. Cases, how- ever, of this kind have been observed in adults. We lately attended a female who frequently voided a considerable quantity of false membranes from the bowels. They appeared, from their size and form, to have been effused on the mucous surface of the small intestines, and evidently, from the history of symptoms, were the result of chronic gastro-enteritis. The disease disappeared after repeated local detractions of blood from the surface of the abdomen, counter-irritation, and a bland diet. Andral mentions a remarkable case of a young girl of twelve years of age, in whom all the air- passages were lined with false membranes; they were found also in the pharynx, oesophagus, and stomach, where they existed in the form of large bands, extending from the cardiac to the pyloric orifice, beyond which point they did not reach. The mucous membrane was much more red be- neath than in their intervals. Pathological writers allude to the discharge of portions of the mucous coat of the bladder. There can be little question, we presume, that these morbid products are false membranes which have formed on the internal membrane of the bladder, and after being detached, have been expelled with the urine. The urethral mucous membrane ap- pears to assume the puriform secretion rather than exudation of lymph. The inflammation frequently , extends to the submucous cellular tissue, and by INFLAMMATION. 765 infiltration and thickening of this structure, con- traction or strictuie is induced. False membranes occasionally form in the cavity of the uterus, in consequence of an irritated or in- flamed state of the uterine mucous membrane. These membranes are sometimes thrown off in detached shreds after painful menstruation, or at irregular periods, when the internal surface of the uterus is inflamed. In some instances they bear the exact mould of the cavity of the uterus, and have such a degree of consistence as to admit of manual examination and even preservation in alcohol. Sterility is a common effect of these false membranes of the uterus. 3. Pustular Inflammation has its seat chiefly, if not entirely, in the mucous crypts or follicles. We not unfrequently meet with a simple enlarge- ment of these glandular organs (glandular so far as they are connected with a secreting function), in certain forms of fever, as well as in other ano- malous affections. When acute inflammation attacks one of these follicles, it becomes enlarged, swollen, and vascular. The mucous membrane and subjacent tissue soon exhibit marks of the in- flammatory action ; and when the membrane is villous, the villi are red and increased in size. A pustule is formed, round and prominent, more or less acuminated; and if a set of aggregated fol- licles become inflamed, the pustule is more flattened, and has a larger circumference. Frequently we find on the apex of these bodies a minute orifice, indicated by a dark spot, through which by pres- sure we soon squeeze out a mucous or puriform fluid, whilst in others we cannot observe any trace of an orifice. The pustules of mucous membranes which we have most frequently an opportunity of examining, are those more especially seen in the membrane of the mouth and pharynx. They are usually known under the name of aphthae, and are essen- tially the same in their mode of origin, as those which are developed on the deeper-seated mem- branes. The pustules on the inner surface of the intes- tinal tube often appear in a form nearly resembling that of the variolous pustule. The occurrence of these intestinal pustules in connection with fever has been minutely noticed by Roederer and Wag- ler in their history of the Gottingen epidemic, and afterwards by Petit, Pinel, and others. They have been supposed to coexist frequently with the cu- taneous eruption of small-pox; and we may add, that although this is not a very frequent occurrence, yet a sufficient number of cases are on record to establish the fact. We may, however, state that the possibility of the existence of pustules on a membrane devoid of an epithelion has been called in question. But if it be considered how numerous are the mucous crypts, and that in general, if not always, the pustule fso called) is found to occupy one or more of these, we can have no difficulty in accounting for its formation. In some instances, the apex of the pustule presenting a minute opening, in others that opening being closed by adventitious mem- brane, the follicular pustules of mucous membranes may be said to correspond in every aspect with the pustules of the follicles and sebaceous glands of the skin, as exemplified in acne, mentagra, porrigo, and some varieties of impetigo. The analogy between the pustules that occur on mem- branes provided with epithelion and those of the skin is sufficiently obvious. It may be mentioned that the most constant and frequent locality of pustular inflammation in the intestinal canal is about theccecal half of the ileum. This is the form of disease described by Breton- neau under the appellation Dothinenteria. (See Feveh.) 4. Ulcerative Inflammation. After a pustule is fully formed, its centre soon becomes depressed, and it loses its conical form. In some cases, this depression is owing to an enlargement of the ori- fice of the follicle, but more frequently it is pro- duced by an incipient ulcer. The increase of this depression, and the gradual disappearance of the pustule, indicate the progress of the ulcerative process ; finally, a circular ulcer, or when several follicular ulcers cohere, a patch of ulceration oc- cupies the site of the original pustule. This is the most frequent commencement of ulcers of mucous membranes : their numerous variations of form, extent, and depth, are dependent on the in- tensity of the inflammation, and the extent to which the neighbouring tissues are involved. Ulceration of a mucous surface does not always originate in the follicles : it is sometimes the result of acute inflammation of both mucous and villous tissue; or of small sloughs, or even of an inflamed or diseased condition of a subjacent tissue ; as, for, instance, when a tubercular deposit in that tissue acts as a source of irritation to the mucous mem- brane. Andral reduces the forms of those ulcers which are met with in the intestinal canal, to the follow- ing :—1. The circular form, remarkable for their great regularity. 2. The oval form, particularly noticed in the ulcerations of Peyer's glands. 3. The linear form, the ulcer appearing as a groove or fissure. 4. The irregular form, the margin being jagged. This latter form occurs most fre- quently. Ulcers of mucous membranes, when considered as to their depth, or as to the nature of their sur- face, present many varieties, from simple erosion to the complete destruction of the mucous tissue. Thus, in some there is merely so much of the surface of the membrane eroded as to prove the existence of a solution of continuity : if the mem- brane be covered with epithelion, it is also removed by the ulcerative process: if it be a villous mem- brane, the villi are likewise destroyed. This form is the result of an inflammation of slight extent. It is more frequent in its occurrence than is gene- rally thought, as from its superficial nature it is verv apt to be overlooked. The floor of the ulcer may be formed by the mucous corion as above described; but when the ulceration is deeper, so as to destroy the corion, the submucous tissue is the foundation of the ulcer, which varies in colour, consistence, or thickness. Sometimes the muscu- lar tissue forms the bottom of the ulcer : this state is met with in fever and in some severe forms of dysentery; not only is the superincumbent tissue removed in these cases, but that which passed m between the fibres of the muscles is, as it were, dissected out. The muscular tissue being de- stroyed, the bottom of the ulcer is formed by thu 760 I N F L A M M A T I O N . serous coat of the intestine. These cases often terminate in perforation of the intestine, whether by rupture of the delicate serous membrane, or by an extension of the destructive process to it. The probability of the occurrence of perforation depends, not on the extent or long duration of the ulcer, but on the rapidity with which it burrows. The possibility of the cicatrization of ulcers of mucous membranes has been disputed: recent observations have, however, fully attested the fact of their cicatrizing. The case of the late Profes- sor Beclard, so well known by reason of the cele- brity of the distinguished individual who was the subject of it, would alone prove the fact. This able anatomist, at one period of his life, laboured under marked symptoms of gastric inflammation, which yielded to an active treatment and rigid re- gimen. Some years after, upon the occurrence of his death from a totally different affection, a distinct cicatrix was found in the small curvature of the stomach. Besides this well-authenticated case, the testimony of Troillet, Louis, and other pathologists, leaves no longer any doubt on this subject. The gastro-intestinal mucous membrane is by far the most frequent seat of ulceration. Next in point of frequency are the bucco-pharyngeal and laryngeal membranes; while the bronchial and urino-genital portions rarely exhibit ulceration. Nervous Tissue. Acute inflammation of the brain is comparatively rare as an idiopathic dis- ease, but is often the result of external violence, in which case it is generally partial or circum- scribed. Examples of general cerebritis are not uncommon as one of the complications of fever ; on examination the brain presents general vascu- larity, but the congestion is greater in the arteries than in the veins; when the blood is accumulated chiefly in the veins and sinuses, it indicates that the lesion partakes more of the character of venous congestion than of inflammation. On cutting into a portion of inflamed brain, numerous red spots appear, the blood oozing from small vessels, which in the healthy state convey only the colourless part of the blood. The cere- bral pulp is at the same time infiltrated with minute effusions, or spots of blood, which give it a striated, or when the spots are numerous, a marbled appearance; and when in still greater numbers, they form small coagula. These bloody effusions, which may occupy a considerable part of one hemisphere, or only a small portion of the brain, extend more or less in breadth, and give rise to the various shades of redness observed in the section of a portion of inflamed brain, the grey or cortical substance assuming, when inflamed, a dark red or brownish colour, and the medullary a light rose tint. The highest degree of inflammation which is compatible with the organization of the cerebral tissue is never general, but confined to portions of the brain of various extent, around which the tissue presents the characters of inflammation in a more moderate degree. These inflamed portions, which acquire a certain degree of firmness and elasticity, are not exactly circumscribed, but are continued and blended with the surrounding tis- sue, the traces of inflammation being gradually 'est in the healthy structure. In subacute or chronic inflammation of the brain, the anatomical appearances are much the same as in the acute, but its duration gives rise to important modifica- tions. The redness soon changes to a crimson, purple, or light brown tint; this change of colour is followed by a diminution in the consistence of the inflamed structure, varying according to the duration of the inflammation, from slight though evident softness of the cerebral tissue to pulpiness, or even semi-fluidity. At the utmost limits of moderate inflammation, a slight though evident softness (ramollisement) may be remarked, and only recognised by comparing the softened with the healthy portions of the brain. This incipient stage of softening, which we have repeatedly ob- served in continued fever, is ascribed by some writers to the infiltration of the inflamed tissue with serous fluid, a supposition rendered extremely probable from the circumstance of the portion of the pia mater which invests the softened pulp being at the same time infiltrated with serum. When the inflammatory action has been still more intense, the structure of the brain is not only soft- ened, but disorganized and infiltrated either with blood or pus. When blood is diffused in the disorganized pulp, it constitutes the red softening, in contradistinction to that form in which globules of pus are mixed with the broken-down ceiebral mass, which, from the colour it acquires, is termed yellow softening of the brain. The red and yellow softening are sometimes combined in the same morbid mass ; blood, pus, and brain being thus blended together, and giving the cerebral tissue a dirty grey appearance, the shade varying according to the proportion in which they are mixed. There is another kind of softening which, though analogous, differs in many respects from either of the preceding—the white softening, in which the cerebral pulp is disorganized and infil- trated with serous fluid. It occurs chiefly in isolated parts of the medullary substance, ve-y often in the corpus callosum, fornix, and septum lucidum. The diseased portions are usually of a pure white colour; but when the cortical sub- stance is affected, it inclines more to a yellow or grey tint. This form of softening is often observed in elderly subjects, and is jgenerally accompanied with serous effusion in other parts of the brain : it is also believed by some pathologists to form one variety of hydrocephalic disease. Softening of the brain occurs more frequently in the cineritious than in the medullary part, the cineritious substance being from its great vascu- larity predisposed to inflammation : of the central parts of the brain, it is found more frequently in the septum lucidum, corpora striata, optic thalami, central part of the hemispheres, cerebellum and crura cerebri, and, according to Dr. Craigie, in the order now enumerated. There is another alteration of the brain conse- quent on inflammation—infiltration of the cerebral tissues with pus, which is in some instances dif- fused in drops through its substance; in others the purulent fluid is confined in distinct cavities of various sizes, the boundary being formed either by the substance of the brain itself, (undefined cerebral abscess,) or by an organized cyst (en- cysted cerebral abscess). INFLAMMATION. 767 Though suppuration may take place in any part of the brain, purulent collections are more frequently met with in the hemispheres. They are occasionally the result of acute, but more generally of chronic cerebral inflammation; their progress is slow, and the symptoms, which are always very obscure, vary according to their ex- tent and situation. Abscesses have been found in the cerebellum &y various pathologists, the pus being generally confined in an organized cyst. Induration has been mentioned as an effect of cerebritis, though some authors deny that it is the result of inflammation or of capillary injection. The fact, however, of its being accompanied with injection of the capillaries, and that the symptoms during life were those observed in chronic inflam- mation of the brain, are strong presumptive evi- dence of its inflammatory origin. The induration, which may be general or circumscribed, varies from the consistence of wax to that of cartilage. Ulceration has been stated to be one of the ter- minations of inflammation of the brain, and with- out asserting that this lesion never occurs in the brain, we are inclined to think that some of the older authors have described softening as ulcera- tion of this organ. In the cases which bear the greatest analogy to erosion, the ulcerative process appears to have commenced at the convolutions, and to have been connected with circumscribed inflammation of the pia mater. Gangrene of the brain is very uncommon. It is described by Baillie (Morbid Anatomy), who ftates that portions of the brain occasionally be- come gangrenous after violent injuries of the head, but that it is extremely rare when the inflamma- tion arises from any other cause. He mentions one case which had fallen under his observation, in which the mortified part of the brain was of a very dark brown colour, and as soft as the most rotten pear. A similar case, succeeding to injury of the head, is given by Saure, (Mem. de l'Acad. de Chir. tome i.), in which the substance of the brain was black and gangrenous to the depth of three fingers' breadth. The spinal marrow being similar in structure to the brain, is consequently liable to the same morbid changes; our knowledge of its lesions, however, is more incomplete, less attention having hitherto been paid to their investigation. The va- rious morbid changes which have been described by pathologists originate in inflammation either of the membrane or substance of the cord ; indeed, though the spinal marrow is enveloped with the same coverings as the brain, inflammation is sel- dom confined to either the membranes or the sub- stance of the cord, but appears to affect both the one and the other at the same time. Those cases, which have been detailed as examples of menin- gitis of the cord by Abercrombie and other writers, confirm this observation. In inflammation of the spinal marrow, the membranes and substance of the cord are much injected. The inflammatory action is soon fol- lowed by softening of the spinal marrow for a greater or less extent; sometimes the softening is limited to a very small portion: in other, cases it extends throughout the greater part of the cord. Blood is sometimes mixed with these softened portions, constituting red softenir.g; and when pus is intermixed, it gives rise to yellow softening. In some instances, the spinal canal contains a quantity of serous fluid, or a layer of puriform fluid is occasionally spread on the membranes, the pus being occasionally mixed with blood, but with- out apparent softening of the cord. These cases constitute undefined suppuration or abscess of the cord. The tissue of nervous cords and their minute filaments becomes occasionally inflamed, and gives rise to a variety of acutely painful sensations. This affection may have a spontaneous origin, but it is more frequently produced by punctured, lace- rated, or contused wounds, or by the application of a ligature, as in the common accident of in- cluding a nervous twig in tying a tdood-vessel for the suppression of hemorrhage or the cure of an- eurism. In these cases it is supposed that inflam- mation is produced in the neurilerna or covering of the nerve, which becomes vascular, indurated, and painful. We have an example of spontaneous neuralgia or nerve-ach in sciatica, in tic doulou- reux, and neuralgia of the median nerve in the arm, and posterior tibial nerve in the leg. These neuralgic affections may also arise from external violence applied in the vicinity of their origin, and of those parts in which they ramify. Inflammation of nervous tissue may terminate in resolution, in effusion of lymph around the nerve, in ulceration, and in enlargement of the nerve from deposition of new matter. This latter state sometimes succeeds to amputation ; the ex- tremities of the nerves become inflamed, and finally much enlarged and indurated — the con- sequences of chronic inflammation of their neu- rilerna. Vascular System. Notwithstanding the im- portant share the blood-vessels have in the patho- logy of inflammation, they are not themselves very often the subject of this action. There is still much difference of opinion among pathologists as to the precise anatomical appearances which should be considered as indicating inflammation of blood- vessels, some attaching no importance to changes in colour and consistence, which others deem im- portant lesions and the cause of many serious diseases. The following are, however, the characters of acute inflammation of a large blood-vessel: red- ness, rugosity, thickening and softening of its in- ternal membrane, the coagulated blood adhering to it either immediately, or through the interven- tion of a layer of effused lymph: the middle and outer coats are also injected, thickened, and lace- rable, and the consistence of the vessel is so much diminished that it is very easily torn. 1. Inflammation of Arteries. Though arteritis was considered by Laennec a very rare disease, subsequent investigations have proved that it is not altogether so uncommon as this celebrated pa- thologist was inclined to believe. The larger arte- rial trunks have been found more frequently in- flamed than the smaller branches; indeed, from the silence of authors on the subject of inflamma tion in the smaller arteries, it may be concluded that it very seldom occurs. Arteritis may be either acute or chronic, in acute arteritis the internal membrane is of a bright ros INFLAMMATION, red colour, and evidently swollen. It is sometimes difficult to determine, whether the redness in the internal membrane of the heart and the larger arteries arises from inflammation, or is the effect of imbibition or staining. When the redness is not accompanied with vascular injection, tumefac- tion, and alteration of tissue, more particularly when it is circumscribed and terminates abruptly, or appears in patches, it is to be ascribed to imbi- bition from contact with the blood contained in the artery. When the redness arises from inflam- mation, the membrane loses its polished and glis- tening appearance, has a villous aspect, and is easily detached from the other coats. The vasa vasorum also become more numerous and injected, and although it is often difficult to recognise these vessels in the centre of an inflamed membrane, they become clearly developed at its limits. The redness of inflammation differs also from that of imbibition in presenting various tints in the differ- ent coats, whereas inflammatory redness preserves the same colour in all. It is, therefore, now agreed that redness of the internal membrane of the heart and arteries, unaccompanied by any other anato- mical characters of inflammation, cannot be deemed evidence of arteritis. In inflammation of arteries the redness is accompanied with thickening and swelling of the inner membrane, effusion of lymph either on its free or adherent surface, and increased vascularity with softening of the middle coat, so that the internal and middle tunics present all the ordinary characters of adhesive inflammation. In genuine arteritis, too, the coats are easily detached from each other, and some writers have observed, in intense cases of arterial inflammation, purulent effusion or infiltration between the coats, but more frequently purulent exhalation from the surface of the internal membrane. Chronic arteritis is also chiefly confined to the larger arteries, being seldom if ever met with in the smaller arterial tubes. The chief feature of chronic inflammation of the inner membrane of the heart and arteries is redness, but even in recent cases it is more deep than in acute arteritis. When the disease is of long standing, the membrane becomes of a dusky red or brown shade, rugous, and generally softened. These appearances are more remarkable in the vicinity of calcareous, bony, and other morbid deposits, from which cir- cumstance many pathologists have concluded that chronic inflammation is the original source of these organic lesions in arteries. Without attempt- ing to deny the possibility of this origin of these de- posits in inflammation, we may remark that their primary formation is not in the inner membrane, but either in the middle coat or in the delicate cel- lular tissue, which connects the middle to the in- ner tunic, and that this coat can often be detached from these deposits. Besides, in endeavouring to come to a correct conclusion on this subject, it is to be kept in mind that these various morbid alterations in the arterial coats, whether steatom- atous, cartilaginous, calcareous, or bony, form in detached points remote from each other, and with- out any appearances which indicate the previous existence of inflammatory action. Laennec states that though we know not the nature of the de- rangement of the economy that produces an ossi- Sctition or a cancer, it is certainly not the same as that which produces pus. Other writers have endeavoured to clear up the difficulty by supposing that all these morbid changes, which are not the usual products of common inflammation, are the effect of specific inflammation ; the calcareous de- posits, for example, requiring the gouty diathesis for their elaboration; so that, according to this view, every variety of disposition must be the re- sult of a different specific inflammatory action. (See Arteritis.) In whatever way these morbid productions are originally formed, the irritation they induce in the arterial coats is evidently a source of chronic arteritis, which may terminate in ulceration. 2. Inflammation of Veins. This is a more frequent and fatal disease than that of arteries. Though frequent allusions were made to this lesion, the first distinct account was given by the late John Hunter, in a paper in the Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, in which many of the most important facts connected with inflammation of veins are clearly pointed out. Since the time of Hunter, many valuable contributions have been made to this department of pathology by Meckel, Breschet, Bouillaud, Velpeau, Dance, Ribes, Hodgson, Davis, Travers, Amot, and Lee. The anatomical characters of an inflamed vein are, uniform redness, more or less deep, with swelling and pulpiness of the inner coat, which is easily detached from the middle tunic. The red- ness and swelling soon extend to the middle and outer coats, so that the vein feels hard and con- tracted, resembling a deep red cord, imbedded in its cellular sheath, which is generally infiltrated with bloody serum. The canal of the inflamed vein is filled wilh coagula of blood often mixed with pus, or a false membrane adheres to the inner membrane, filling its cavity completely, and rendering the vessel an impervious cord. When a vein becomes inflamed after a wound or puncture, the inflammation sometimes extends along its inner or lining membrane to the princi- pal venous trunks, and occasionally to the mem- brane which lines the cavities of the heart. From the facts adduced by Mr. Amot, it appears that there are considerable differences in the extent of vein occupied by inflammation in phlebitis. In some instances the inflammation is limited to the vessel in which it originally appeared ; in others it is found to have spread into several or most of the veins of a limb, from that primarily affected. These circumstances, as well as the fact that death has resulted from phlebitis limited to a few inches only, lead to the conclusion that the danger from this disease bears no ratio to the extent of the in- flammation of the vein. The anatomical appearances of an inflamed vein are uniform deep redness of the inner mem- brane extending over a limited or more extended portion of the vessel. The coats of the vein are generally swollen and indurated, and more easily separated than in the healthy state. The dense cellular substance in which the vessel is imbedded, is at the same time injected and infiltrated with bloody serum. The cavity of the vein is filled with coagula, with which purulent matter is occa- sionally blended, and its diameter contracted' o* INFLAMMATION. 769 often obliterated by false membranes which adhere to the surface of the inner coat, and thus render the vessel a hard impervious cord. In fourteen cases out of nineteen, Mr. Arnot found pus, or pus mixed with lymph, in the cavity of the vein; in two the contents are described as consisting of "adhesive matter," and in another the vena cava contained " flakes of lymph." In one case, de- scribed by Mr. Hodgson, in which the inflamma- tion occurred in a vein previously diseased, neither pus nor lymph was found in the vessel. The characters of chronic inflammation of veins differ little from the acute. The redness is of a more deep brown or violet tint, and the coats more thick, so that when the vein is cut across, it preserves its cylindrical form like an artery. The contents of the vein are similar to those described in acute inflammation. Ulceration occurs more frequently in the larger arterial trunks than in the veins. We have al- ready noticed ulceration of the internal membrane of the heart as an occasional consequence of in- flammation. In arteries, the ulceration may be confined to the internal tunic alone, or it may ex- tend to and destroy the muscular coat, so that the blood escapes through the erosion, and; distending the external coat, gives rise to the aneurismal dila- tation so minutely described by Scarpa, and which indeed, in the opinion of this pathologist, consti- tutes the true anatomical character of aneurism. In process of time, however, or from violence, the external coat may be lacerated ; the blood then escapes into the cellular sheath in which the artery is enveloped, and thus a true aneurismal tumour is formed. When ulceration of the larger veins has been observed, it has apparently commenced in the in- ternal lining membrane, and gradually extending to the other coats. The vein has sometimes formed an attachment to some adjoining hollow viscus, the tissue of which becomes also destroyed by ulcerative absorption, and the blood thus es- capes into its cavity. Blood-vessels may be said to be insusceptible of gangrenous inflammation, as they escape the general destruction of the tissues in mortification and sphacelus. It is extremely doubtful if the tissue of the heart be ever affected with gangrene, the cases mentioned by Senac, Portal, and Corvi- sart, in which gangrenous spots were seen on the surface of the heart, being too vaguely described to be admitted as examples of this lesion. The tissue of arteries seems to have great power in resisting mortification. Dr. Thomson relates that he has seen instances of phlegmonous ery- sipelas, in which several inches of the femoral artery were laid completely bare by the gangrene, ulceration, and sphacelus of the parts covering it, without its giving way before death. The arteries had the appearance of raw flesh, and were ob- viously thicker and more vascular than natural, the blood circulating through them, and assisting in supplying with nourishment the parts on which they were distributed. When gangrenous inflam- mation has been so severe that it extends to the blood-vessels, it has been observed that hemor- rhage does not take place, either when the vessel is divided, as in amputation of the limb, or when the limb has dropped off. The blood is prevented Vol. II. —97 from escaping in those cases partly by the exten- sion of adhesive inflammation, which occurs in the line of separation between the dead and the living parts, to the blood-vessels of the limbs, so that their surfaces are pressed together, and ad- here more or less completely, and partly also by the coagulation of blood in the extremity of the vessels. This filling up of an artery by coagu- lated blood happens, Dr. Thomson conceives, by the closure, by adhesive inflammation, of the small branches going off from the trunk, and by the disposition which is given to the blood to coagu- late, in consequence of the secretion of coagulable lymph on the inner surface of the inflamed vessel. Inflammation of the Lymphatic Vessels.— This system of vessels is not unfrequently in- flamed ; and, according to Bichat, inflammation occurs more frequently in the absorbents than in the veins. This assertion is corroborated, when we reflect that the absorbents are constantly ex- posed to irritation from wounds, punctures, and the introduction of morbid poisons into the system through the external surfaces. Though inflam- mation of the absorbents is by no means a rare disease, it seldom proves fatal, the inflammation generally terminating in resolution. In those cases in which an opportunity has been afforded of ex- amining an inflamed absorbent, its coats have been found swollen and indurated, and a layer of plastic lymph adhering to its inner membrane. The cellu- lar tissue surrounding the inflamed vessel is in- volved in the inflammatory action, denoted during life by a red line, which is exquisitely painful, and after death by induration and serous infiltration. Andral has examined the thoracic duct and lymphatic vessels in upwards of six hundred sub- jects, and found but in a very few instances any appreciable alteration of the thoracic duct. In three cases only its parietes appeared red and in- jected ; and in one of these the interior of the duct was filled with pus, and its coats were thick- ened and friable. In the case of a woman, who died at La Charite, with cancer of the uterus, the thoracic duct, which was considerably enlarged, and of a dead white colour, was filled with a pu- riform fluid, and its internal surface studded with an infinite number of round white bodies about the size of peas; in the intervals between which the parietes of the duct were thickened, and of a dead white colour, traversed here and there by reddish lines, and in other points they were re- duced to a soft pulp of a dirty reddish white. The left subclavian vein, into which the duct opened freely, was distended by a number of dense firm clots of blood firmly adhering to the coats of the vein, the inner surface of which was wrinkled, and of a deep brown colour. This affection of the thoracic duct and subclavian vein evidently ori- ginated in inflammation. Andral has occasionally met with the same morbid changes in the lympha tic vessels. Inflammation of the lymphatic ganglions is mpre common than that of the lymphatic vessels. Those ganglions are composed of two distinct tissues,—lymphatic vessels variously convoluted. and cellular tissue, by which these convolution* or ganglions are united. These distinct structures may be demonstrated in the human subject by anatomical injection and nice dissection, and tne 3f 770 INFLAMMATION. various diseases to which these ganglions are liable originate in one or other of those two anatomical elements. Inflammation of the lymphatic gan- glions, which may be propagated from the lympha- tic vessels, or arise primarily in the ganglions, is characterized by redness and swelling. The in- flammation may be confined to one ganglion, or it may extend to several. The enlargement appa- rently arises from tumefaction of the cellular tissue, which unites the convolutions of the lymphatics, or from thickening of their coats, as a mercurial injection passes freely through all the convolutions of an inflamed lymphatic ganglion, proving that their cavity is still pervious. When an inflamed ganglion is cut into, a num- ber of small brownish red points are seen on the divided surfaces; these are exudations from the divided blood-vessels, which have become diffused in the red substance of the inflamed ganglion. When the inflammation is more intense, the con- sistence of the ganglion becomes of a dark violet colour, spongy and soft, and often mixed witu blood. When the inflammation terminates in suppura- tion, the pus may be infiltrated in cellular tissue connecting the convolutions, or in the structure of the ganglion, giving it a dirty grey or ash colour. In other cases an abscess forms, so that all traces of its parenchymatous structure arte lost, the cellular envelope of the ganglion alone re- maining and forming a cyst to the abscess. When lymphatic ganglions are affected with chronic inflammation, the swelling and hardness are greater than when the inflammation is more acute. The cellular tissue, in which they are enveloped, becomes also inflamed, and forms a dense capsule around the ganglion. Lymphatic ganglions may enlarge in groups, as when the mesenteric glands become enlarged from follicular ulceration, or in chronic non-suppurating buboes of the axilla or groin. When an incision is made into a ganglion affected with chronic inflamma- tion, it presents a dense homogeneous structure of a brown red colour, the vessels with which it is traversed being increased in number, tortuous and dilated, ramifying in all directions, and inter- spersed with white cellular filaments. Chronic inflammation of lymphatic ganglions seldom terminates in suppuration unless acute in- flammation supervene. The pus in these cases is infiltrated in the cellular tissue covering the inflamed ganglion. Inflammation of Muscular Tissue.—From the comparatively few opportunities of examining inflamed muscular tissue in the human subject, it has been necessary to institute experiments on the lower animals, with the view of ascertaining the appearances this tissue presents when inflamed. The muscular tissue itself does not seem to as- sume readily inflammatory action; at least in- flammation does not leave any well-marked traces of its existence. The principal alteration appears to take place in the intermuscular cellular tissue, which becomes red from increase in the number and size of its blood-vessels; the muscular fibres are at the same time somewhat increased in density, while the contractility, and consequently the power of motion, are more or less impaired, according to the degree and duration of the in- flammation Gendrin states that if a portion of the cent™ of a long muscle be once inflamed, its extremities alone retain the contractile power, the middle or inflamed part remaining quite motionless, although the nerve which supplies the muscle is irritated, or even when it is subjected to the influence of galvanism. As the inflammation advances in duration or intensity, the cellular tissue which enters into the composition of the muscle, as well as that which connects it to the surrounding parts, becomes swollen and infiltrated with sero- sity, with which a portion of coagulable lymph is generally mixed, whereby its de/isity is not only increased, but the muscular tissue so firmly bound and interwoven, that it is difficult to separate the two tissues, and when this is effected by dissec- tion, the muscular tissue appears sensibly swollen, and of a more or less deep red colour. When the inflammation is intense, the cellular as well as the muscular tissue assumes a deep red or violet colour, and traces of commencing disor- ganization are perceptible, the muscle and its con- necting cellular membrane becoming softened and infiltrated with blood. Suppuration finally takes place, the pus being diffused both in the cellular tissue which surrounds, and in that which enters into the composition of the muscle. The mus- cular substance becomes finally completely disor- ganized, and often sloughs extensively ; or it is converted into a grey indurated mass, in which irregular cavities form, containing a dirty serosity or ill-conditioned pus. It appears too from repeated experiments, that when the muscular tissue is destroyed, it is never regenerated ; the lesion being repaired by the for- mation of a cellular or fibrous web which fills up the vacant space. There are several instances of chronic suppurative inflammation in muscle on record, the best example of which is inflammation of the psoas muscle, of which Schoenmezol (De musculis psoa et iliaco suppuratis, Heidelbergo1. 1776,) has given a case in which the whole of the psoas magnus and iliacus of the right side was destroyed and converted into purulent matter, forming a sac which extended from the last lum- bar vertebra along the surface of the ileum to the small trochanter. Inflammation of the muscular tissue of the heart is acknowledged to be a very rare affection, and according to the testimony of Baillie and Laennec, when it does happen, it is never a pri- mary disease, but the consequence of extension or inflammation of the pericardium to the mus- cular structure of the heart. Though cases of genuine carditis are confessedly rare, the proba- bility of its occurrence is placed beyond doubt by the instances which have been recorded ; the most satisfactory we have met with is that related by Mr. Stanley, (Med. Chir. Trans, vol. 7,) in which the inflammation was general throughout the tissue of the heart. The most unequivocal proof, however, of true carditis is when the inflammation terminates in suppuration. In these cases the inflammation is partial, and confined to those portions of the cai- diac tissue in which the pus is deposited. The abscess is uncircumscribed, the purulent matter being infiltrated in the cellular membrane which connects its muscular fibres. INFLAMMATION. 771 Ulcers of the heart have been found both on its external and internal surface, though this lesion also has been very rarely observed. The only case Laennec ever met with occurred on the internal surface of the left ventricle; it was an inch long, and half an inch wide, and more than four lines deep in the centre. This ventricle, which was at the same time in a state of hyper- trophy, ultimately ruptured. The patient survived only two days. Inflammation of the tongue (glossitis) is a very formidable disease, whether we regard its effects on respiration or deglutition. The organ, when inflamed, becomes swollen, of a vivid red colour, and very painful; as the inflammation proceeds, the swelling increases often to such a degree, that the tongue is thrust out of the mouth, and by its pressure on the larynx impedes both respiration and deglutition. The inflammation may terminate in resolution, suppuration, or even gangrene. The first is the more frequent result, which the practice of making deep incisions into the inflamed tongue tends greatly to promote. When suppuration takes place, the abscess is sometimes superficial, so that it points, and may be opened by an incision. In other instances it is deep-seated, and from the increased swelling there is so great hazard of suffo- cation, that, if deep incisions made into the tongue do not reach the abscess, it may become necessary to open the windpipe to save the patient's life— an operation which has been repeatedly performed with success in such cases. Gangrene is a rare termination of glossitis, and is indicated by the dark livid colour of the tongue, and the gangrenous odour from the mouth. (See Glossitis.) The uterus being a muscular organ, is liable to the effects of inflammation of this tissue. Uterine inflammation is generally partial, occupying par- ticularly the fundus and posterior part of the organ, and is almost invariably accompanied with inflam- mation of that portion of the peritoneum which covers its fundus. Its vessels are at the same time gorged with blood ; the internal membrane of the organ is of a violet red colour, the injection of the muscular substance giving it a vermilion red or livid hue, according to the duration of the disease; and when blood is extravasated, the portion .if the tissue in which this takes place appears marbled, and of a soft spongy consistence. In the mere advanced stage of uterine inflammation, pus is in- filtrated through its substance, and is generally found at the same time in the uterine veins. Ulceration is another effect of inflammation of muscular tissue. This is sometimes observed in deep ulcers of the extremities, which corrode in succession the skin, cellular membrane, fascia, and ultimately the muscular tissue. It is also observed in the tongue in idiopathic inflammation of this organ, or when it arises from the use of mercury. We have already seen that ulceration occasionally takes place in the heart, and chronic ulceration of the cervix of the uterus is familiar to every patho- logist. „ , Gangrenous inflammation of muscular tissue occurs in the external muscles, as well as in in- ternal organs which have a muscular formation. This lesion is recognised by the black or green -.olour of the muscular fibres, which are very soft and easily torn, and by the peculiar gangrenous odour of the sphacelated part. When gangrene occurs in an external muscle, the sphacelated por tion may slough off, and the patient ultimately re cover. If the sphacelus be extensive, it generally destroys life. Gangrene of an internal organ is almost invariably fatal. Fibrous Tissue. — Bichat included under this term, tendon, ligament, fascia, aponeurosis, and periosteum, in which arrangement he has been followed by succeeding anatomists. This general arrangement, however, has been disputed by Dr. Craigie, who regards the anatomical structure of those several tissues, as well as the chemical com- position of some of them, so essentially distinct as to preclude this general classification. For ex- ample, the structure of tendon differs from that of ligament and periosteum in being united in regular parallel fibres, and having greater tenacity—-the fibres in the latter crossing in all directions, and consequently being with difficulty separated. In- flammation of fibrous tissue is attended with the ordinary effects of inflammation, but it rarely if ever terminates in suppuration or ulceration. We shall examine the effects of inflammation in indi- vidual fibrous tissues. In inflammation of tendon, the natural polished glistening appearance is lost, and is succeeded by faint redness; when it is more violent, this injec- tion is accompanied by softness or pulpiness of its texture, and as the inflammation proceeds, the redness gradually passes into a leaden grey colour; the tissue of the tendon becomes subsequently much thickened, and of a doughy consistence, indicating that its vitality is lost. These changes in inflamed tendon are frequently observed in common whitlow, and in severe injuries of the extremities accompanied with laceration, but par- ticularly in gun-shot wounds. The structure of ligament, periosteum, and fascia, especially that of the two first, is exceed- ingly similar. The minute filaments of which it consists are so interwoven in various directions, as to form one of the strongest and most compact tissues of the body. It is very sparingly supplied with blood-vessels, nerves, and absorbents. In- flammation of the capsular ligaments of the larger joints, or of the funicular ligaments, as, for ex- ample, the lateral ligaments of the elbow, wrist, knee, or ankle-joints, may arise spontaneously, from external injury, or from extension of inflam- mation of the synovial membrane or articular cartilages to the ligaments. When the inflamma- tion is spontaneous, it is generally of a more chronic kind than when it arises from other causes. Inflammation of ligamentous tissue is speedily followed by thickening of its structure; the in- flammatory action is seldom limited, but spreads to the synovial membrane and surrounding cellular tissue, giving rise to effusion into the cavity of the joint, and swelling of its external tissue, which not unfrequently terminates in the formation of superficial abscesses. Ligamentous inflammation may terminate n, resolution or in ulceration, of which latter we have an example in strumous disease of the hip-joint, in wnich not only a portion of the capsular liga- ment, but the round ligament which connects the femur to the acetabulum, is destroyed by the ul cerative process. /72 INFLAMMATION. Inflammation of the periosteum (periostitis) differs little in anatomical characters from that of ligament. It is never confined to this tissue, but extends to the cellular tissue, by which it is con- nected to the skin and subjacent bone, and from which it is easily separated. A perceptible tumour is thus formed, which is hot and painful, and when examined, is found to consist of injected cellular and periosteal tissue, infiltrated with serum or lymph. Periosteal inflammation may be limited, or it may spread over a considerable extent. When it is limited to a small spot, it constitutes the swell- ing termed node, which forms more readily in some situations than in others, more particularly on the tibia, radius, ulna, clavicle, and sternum. Nodes are sometimes converted into bony swellings (ex- ostosis), the lymph which is effused being mixed with calcareous matter. Periostitis sometimes ter- minates in suppuration and abscess, in which case the skin and cellular membrane over the diseased periosteum become red, swollen, and very painful; fluctuation is perceptible, and when the abscess is punctured, or bursts spontaneously, the corres- ponding portion of the bone is generally destroyed by caries. Some cases of periostitis are merely symptomatic of primary inflammation or other disease of the bone, the inflammation having spread from the bone to the periosteum. Fascia, from its extent and importance in the construction of the body, as well as its being evi- dently the seat of rheumatism, requires special notice. Dr. Craigie has ably combated the idea that inflammation of the muscular tissue is a cause of rheumatism. " Independent of the fact that the rheumatic pains occur often round joints in which there are no muscles, the theory is at best only an ingenious assumption, and is not supported by any strong facts or arguments. "Though rheumatic pain is often referred to muscular parts, it is less frequently so than to joints and parts covered by aponeurotic sheaths and fasciae. Of 520 cases, Haygarth observed in 388 the rheumatic action to be seated in joints, in 118 in muscular parts, and in 14 wandering, general, or migrating through the limbs. Of 170 cases, in 154 one or more joints were inflamed ; in 33 cases both joints and muscles were simulta- neously affected ; and in some cases only were the muscles affected without the joints. " Though from these facts Dr. Haygarth infers that acute rheumatism is seated chiefly in the joints, he does not attempt to ascertain the par- ticular texture, in the affection of which the dis- ease consists. It is further manifest that while it is impossible to exclude affection of the muscles entirely, it results that this affection is only secondary. The proof adduced by Dr. Scudamore from pressure of the whole course of a muscle, and grasping its substance during severe rheumatism, to show that the fleshy part is not the seat of complaint, is entitled to attention. Combined with those already mentioned, and with other considerations to be adduced immediately, it re- sults that the rheumatic action is seated in a tex- ture, which, confined neither to the site of the joints nor to that of the muscles exclusively, is common to bo h, and which, from its extensive distribution and complicated arrangement, accords best with the phenomena, progress, and effects of the disease. It is unnecessary to repeat the con siderations above adduced from the anatomical relations and characters of fascia and its various divisions. That they are the chief seat of acute rheumatism, may be inferred from the following circumstances: " 1. When the rheumatic action is seated in muscular parts, instead of being confined to the muscular fibres, it may always be referred to the aponeurotic membrane which covers or penetrates them. 2. The peculiar pains of rheumatism are always most distinct in those situations in which several folds of aponeurotic membranes meet; and their migrations may be traced from one ex- tremity to another of aponeurotic membrane, and along the course of its principal divisions. 3. The kind of pain which attends rheumatism resembles that of the fibrous tissues in general when in- flamed, in undergoing aggravation under the influ- ence of external heat, and during the night. 4. This view of the seat of rheumatic disorder affords the most probable explanation of the effusion which takes place in the tendinous sheaths (bursx mucosx); for since each sheath is partly enve- loped in aponeurotic membrane, the inflammatory process which takes place in the latter soon gives rise, as in analogous cases, to effusion, critical or non-critical, from the contiguous synovial mem- brane. 5. This view also affords the most rational explanation of the fact remarked by all authors, that rheumatism almost never terminates in sup- puration. To suppose that muscle does not sup- purate is, perhaps, erroneous, from what has been above adduced. That fascia and fibrous tissue in general is little disposed to suppurate, unless when mechanically injured, is manifest from a number of circumstances; and this may, perhaps, be regarded as the true explanation of the fact now noticed. 6. It must further be remarked that inflammation in this tissue renders it thick, hard, and rigid; and occasionally causes between its fibres effusion of lymph, which increases this thickening, induration, and rigidity. On these changes depend the immobility of rheumatic parts, and the loss of power which follows long and ob- stinate or neglected and repeated attacks of the disease. " The question whether there be any thing peculiar in the nature of rheumatic inflammation, is not undeserving attention. This, however, is not the place for discussing it; and if the views now advanced be well-founded, it may be inferred that its peculiarities consist in the anatomical and physical qualities of the texture in which I have attempted to show it is seated. "Though in acute rheumatism the inflamma- tion affects a large proportion, if not the whole, of the fascial system, local forms of the disease may occur, in which it is confined, with more or less accuracy, to one or two fasciae. Thus in- flammation of the fascia of the temporal and mas- seter muscles produces rheumatism of the temple and rheumatic locked-jaw; that of the occipito- frontal fascia, rheumatism of the head; that of the cervical fascia, crick in the neck; that of the pectoral fascia and the intersections of the inter- costal muscles, spurious pleurisy (pleurodyne) ; INFLAM that of the abdominal fascia, a rheumatic belly- ach; that of the lumbar fascia, lumbago; and that of the aponeurotic parts of the glutaeal muscles, genuine sciatica or hip-gout. (Op. cit. Inflammation of cartilage, which is generally of a chronic character, may take place as a primary disease; but it more generally succeeds to synovial inflammation. It is characterized by redness, spongy swelling, softness, and finally ulceration or erosion of its structure. Erosion, which in cartilage is analogous to caries in bone, consists first in minute perforations, which extend in num- ber and depth, and, by their coalescence, form patches of an irregular size and shape. When the erosion extends in depth, the epiphysis of the bone is exposed, excavations form, and sometimes the cartilage is entirely removed. The joint is thus destroyed, unless, as in some cases, ancylosis take place. We have another instance of inflammation and ulceration of cartilage in the larynx, in which the inflammation may either take place primarily, or it may spread from the mucous membrane of the throat to the perichondrium or investing mem- brane. The disease in these cases is generally chronic, even at its commencement; and, though it may arise from cold, it is more generally to be traced to the effect of a specific poison—the syphi- litic or the mercurial. It often succeeds to the development and subsequent disorganization of tubercular formations in the structure of the larynx, giving rise to the disease termed phthisis laryngea. Both these differ essentially from the more acute and rapidly fatal forms of laryngitis, which consist in acute inflammation and infiltra- tion of the submucous cellular tissue of the glottis. Fibro-cartilaginous tissue is regarded as inter- mediate between the fibrous and cartilaginous, possessing the flexibility and elasticity of the for- mer, with the toughness and resistance of the lat- ter. The intervertebral substance of the vertebrae, the semilunar cartilages of the knee-joints, and the cartilages which unite the pelvic bones, are composed of this tissue. These parts are liable to inflammation, which may either originate in their own substance, but more generally in the sur- rounding structure, or in the synovial membrane with which they are in most instances invested. The inflammation in fibro-cartilaginous tissue pro- duces swelling and softening, which frequently terminates in erosion, as we occasionally observe after inflammation of the semilunar cartilages of the knee-joint and of intervertebral substance. Mortification may take place in fibrous tissue. When this occurs, its glistening appearance is lost, and changed to an ash-grey colour, while its texture becomes softened and easily torn. It may even become completely dead or sphacelated, as in sloughing of the cornea, or when large portions of the soft parts, or even an entire limb has been removed by idiopathic gangrene: in these cases the fibrous tissue sloughs with the other struc- tures of the mortified limb. Bone.—The structure of bone undergoes the process of inflammation, which is the origin of many of those diseases to which the osseous sys- tem is liable. It may arise spontaneously, or from various kinds of injuries. The process by which 3 P * M A T10 N. 773 the extremities of fractured bones are united, and the erosion which takes place when the epiphyses become separated, are examples of the adhesive inflammation of bone. The bony union by which these injuries are repaired is effected by the blood which oozes from the periosteal and medullary arteries, and the subsequent elaboration of coagu- lable lymph into which new vessels penetrate, so that the lymph becomes an organized substance similar to granulation, and is termed callus. Upon this new substance points of bone are deposited by a peculiar and hitherto unexplained action of the nutrient vessels; these points of bone become gradually more numerous, and finally coalesce into larger masses, until the fractured extremities are at length united by solid bone. Idiopathic inflammation of bone may arise either in the periosteal covering, or in the cancelli, or medullary structure. We have already explained the effects of inflammation of the periosteum in producing those swellings called nodes : when the periosteal inflammation is very acute, it pro- duces not only thickening of the membrane and deposition into the subjacent cellular tissue, but inflammation of the portion of bone with which it is in contact. If the inflammation be not promptly arrested, suppurative inflammation of the periosteum, followed by caries or ulceration of the bone, succeeds, which often penetrates the sub- stance of the bone to a considerable depth. Another form of osseous inflammation is that arising in the filamentous medullary structure of long bones, producing swelling and effusion into the cancelli, which may terminate either in per- manent induration and enlargement of the bone, or in suppuration. When suppurative inflamma- tion thus takes place, the matter is sometimes deposited in the cavity of the bone, and generally proves a source of great constitutional disturb- ance. In other cases the vitality of the bone is gradually destroyed from within outwards, con- stituting the disease termed necrosis by surgical writers. This may affect either a part or the whole of the shaft of the bone ; so that the epiphy- ses and periosteum, which are seldom affected, only remain. In the progress of the disease the dead portions are enclosed in a case of newly- formed bone, and covered with thickened peri- osteum. The two diseases termed caries and necrosis afford an illustration of ulceration and gangrene of bone. In necrosis, however, reparation is effected by the formation of a new envelopment around the mortified or dead bone. In superficial gangrene of the long bones, such reparation is not observed ; these latter cases, therefore, have a greater affinity to gangrene of soft parts. Inflammation of the medullary texture of the epiphyses, and of the short or cuboid bones, such as the vertebral, tarsal, carpal, and digital, is the cause of the disease described by surgical writers under the term spina ventosa. Dr. Craigie states that the cancellated arrange ment of the osseous matter and of its medullary web in these bones, explains the progress and phenomena of the disorder. That this is the sea of its action is to be inferred, first, from the phe- nomena of the disease ; and, secondly, from it* effects as seen in diseased bones. Spina ventom 774 INFLAMMATION. never occurs in a bone with distinct medullary canal, unless at the epiphyses, where the structure is cancellated. When it takes place in these situations, it first induces an enlargement of the epiphyses, with extreme deep-seated pain in the bone. Soon after the periosteum becomes thick and swelled; and in no long time sanious matter is found beneath it issuing from the cancelli, which are then softened, partially destroyed, and excavated. If in this state such a bone be ex- amined, the broken cancelli are filled with a red- dish, soft, spongy, vascular mass, producing flabby granulations passim, and secreting bloody sanious fluid. The compact shell is partly destroyed by irregular ulceration, and partly extruded by the distending force of the swelled medullary web. The diseased epiphysis then presents a large irre- gular anfractious cavern, filled with soft spongy substance, which is either the web itself, or the new products which its inflammation has gene- rated. In this manner it is frequent in the upper end of the tibia or the lower end of the femur, or in the extremities of the radius or ulna. (Op. cit.) The effects of inflammation in the different tis- sues having been briefly considered, it is necessary to show the changes induced by inflammation in organs which are composed of several tissues (complex tissues). The structure of the lungs is, of all the organs in the body, the most complex : it consists of arteries, veins, absorbents, nerves, and the ramifications of the bronchial tubes, lined with mucous membrane, and terminating in very small round cells; all these component parts being firmly united by cellular tissue. It is necessary to be able to distinguish congestion from inflam- mation of the pulmonary substance, as there is certainly no organ in the body so frequently the seat of congestion. We find very generally, on examining the lungs, even when the person dies in an exhausted state, as in continued fever for example, that the most depending portions are in a state of congestion. This is owing to the blood gravitating from the position of the body after death. This appearance, though often mistaken for the effect of inflammation, is a pseudo-morbid appearance. It is frequently found in cases where there has been a severe and protracted struggle previous to dissolution, or where there has been a mechanical obstruction to the circulation pro- duced by some organic disease of the heart. The anatomical characters of inflammation of the substance of the lungs (pneumonia) differ according to its stage or degree. Laennec has described three stages, which he considers may be easily recognised ; these he has distinguished by the terms obstruction (engouement), hepatization, and purulent infiltration, all of which present different anatomical characters. In the first degree (engouement, or obstruction) the portion of inflamed lung is externally of a livid 01 violet colour, which is not removed by immer- sion in water, or even injecting water into the pul- monary vessels, and more heavy and dense than natural. When pressed between the fingers it is still crepitous, though less so than in its sound state, retaining the impression of the finger like un cedematous limb. It is necessary, however, to >>eai in mind that lungs which possess naturally a considerable degree of density have proportion- ally less crepitation. This density of the pulmo- nary tissue is more remarkable in children. When cut into, the structure is of a dark red colour, the tissue being filled with a serous fluid, more or less tinged with blood ; but though evidently injected, the natural soft spongy texture is unaltered, and still permeable to air. In a more advanced stage of pulmonary inflam- mation, the smaller bronchia, air-cells, and con- necting cellular membrane, become swollen, so that the quantity of air in the inflamed portion of lung is diminished and supplied by blood. This constitutes the second degree of pneumonia (hepa- tization). It is characterized by a deep red colour of the inflamed portion of the lung, varying in different points from that of violet grey to blood red, and by the greater density and consist- ence of the granulated texture exhibited in its sec- tion, giving it somewhat the appearance of liver, from which the term hepatization has been derived. The hepatized portion of lung has lost its crepi- tous feel, is impermeable to the air, and sinks in water; and when divided, no air escapes, but a small quantity of bloody serum, mixed with a thick opaque fluid, may be expressed. When the minute structure is examined closely, the natural pulmonary texture has lost its cellular appear- ance, and appears to be composed of a number of small red grains, oblong and flattened, which, ac- cording to Laennec, are the air-cells transformed into solid grains, by the thickening of their pa- rietes, and the obliteration of their cavities by a concrete fluid. Andral, however, states that this granular appearance is often altogether wanting, so that its surface, when cut into, appears smooth and compact. He supposes the granular appear- ance to depend on the degree of tumefaction which the air-cells undergo; for when the tumefaction passes a certain limit, its effect is to approximate the cells so closely that they become confounded together, and the granular appearance vanishes entirely. The extent of pulmonary substance occupied by these two degrees of inflammation is various. Sometimes the inflammation extends over an entire lobe, (pneumonia lobaris) : in other instances it is confined to one or more lobules (pneumonia lobularis) : in some cases it affects only the air- cells (pneumonia vesicularis): some writers in- deed consider that in pneumonia the inflammation commences in the air-cells, from which it is pro- pagated to the parenchymatous tissue. When pulmonary inflammation has advanced to the formation of pus, this fluid is found either in the form of purulent infiltration, or collected into an abscess. Purulent infiltration is by far the more common appearance; this succeeds to the most intense degree of pulmonary inflamma- tion, and often takes place with great rapidity. According to Andral it has formed within four days after the first symptoms of pneumonia had made their appearance. The portion of lung in which the purulent infiltration has taken place presents an ash-grey colour, from which it has been termed grey hepatization, to distinguish it from the second stage of pneumonia, the red he- patization. If the pus be squeezed from the pul- monary texture, it assumes the colour of the red INFLAMMATION. 775 hepatization, but it is much softened and conse- quently easily lacerated. The grey colour is evi- dently owing to the admixture of pus with the red tissue of the inflamed lung. These three stages of pulmonary inflammation may be often seen in different portions of the same lung; sometimes an entire lung is infiltrated with pus, while the other presents different stages of pneumonia ; some portions being in a state of red, others of grey hepatization, the one stage passing by insensible degrees into the other. With regard to the portion of lung most fre- quently affected with pneumonia, it appears from the statements of Laennec, Andral, and others, that it occurs most generally in the lower portions, though it is not uncommon to meet with a cir- cumscribed portion of the centre of the lung in- flamed, the surrounding parenchyma being quite sound. It is a singular circumstance, also, that the left lung should be much more frequently the seat of pneumonia, and, indeed, of almost every lesion, than the right. Of two hundred and four cases of evident pneumonia, the right lung was affected in one hundred and twenty-one instances, the left lung in fifty-eight, and both lungs in twenty-five. (Andral, Clin. Med. tom. ii.) Abscess of the lung has been very rarely met with, though cases succeeding to pneumonia are recorded by several writers. In these instances the boundary of the excavation in the lung, which is filled with pus, is formed by the pulmonary tissue. Another and perhaps more frequent form of pulmonary abscess is that in which pus is depo- sited in the lung, not as the consequence of in- flammation, but from this fluid, formed in some other part, being conveyed through the medium of the circulation, and deposited in the lung. There are many striking instances of these puru- lent deposits succeeding to important operations, and to purulent collections in other organs of the body, which, after an attentive examination, An- dral proposes to range in two classes. In one, it appears that the pus is formed in the torrent of the circulation, or is introduced into it from some organ in a state of suppuration, and in its passage through the tissue of the lung is separated as through a filter, and either collected into an ab- scess, or infiltrates the pulmonary tissue. It is probably by a similar process that mercury injected into the crural vein of a dog traverses the whole circulating system until it arrives at the lung, where it abandons the circulating fluid. In the other class of cases, some cause with which we are unacquainted alters the blood, coagulates it in the pulmonary vessels, and transforms it into pu- rulent matter in the smaller branches of these vessels. (Anat. Patholog. tom. ii.) The termination of inflammation of the lungs in gangrene is exceedingly rare, and when it is met with, it is not always to be regarded as an indication of the intensity of the pneumonia, as it has been found in cases when the symptoms, as well as the appearances of inflammation, were very slight and equivocal. Laennec regards it as very similar to idiopathic gangrene, such as an- thrax, pestilential bubo, and malignant pustule. \ndral, on the other hand, asserts that gangrene of the lung, as well as of other parts of the body, may succeed to every species of hyperaemia, whether mechanical or vital, provided it be so con- siderable as to impede or prevent the afflux of arterial blood to the part. Gangrene of the lung occurs under two forms —the circumscribed, and the uncircumscribed; the one differing from the other only in extent. Circumscribed pulmonary gangrene occurs in u small portion of the lungs only ; the mortified part is separated by a suppurative process which is established around it, and the eschar or slough is expelled with the expectoration through perfo- ration of one or more of the bronchial tubes. An ulcerous excavation discharging a dirty fluid re- mains, which, by mixing with the expectoration, gives it a most offensive odour. When the gan- grene occurs near the surface of the lung, it pro- duces erosion of the pleura, which is succeeded by pleurisy and pneumothorax. Uncircumscribed pulmonary gangrene is much less common than the circumscribed. Laennec had only seen two cases of it during twenty-four years, and he had only known of five or six cases of it in the hospitals at Paris during the same pe- riod. He gives the following characters of this lesion, which may occupy a great portion of one lobe, or occasionally the greatest part of one lung. The pulmonary tissue, more humid and less co- hesive than in the sound state, has the same de- gree of density as in the first state of peripneu- mony, oedema of the lungs, or the serous engorge- ment occurring after death ; its colour varies from a dirty white or slightly greenish hue, to a deep green, approaching to black, with a mixture, oc- casionally of brown, or of earthy or yellowish brown. In some places the pulmonary substance, altogether or nearly sound, blends insensibly with the gangrenous part; in other instances, these are separated by a portion of lung inflamed in the first degree, and in still rarer instances by pulmo- nary hepatization. Spleen.—The spleen consists of few anatomical elements — first, a fibrous investing membrane, constituting its proper capsule of the organ; secondly, an internal cellular arrangement into which the blood is poured ; thirdly, blood-vessels, lymphatics, and nerves. As the parenchyma of this organ, therefore, consists of two component ingredients only, fibrous tissue and blood, its dis- eases must be referable to one or other of these. Andral thinks its diseases ought to be the same as those of the veins, for it is evidently a vast venous network, in which the cellular is substi- tuted for the vascular form. He therefore consi- ders the lesions of the spleen to be of two kinds , those of the first, which are rare and unimport- ant, have their seat in the capsule, or in its fibrous prolongations, which constitute the walls of the splenic cells : those of the second, of much greater frequency and importance, originate in some of the elements of the blood. The capsule of the spleen is liable to the dis- eases of fibrous tissue, and consequently to in- flammation, though such instances are rare Abercrombie has seen the spleen completely enveloped in a thick dense covering of false mcrn brane, in connection with peritonitis, but without any disease of its substance. In such cases, 776 INFLAMMATION. however, the lymph was probably effused from the inflamed peritoneum, and not by the capsule of the spleen. This membrane has also been found adherent to the contiguous viscera in cases of purulent infiltration, when the pus is making its way towards the surface of the spleen, and if the organ to which it becomes attached be hollow, (as the stomach or alimentary canal,) the matter is discharged into it. The capsule of the spleen has been found in many of those instances soft, pulpy, and lacerable. Cases of purulent formations in the spleen are not very common, more especially those in which pus is found in no other organ. It is improbable that such instances originate in inflammation of its parenchyma, since we have seen that its structure is such that it may be said to be almost insusceptible of inflammatory action, unless the blood be presumed to be susceptible of inflamma- tion. Whence, therefore, originates the pus ? This is a question of rather difficult solution, though Andral thinks from some experiments it would seem probable that the blood in the spleen may be converted into pus; and that the disturb- ance in the system which has been observed to accompany this lesion, is to be regarded as the result of the conversion of the blood into puru- lent matter. A more frequent form of purulent formation in the spleen is when this organ becomes infiltrated with pus, at the same time that similar purulent deposits take place in other organs. In these cases it is supposed that the pus is formed in some distant organ, and after being carried in the blood, is deposited in the spleen and other organs at the same time. In such examples, the primary disease has sometimes occurred in connection with diseases of the uterus, or of the uterine veins; as in a case recorded in the Transactions of the College of Physicians, (Vol. v. p. 304,) and in another alluded to by Andral, (Anat. Path.) : in other instances, the purulent depositions have succeeded to external injuries and severe surgi- cal operations. The pus may be collected in drops, or in cavities of greater or less extent; it is sometimes confined in a cyst of false membrane, but more frequently the wall of the abscess is formed by the structure of the spleen, in which case the abscess is often of very considerable extent. The termination of such cases is various : the abscess may, by adhesive inflammation and the subsequent process of ulcerative absorption, burst into the cavity of the chest, belly, stomach, or intestines, or it may be discharged through the kidneys by the urine. Splenic abscesses have been known also to open externally through the walls of the abdomen, the back, or the loins. (Andral.) Though the thyroid gland is occasionally in- flamed, it seems to be as little susceptible of in- flammation as any gland in the body. When inflamed, its vessels are numerous and injected, so that its tissue is red and swollen, and feels much firmer than in its natural state; these changes being produced partly by serous infiltra- tion, or when the inflammation is more intense, by the effusion of coagulable lymph or blood into Ms structure. From the rare occurrence of inflammation of this gland, its pathological appearances consequent to inflammation have been scarcely noticed in the writings of pathologists. Inflammation of Glandular Organs of Secre- tion.— Without entering into the disputes of anatomists, as to the form and texture which are necessary to constitute glandular structure, we shall merely state, that the most perfect glands are the lachrymal, salivary, submaxillary, sub- lingual, mammary, and prostate — the pancreas and testicle (colourless glands), and the liver and kidneys (coloured glands). Their external form is generally round or ovoid, and most of them consist of small lobules, connected by cellular tissue. For their size they are the most vascular parts of the body, a large supply of blood being necessary for the purpose of elaborating the va- rious fluids secreted by glands. When a glandular organ is inflamed, it in- creases in size, and its excretory ducts become enlarged and distended: the tissue of the colour- less glands is of a slight rose tint: in the colour- ed, the natural redness becomes deeper, the injec- tion extending throughout the interlobular cellular membrane. The excretory ducts are filled with fluid which is generally limpid, unless the inflam- mation be intense, when it becomes red, and even bloody. These anatomical appearances, however, pass off very rapidly after death. Inflammation of a gland generally terminates in resolution; but if, from its intensity or improper treatment, it proceed to suppuration, the purulent matter forms in the cellular tissue of which the gland is partly composed, the proper substance of glands being not very susceptible of the suppura- tive process. When, however, the inflammatory action is very intense, it undergoes a species of suppuration ; it loses its consistence, and to the softening succeeds infiltration with a thin kind of pus, the sensible qualities of which depend very much on the state of health and particular consti- tution of the individual. When suppuration takes place in glands which have large secreting ducts, as the liver and kidneys, the mucous membrane with which these canals are lined sometimes assumes the suppurative action; hence, when pus is mixed with the fluid which the gland secretes, (the bile or urine for example,) it may be secreted either by the inflamed mucous lining of the duct, or there may be a communica- tion between an abscess in the organ and the duct through which the matter is discharged. These general observations being sufficient to give an idea of the effects of inflammation in glandular organs, we shall, without noticing spe- cially the external glands, make a few remarks on inflammation of the internal organs of secretion— the pancreas, liver, and kidney. 1. The pancreas appears to be seldom the sub- ject of inflammation and its consequences; in those cases which have been reported as instances of inflammation of this organ, the symptoms during life were not only very obscure, but the anatomical characters of the lesion not well defined. In the cases which are reported, redness, more or less deep, and loss of consistence of the substance of this organ, with injection and infiltration of the interlobular cellular membrane, are the morbid INFLAMMATION. 777 appearances described. The inflammation does not appear to have extended through the whole structure of the gland, but limited to one portion of it. When inflammation of the pancreas has termi- nated in suppuration, the small lobules of which the pancreas is composed assume a grey-red colour, and become soft, and finally so completely disor- ganized, as to lose all trace of their original struc- ture. The purulent matter is in some cases dif- fused through the cellular substance ; in other in- stances the pus is confined in a distinct cavity or cyst, the abscess sometimes forming a tumour of considerable size adhering to the surrounding vis- cera. Sometimes, again, the pancreas has been found hard and shrivelled in the centre of the purulent deposit. These pancreatic abscesses have been known to make their way across the cel- lular tissue of the mesocolon, and, by perforating this membrane, the purulent matter has escaped into the cavity of the abdomen. 2. Congestion of blood may take place in the parenchyma of the liver, from causes originating in the organ itself, or as the effect of sympathetic disturbance in some other part. Again, when there is any obstacle to the free return of blood to the right side of the heart, the blood accumulates in the liver, and thus passive hepatic obstruction or congestion is induced. When this takes place, the liver is of an uniform red colour, a little in- creased in bulk, and evidently changed in density or consistence. Under the pressure of congestion the blood-vessels sometimes give way, and the blood is diffused through its parenchyma, constituting what the French writers term hepatic apoplexy. This lesion may be the result of rupture of one or two of the larger hepatic vessels, or of exuda- tion from the capillaries. Inflammation of the liver is more common in warm than in temperate climates ; and notwith- standing the frequency of its occurrence, its ana- tomical characters are not very distinctly laid down, which may arise from hepatitis being very rarely fatal in the inflammatory stage, so that few oppor- tunities of ascertaining the morbid appearances occur. The appearances in inflammation of the liver differ according to its intensity, duration and extent. Though inflammation may occur either in the serous covering, or in its parenchyma, it appears to be much more frequent in the latter. Indeed, from the history of hepatitis, given by writers who have had extensive opportunities of observing the disease in hot climates, we are in- formed that inflammation of the capsule of the liver is of comparatively rare occurrence. In the milder forms of hepatic inflammation the organ is slightly increased in size and density, and of a dark red colour, from accumulation of blood, which flows freely where an incision is made. These changes are more evident when the inflam- mation is circumscribed or partial, as the morbid may be then contrasted with the healthy structure. In the more advanced stage, or when the inflam- mation has been from the beginning more intense, the parenchyma is more or less softened, and very vascular, the vena portae, mesenteric vessels, and mucous membrane of the duodenum, being gorged with blood. . The degree to which this hepatic softening oc- Vot. II. — 93 curs depends on the degree and duration of the inflammation. In the more intense cases, the tissue of the liver occupied by the inflammation is reduced to a soft lacerable pulp of a deep violet or brown colour. When hepatic inflammation terminates in sup- puration, the pus may be diffused through the parenchyma of the liver, so as to give it a green- yellow colour, the tissue in which it is infiltrated, and for some extent around, being softened and disorganized. In other instances the pus is con- fined in abscesses, varying in size, sometimes dis- tinct from each other, but occasionally communi- cating by perforations. These abscesses may be bounded by the parenchyma of the liver only, or by a more or less completely organized cyst; they often acquire a very large size, in some instances containing several pints of pus. The termination of abscess of the liver is various; —1, it may be discharged through an opening in the hypochondrium, or some other situation : 2, when adhesion between the hepatic abscess and some portion of the alimentary canal or kidney takes pia e, the pus may be discharged by the stomach, bowels, or kidney: 3, the abscess may burst into the cavity of the abdomen: 4, it may perforate the diaphragm and be discharged into the cavity of the chest or pericardium; or if an adhesion form between the hepatic abscess and the lung, the pus may be discharged through a perfo- ration in the bronchial tubes by expectoration. Andral alludes to a case of hepatic abscess situated near the gall-bladder, emptying itself into it, and passing from thence into the biliary duct; and also to a case in which abscess of the liver com- municated with the vena cava. Gangrene of the liver, if it do really occur, must be regarded as an extremely rare termination of hepatitis, as no unequivocal instance of this lesion has been recorded. Mr. Annesley, whose exten- sive opportunities of observation entitle him to be regarded as an authority, states that he never ob- served it as a termination of hepatitis of warm climates. 3. Inflammation of the kidneys is characterized by obscure redness of the tubular, and bright-red colour of the cortical substance, the tissue of the former acquiring a degree of firmness, the latter becoming softened, and easily torn. The emulgent vessels are generally turgid, and the inner membrane of the pelvis and infundibulu red and injected, the redness often extending along the membrane of the ureters. In more intense renal inflammation the tissue of the kidney becomes of a deep red or chocolate colour, and remarkably softened. Inflammation of the kidney may terminate in resolution, softening, and induration of its paren chyma, or in the formation of pus. Purulent formations in the kidney may take place in three different modes. 1. The inflammation may com- mence in and be confined to the tubular or secre- ting portion, and pass into suppuration, in which case the uriniferous tubes, infundibula, and pelvis of the kidney, secrete purulent matter, which is discharged with the urine. In these cases the kidney is not enlarged in size, and the signs of inflammation are confined to the secreting part of the organ. 2. The pus may be infiltrated through 778 INFLAMMATION. the tissue of the kidney, accompanied with deep- red colour and softening of its substance; a num- ber of white spots, frequently mixed with blood, are seen, from which pus may be squeezed; they are often mistaken for masses of tubercle. This form may be the result of inflammation, or of general purulent diathesis, when pus is found in other organs. 3. The purulent matter may be collected in distinct abscesses. These may be of small extent, the surrounding parenchyma being scarcely altered ; or the whole tissue of the organ may be transformed into a purulent sac, which, according to Andral, is generally multilocular, the septa consisting of hard lardaceous tissue. They may exceed in bulk the kidney itself, and thus produce a tumour distinguishable through the ab- dominal parietes. The inflammation in some cases commences in the renal capsule, to which it may be limited, or it may extend to the adjacent portion of the kidney. In these cases suppuration generally follows, but the abscess is exterior to, and unconnected with the substance of the kidney, the structure of which is urialtered, though often, from the pressure of the abscess, diminished in bulk. Abscesses sometimes form in the abundant loose cellular tissue which lies beneath the peritoneum, and surrounds the kidney and its proper capsule. Morgagni gives a case of this kind, which contained four pounds of purulent matter. Renal abscesses may be discharged in various ways:—1, the pus may pass off with urine ; 2, it may burst into the abdominal cavity and produce peritonitis, which is speedily mortal; 3, the abscess may form an adhesion and open into the colon ; 4, it may be discharged externally by a perforation in the loins. Gendrin has quoted a case from Ledran, in which a renal abscess opened at the loins, and the matter having forced its way in the sub-peritoneal cellular tissue down under Poupart's ligament and around the crural vessels, was also discharged at the inner part of the thigh. He alludes also to that case related by De Haen, in which an abscess in the left kidney, after destroying the substance of the organ, formed an adhesion to the diaphragm, which it perforated, and destroyed the inferior lobe of the left lung, the kidney and lung thus forming one large sac. Causes of Inflammation. — There are few circumstances connected with pathology more ob- scure and unsatisfactory than the etiology of dis- eases. This is fully exemplified in the obscurity in which the origin of almost every form of in- flammatory disorder is involved. Many, indeed, arise without evident cause, constituting what has been denominated by practical writers spontaneous inflammation—a term which simply denotes that the causes are so obscure as to elude observation. It would appear, however, that certain circum- stances predispose the system or render it more liable to inflammation; this predisposition may exibt either in the system in general, or it may be confined to a particular region, organ, or tissue. The predisposing causes may be arranged in two classes, the first depending on general san- guineous plethora; the second are connected with .ocai determination of blood. Practical writers aave usually mentioned the sanguine temperament among the individual causes which predispose to inflammation. Persons who possess this tempera ment are generally supposed to have a superabun- dant quantity of blood, whereby the vessels, more especially the capillaries, are kept in a state of undue distension, the blood having at the same time great consistency or richness. It is also as- serted that adults, especially male adults, and those possessing what is called a strong constitution, are more predisposed to inflammatory diseases. It has always appeared to us, however, that these views are not supported by facts and observation, and in our own experience, we have generally found that weak and delicate persons are much more fre- quently attacked with inflammation than the more robust and vigorous. Not less unsupported by evidence is the notion entertained by Van Swieten, that serous evacuations, such as profuse sweating, salivation, or copious flow of urine, predispose the body to inflammation, in consequence of the blood acquiring greater consistence from the abstraction of its watery principles. A predisposition to in- flammation, or tendency to particular local deter- minations of blood, is observed at certain periods of life. We accordingly find that there is a greater tendency to cerebral fulness in infancy and child- hood than at other ages; towards puberty, we observe fulness of the pulmonary system, which accounts for the frequency of nasal and pulmon- ary hemorrhage at this period. In adults, on the other hand, diseases of the abdominal viscera con- nected with vascular fulness are more common, though it should be kept in mind that congestions or irregular distributions of blood are more com- mon than organic inflammation. It is often of great consequence to discover those circumstances which give a predisposition to inflammation in particular organs and tissues. These may often be traced to a state of partial or local plethora, connected with causes which are inherent in the part itself, though a predisposition to local inflam- mation is frequently acquired. Thus the undue exercise of an organ frequently predisposes it to inflammation, an illustration of which is the ten- dency to ophthalmia or retinitis induced by long- continued use of the eye, or straining this organ in examining very minute objects ; in the effect of long-continued application to study in producing slow, insidious, cerebral fulness ; in the effect of long-continued exposure to cold in laying the foundation of pulmonary diseases ; and in the tendency to hepatic inflammation engendered by residence in a warm climate. It is also a well-known fact that a predisposi- tion to inflammation is given by previous attacks. This is so much a matter of experience and observation that it is scarcely necessary to adduce examples in illustration. Whatever circumstance or combination of cir- cumstances breaks up the general powers pre- disposes the body to inflammatory diseases, by rendering it unable to contend against the exciting causes. It is in this way that undue bodily or mental exertion, the depressing passions, long- continued watching, impure air, improper or scanty supply of food, or insufficient clothing, may be regarded as predisposing causes of inflam- mation. It is worthy of remark that the predisposing INFLAMMATION. 779 causes have a considerable influence in determin- ing the type of the subsequent inflammation, as well as the nature and extent of the curative measures. Those inflammatory diseases which arise suddenly, are generally connected with a full habit, and require active treatment; while those which come on more slowly, or in exhaust- ed constitutions, are of the asthenic character, requiring greater circumspection in the nature and extent of antiphlogistic remedies. In such cases we are often obliged to support the general powers, when the local symptoms render the topical and even the general abstraction of blood, among other antiphlogistic measures, expedient. The exciting causes of inflammation are no less obscure than the predisposing. Many pa- thologists have expressed their doubts as to the possibility of inflammation ever arising spon- taneously. There can be no doubt that in many instances organic inflammation appears without our being able to discover its cause. Thus, in- flammation is often set up in the brain, chest, or abdomen, without any evident cause. The inflam- mation is then termed spontaneous, in contradis- tinction to accidental inflammations, which are so called from their originating in causes applied immediately to the part affected. It would be unreasonable to say that in such cases the in- flammation arose without some cause, though it may not be possible to detect it. There has been too great disposition, on the part of systematic writers, to take for granted the ordinary list of exciting causes of inflammation. A little reflection will soon convince the patient observer of nature, that the causes of diseases are more mysterious than we are led to suppose from perusing systematic treatises. If the etiology of diseases were studied at the bedside, the obscurity of this department of medicine would be apparent; and it has been constantly observed that most idiopathic inflammations are developed by causes which elude our observation. The effect of atmospheric causes on diseases in general has attracted the notice of physicians from very early ages. Inflammatory disorders are certainly more common in cold, variable, moist weather, and more especially when the wind blows from the north ; hence, in the winter and spring, we observe the various types of inflamma- tory diseases. The mucous membranes seem to suffer more particularly in cold moist weather, and the serous membranes and parenchyma of organs in cold dry weather; white in summer cutaneous inflammations (idiopathic or secondary) are observed to be most frequent. Inflammation may arise from injuries of various kinds, such as wounds, whether punctured, incised, lacerated or contused; from the irritation of foreign bodies, such as renal, biliary, gouty, and salivary concretions ; and from pressure, as in the instance of a bandage or ligature applied to the extremity; or in the example of pressure produced on an internal part by aneurismal or other kinds of tumours, whether solid or fluid, the pressure of which causes inflammation in the parts to which it is applied. , Another exciting cause of inflammation is the direu application of heat. This is exemplified in the effect of exposure to the rays of the sun in producing inflammation of the brain or external integuments, of the head and face, and in the effect of heat in producing scalds and burns. The effects of cold, as an exciting cause of inflammation, more especially if combined with moisture, are well known. We observe inflam- mation occur in parts to which the external air has free access—the eye^the ear—the tonsils— the larynx or trachea, and the mucous membrane of the lungs, after exposure to cold. These are instances of the effects of the direct application of cold. At other times the application of cold is followed by inflammation of a distant organ, an indirect effect being sometimes thus produced on an internal part, by the local application of cold and moisture. Thus a person who gets the feet thoroughly wet may afterwards have inflammation of the throat, of the lungs, or intestines, according to some local but still unexplained predisposition. We have another exemplification of the effect of cold in producing inflammation in frost-bite, in which very often rapid destructive inflammation is set up from the application of intense cold. Undue exercise of the functions of an organ may become not only a predisposing, but an ex- citing cause of inflammation. In this way undue exercise of the mental powers is a frequent cause of inflammation of the brain. In like manner, also, inflammation may be produced in the eye, as is frequently observed in persons who are obliged to use this organ unduly in their daily avocations. Inflammation of the vocal organs is a common consequence of long-continued loud speaking; hence noisy maniacs frequently become hoarse from the constant vociferation in which they indulge. Some substances, when taken into the stomach as remedies in disease, produce inflammation of particular parts. We have an example of this in the inflammation of the salivary glands, and sometimes of the skin, produced by the exhibition of mercury, or in the gastro-intestinal inflamma- tion which is the result of the employment of arsenic as a remedy in some diseases, but more especially when it is taken in such quantity as to act as a poison. To the same head of causes of inflammation, we may refer the various examples of local irritation and its consequences arising from irritant poisons. According to Dr. Christi- son, these effects of local irritation vary from the slightest redness to ulceration and even gangrene. Thus externally, alcohol reddens the skin; cantharides irritates the surface of the true skin, and causes vesication ; tartar-emetic causes deep- seated inflammation of the true skin and a pustu- lar eruption; the juice of manchineel, spreading inflammation of the subcutaneous cellular tissue ; arsenic has all of these effects, as also death of the part and subsequent sloughing. Internally, alcn hoi reddens the stomach as it does the skin, but more permanently ; while other substances, such as the diluted mineral acids, nitre, arsenic, can tharides, euphorbium, and the like, may cause all the phenomena of inflammation in the stomach and intestines, namely, extravasation of Nood, effusion of lymph, ulcers, and gangrene. (Chris- tison on Poisons, second edit.) There are other substances belonging to tlu1 class of irritants — the acro-narcotic poisons 780 INFLAMMATION. which have a compound action, the one local and irritating, the otifer remote, producing an impres- sion on the nervous system. To this class belong the atropa belladonna (deadly nightshade,) the datura stramonium (thorn-apple), and the nico- tiana tabacum (tobacco). The morbid cnimal poisons, as exciting causes of inflammation, belong also to this head. Some of these have a local action only, as the poison of itch or syphilis; more generally, however, the poison, though introduced locally, affects the ge- neral system; as in the instance of small-pox and ;ow-pox, and the poison of hydrophobia. It would appear, moreover, that some animal poisons operate through the medium of the blood. It is probably in this way that measles, scarlet fever, plague, the natural or uninoculated small-pox, md some other acute disorders, are produced. Many of these diseases, as is well known, give rise in their progress to various local inflamma- tions, the danger to life depending in a great measure on the severity of these local lesions. Terminations or Effects of Inflammation. —The mode in which inflammation terminates depends on several circumstances, more especially the nature of the exciting cause, the intensity and duration of the symptoms, the peculiar constitu- tion of the individual, the curative measures adopted, and the stage of the disease at which they have been employed. 1. Resolution.—Inflammation may gradually subside by the unassisted efforts of the system, constituting spontaneous resolution; or its pro- gress may be arrested by the employment of remedies before it has effected any change of structure in the part. Resolution is not only the most favourable, but the most common termination of inflammation ; it is indicated by the progressive abatement of the local as well as general symp- toms, and especially by the restoration of the natural functions of the part. When resolution takes place suddenly, the French writers apply the term delitescence (from the verb delitesco), implying sudden disappearance; this is exem- plified when a primary inflammation suddenly disappears and attacks another organ. This sudden decline of the inflammatory action is less frequently observed, however, than the more slow and gradual process of resolution. The resolution of inflammation is often pre- ceded or accompanied by metastasis, or transla- tion of the disease from one part to another. We have an instance of this in the common occurrence of inflammation suddenly leaving one tonsil and seizing on the other, in the sudden recession of the glandular inflammation in mumps, and the subsequent inflammation of the testicle in the male, or the mamma in the female. In gouty ind rheumatic inflammation, such sudden trans- lation is frequently observed. The articular in- flammation in gout sometimes recedes from the foot, and appears in the hand or knee, and occa- sionally attacks some internal organ, the stomach or brain. The sudden recession of rheumatism from joint to joint is a still more common occur- rence, and is the cause of the generally protracted nature of this disease. A still more dangerous effect of the recession of rheumatic inflammation u», when it leaves the joints and fixes on the mem- branes of the brain or the serous covering of the heart. Physicians, from observing the complete cessa- tion of inflammation, when a secondary disease is produced, have endeavoured to imitate nature, and by means of derivation or counter-irritation applied in the vicinity of an inflamed organ, to establish an internal disease, in the hope of with- drawing the inflammation from an internal to the external and less important part: these measures now form an important part of the local treatment of inflammation. (See Cocxteh-irritation and Derivation.) When inflammation is about to terminate in resolution, various changes take place according to the stage and intensity of the inflammatory ac- tion, and the structure of the inflamed part. In the slighter grades of the disease, the frequency of the circulation diminishes, the blood-vessels contract in their diameter, so that those which, during inflammation, were so much dilated as to admit the red particles of the blood, again receive only a colourless fluid. When the inflammatory action has been more severe, the resolution is ac- companied, if not effected, by an increase of the natural secretion of the part. If the inflammation occur in a serous membrane, the exhalants secrete an undue quantity of serum, or even coagulable lymph, which goes on so long as the inflammatory action continues; but whenever resolution takes place, the further progress of effusion is not only arrested, but the fluid already thrown out is gra- dually removed by absorption. When inflamma- tion occurs in a mucous membrane, the natural secretion, though at first diminished, is afterwards increased, and more or less altered in its quality, more particularly if the inflammation have passed into the chronic stage. Thus we find in bronchitis and muco-enteritis, that though in the primary stage of inflammation of these membranes the natural secretion is sup- pressed, as the diseased action proceeds, the natu- ral secretion is first restored, and afterwards in- creased in quantity, and finally altered in quality. The error of attempting to check the secretion from an inflamed mucous membrane, especially in the early stage of the disease, the increased discharge being the natural solution of the dis- eased action, is, therefore, obvious. Besides these local circumstances which are observed when in- flammation terminates in resolution, we find occa- sionally other changes take place, which, from their supposed influence in effecting this desirable solution, have been considered critical. There is sometimes an increase of the perspiration, or moderate diarrhcea, but more generally the urine exhibits marked alteration in its physical and chemical characters. While the inflammatory action is proceeding, the urine, though high- coloured, is clear, and does not, on cooling, de- posit a sediment; but when the inflammation is disappearing, it deposits, on cooling, a red sedi- ment. The following ingenious explanation of this appearance of the urine is given on the authority of Dr. Prout In healthy urine there is lithate of ammonia, which is pale and white, as also a yellow colour- ing matter, the nature of which is unknown, but [ which is thought to be, perhaps, a modification INFLAMMATION. 781 of lithic acid. If to lithate of ammonia out of the body what are called the purpurates be added, a pink substance is immediately produced, such as is observed in hectic fever; and if the urine have its usual yellow colouring matter, a mixture of that with the pink appearance produced by the purpurates and the lithate of ammonia gives a red colour, pink and yellow mixed together, form- ing a red colour. In this diseased state we are informed by chemists that nitric acid in excess is formed in the urine, which acts on the lithic acid, and converts some of it into a new acid called the purpuric, which, uniting with the salts of the urine, forms the purpurates; and these purpurates, mixing with the lithate of ammonia, which is always in the urine, produce a pink deposit, which, united with the yellow colouring matter, becomes red. The lithate of ammonia and soda are formed in some degree of excess in the urine under inflammation, and nitric acid is produced ; which, as has been stated, acting on the lithic acid, produces purpuric acid; and thus the forma- tion of the purpurates is explained. Those mix- ing with lithate of ammonia produce a pink sub- stance; and when this unites with the yellow colouring matter, the colour is changed to red. The cause of the urine being high-coloured or red, without sediment, till the inflammation de- clines, is this, that the same substances are in the orine, but held in solution by the activity of the complaint; but when it declines, an excess of lithic acid is formed, producing super-lithates, which are very insoluble; and, therefore, a great portion of them falls down in the form of a pre- cipitate : hence the red sediment. (Elliotson's Lectures on Inflammation.) The resolution of inflammation is sometimes accompanied by hemorrhage, with which inflam- matory action is often intimately connected. Critical hemorrhages may take place either imme- diately from the inflamed part or from some neighbouring organ. We have an instance of the one, in the hemorrhage which succeeds to in- flammation of mucous membranes, and of the other, of epistaxis in apoplectic or inflammatory states of the brain. These spontaneous hemor- rhages are always followed by most marked relief of the local and general symptoms. When inflammation does terminate in resolu- tion, it effects other morbid changes in the in- flamed tissue. The terminations, or, more pro- perly speaking, the effects to which we allutte, are Effusion, Suppuration, Mortification, Ulcera- tion, Induration, Softening, and Hemorrhage. 2. Effusion. The exemplification of effusion as a consequence of inflammation is best illustrated in the serous membranes. After the violence of the inflammatory action has subsided, and the natural secretion of the membrane, which, during the primary stage of inflammation, had been sus- pended, is restored, an increased effusion of sero- sity takes place. The fluid which in .these cases is secreted, and which happens only when the in- flammation is moderate, bears so strong an ana- logy, both in its physical and chemical characters, to the serum of the blood, as to have received the appellation of serosity or serous fluid. It is gene- rally of a pate straw colour and transparent, though occasionally, when the inflammation is a little 3 o. more intense, it contains a small proportion of albumen, which renders it slightly turbid. When the inflammatory action has been more violent, the fibrinous principle of the blood is separated ; the admixture of which with albumen and serum constitutes coagulable lymph. It is this product which, when mixed with serous fluids, renders them turgid ; the flakes of coagulable lymph, from their greater specific gravity, generally falling to the bottom of the cavity in which the effusion takes place, lining at the same time the surface of the inflamed membrane, and constituting that product termed false membrane. When an intense inflammation has lasted seve- ral days, the fluid acquires a yellow colour from admixture of purulent matter: when this is con- siderable, the effusion very nearly resembles in appearance well-formed pus; but it still contains a large proportion of coagulable lymph and serous fluid. In the commencement of the formation of false membranes, the exudation is soft and without con- sistence ; but from the thinner parts being gradu- ally absorbed, they become more dense, and ad. here to the inflamed membrane, forming webs of various figures, which extend from one point to another of the surface on which they arise. When subjected to pressure, they give out a large pro- portion of fluid consisting of serum mixed with albumen; the solid substance appearing globular when viewed with the microscope, and, according to the analysis of Davy, consisting chiefly of fibrine. False membranes often become completely or- ganized, and of a distinctly cellular structure, capa- ble of being injected; and when the inflammatory action ceases, they are converted into cellular tis- sue covered with a serous membrane, and after- wards liable, like serous tissues, to inflammation. Fibrine is also sometimes effused from inflamed mucous membranes, and gives rise to the formation of false membranes, such as that which is effused in the larynx and trachea, or from the mucous surface of the intestines or uterus. The false membranes formed in mucous cavities, however, are less consistent than those which are effused on serous surfaces, probably owing to their con- taining less of the fibrinous principle. When an inflamed mucous membrane is about to terminate in the exudation of a false membrane, an unusual quantity of viscid mucus is secreted, which gra- dually becomes more consistent from the admix- ture of fibrine which is effused in the subsequent stage of the inflammatory action. These pseudo membranes, as was stated before, generally beai the mould of the cavities in which they form. [When the effusion of liquor sanguinis is ex- amined by the microscope at the commencement of its becoming organized, a number of exudation corpuscles, formed as the fibrin coagulates, is seen in it. These have the appearance of regular cells, arranged in layers, and adhering together by an unorganized substance. Some hours later a fibrous character presents itself, which is supposed to be owing to the adhesion of the cells together in lines. Between the cellular fibres a considerable amount of cystoblastema yet remains, and they may be readily separated or torn in any direction A vascular network next appears, which forms « 782 IN F L A M M A T IO N. communication with the vessels of the subjacent surface. (Gerber, General Anatomy, by Gulliver, Lond. 1842.) According to M. Andral, (Hematologic Patho- logique, Paris, 1843, or Amer. edit. Philad. 1844,) two matters—the one globular, the other reticular — characterize, in the solid, the morbid process which we term inflammation. The reticular mat- ter is nothing more than fibrin, perfectly similar to that which exists in the blood;—the globular matter, he thinks it probable, is also fibrin, but altered in its nature, and arrested in its coagula- tion. These two matters have very different destinations. The one—the reticular—is suscep- tible of passing into the organized state : vessels may be seen ramifying in it, and it may become a tissue. It is this which forms adhesions, and under the name of'coagulable lymph'is interposed between the lips of wounds, and becomes the me- dium of their reunion. In place of being injuri- ous by its presence, it is, consequently, an instru- ment of reparation for the tissues, and ultimately becomes completely identified with them. The other, on the contrary—whether it have a com- mon origin or not with the reticular—can never remain in the textures without disturbing more or less the whole economy. It is incapable of organ- ization ; exhibits no trace of vitality, and is rejected by the organism. If not eliminated, disease re- sults, and the elimination itself is frequently not accomplished without the supervention of unplea- sant symptoms.] The organization of coagulable lymph gives rise also to the process of adhesion—an operation of nature by which surfaces of parts which have been recently divided become re-united, the lymph becoming a living intermedium whereby the con- tinuity of the part is ultimately restored. A know- ledge of the fact that parts which have been divided may be again united by adhesive inflammation, has laid the foundation of many of the most im- portant improvements in surgery. The mode in which divided parts are united, and injuries repaired, termed union by the first intention, is similar to that which takes place in the formation of false membranes. If a surface which has been divided, an incised wound, for example, be examined a few hours after the solu- tion of continuity has taken place, it will be found fovered with a layer of coagulable lymph. Dr. Thomson made some experiments upon animals with the object of ascertaining the earliest period at which coagulable lymph is effused from the surface of a wound ; he observed a distinct layer of lymph covering wounds he had made within less than four hours after they had been inflicted ; though he thinks a longer period may be required in the human subject, in different persons, in dif- ferent textures of the same individual, and in the different states of health and disease. The exudation of the lymph is speedily followed by the formation of blood-vessels, which often become, in the course of a few hours, so large as to be capable of being injected. This is the state of ie-union termed by Mr. Hunter adhesive inflam- mation. In many instances the reparation of an injury " divided surface is effected by a different process -that of granulation, termed by the older writers union by the second intention. The process ol granulation takes place, when from various cir- ! cumstances wounds do not unite by adhesive in- flammation, or when there has been a considera- ble loss of substance in a part, as in abscesses, ; ulceration, and gangrene. In these cases a layer of coagulable lymph is effused on the surface of the wound, which, as in the process of adhesion, becomes penetrated with blood-vessels, and thus a living intermedium is formed. Soon afterwards the surface is covered with purulent matter thrown out by a peculiar action of the vessels of the part. in which circumstance, besides the non-union of the divided tissue, the granulating differs from the adhesive process. Granulations assume the ap- pearance of small red points and eminences, and according to Dr. Thomson, the mode in which nature effects their formation may be seen by in- jecting and carefully examining the internal sur- faces of abscesses, or the granulating surfaces of healthy sores or ulcers. From numerous observa- tions made in this way, it appears the exudation of a layer of coagmlable lymph may be regarded as the first step in the process of granulation. The second consists in the penetration of this lymph with blood-vessels, nerves, and absorbents; the third, in the inosculation, or union by open extremities, of the vessels in these granulations; and in the last step, if it may be called so, of their formation, the granulations are covered over with cuticular substance by which the further secretion of pus is prevented, and the process of healing by granulation completed. (Lectures on Inflamma- tion.) In this way the process of cicatrization is explained. The subject of adhesive inflammation was minutely investigated by John Hunter, and in the chapter of his work on inflammation, entitled " On the LTse of Adhesive Inflammation," he has pointed out this admirable contrivance of nature in preventing the extension of diseased action, and in repairing its effects in different structures. Mr. Hunter has also given a description, which has never been excelled in modern times, of the various processes by which this reparation is effected. The first step of the process by which solutions of continuity, whether simple incised wounds or loss of substance in any organ or part of the body are united or regenerated, is adhesive inflammation, which varies in intensity according as the reparation is to be accomplished by the first intention (adhesion), or by the process of suppuration. In the first mode, the inflammatory action never reaches the stage of suppuration; ir the latter the inflammation should be moderate in order to insure cicatrization. It is well known to surgeons, that if a wound be irritated during the process of union by the first intention, the adhe- sive readily passes into the suppurative inflamma- tion, so that the union by the first intention is frustrated ; if, on the other hand, the surface of a suppurating wound be irritated during the healing by granulation, cicatrization is retarded and often entirely prevented. The necessity, therefore, of moderating inflam- mation in the treatment of wounds, that this action, which is indispensable for the accomplish- ment of union by adhesion and cicatrization, may never exceed proper limits, or of occasionally I N F L A M stimulating the surface of a sore when the healing process is languid, is thus explained. [It has been maintained, however, by Dr- Ma- cartney, of Dublin, after a comparative survey of the operations of reparation and inflammation, as performed in the different classes of animals, (Treatise on Inflammation, Dublin, 1838,) that the powers of reparation and reproduction are in proportion to the indisposition or incapacity for inflammation;—that inflammation is so far from being necessary to the reparation of parts, that in proportion as it exists, the latter is impeded, re- tarded or prevented,— that when inflammation does not exist, the reparative power is equal to the original tendency to produce and maintain organic form and structure,—and that it then becomes a natural function, like the growth of the individual, or the reproduction of the species.] In every tissue, adhesion is effected, as before explained, by the effusion and subsequent organ- ization of lymph, which in the course of time is transformed into a new substance, similar to cellu- lar or fibro-cellular tissue, which adheres to the lips of an incised wound, and constitutes the me- dium or bond of union by the first intention; or it is deposited in the cavity of suppurating wounds, and upon which granulations are subsequently deposited, so as to fill up the vacuity which has been occasioned by the solution of continuity. [If examined with a microscope at the com- mencement of the process of organization, it is seen to contain a large number of exudation cor- puscles. In a short time, these corpuscles present the appearance of regular cells, disposed in layers, and adhering together by an intermediate unor- ganized substance, bearing a strong resemblance to the cells of tesselated epithelium. Some hours later, the mass exhibits an evidently fibrous cha- racter, owing to the adhesion of the cells together in lines, their form being prolonged in the same direction. A vascular rete next makes its appear- ance and forms connections with the vessels of the subjacent surface: the first appearance of this net- work is in the form of transparent arborescent streaks, which push out extensions on all sides; these encounter one another, and form a complete series of capillary reticulations, the distribution of which very nearly resembles that which has been seen in the villi of the intestines. Before the vas- cular rete appears, pale-coloured cytoblasts are produced, which, after the completion of the rete, pass over into the nearest capillary veins, being pushed on by the blood, which is brought from the nearest arteries; and in this manner the circu- lation is established. (Carpenter, Principles of Human Physiology, § 600.)] In the reparation of cellular tissue, the first stage is the effusion of lymph, which becomes gradually organized, and transformed into a tex- ture so similar to the primary tissue, that it is im- possible to distinguish the one from the other except by its greater degree of density or hardness, and that its cells do not communicate so freely, for in oedema the cicatrices of wounds or abscesses do not fill with fluid. Serous membranes become united by adhesive inflammation, either by union of the two serous surfaces, as we observe in pleuritic adhesions, or when there is a solution of continuity of this ATI ON. 7-3 membrane, as in wounds of the lungs or intes- tines. Dr. Thomson states, that in some experi- ments in which he removea a portion of the pleura pulmonalis, it appeared to be regenerated, as he was unable to distinguish easily the cicatrix from the surrounding parts. Gendrin also found the peritoneum thickened at one point in which ulceration of the intestine had commenced in the peritoneal tunic. In solutions of continuity of the skin, when union by the first intention takes place, adhesion is effected by fibro-cellular tissue, which nearly resembles in formation the cutaneous structure. It differs, however, in some respects, chiefly in the non-regeneration of areolae, indentations, or fatty matter. In extensive losses of the cutaneous tis- sue, the reparation is effected by suppuration, granulation, and the ulterior stage of cicatrization; but although the newly-formed substance is co- vered with an epidermis so as to resemble the original skin, it never acquires the perfect organ- ization of cutaneous texture; it is less yielding, movable, and elastic, and without indentations by which sound skin admits of distension. Its vital- ity is also less active, for, as is well known to sur- geons, when an old sore-breaks out, the cicatrix is gradually destroyed. A similar process to that just described appears to take place when portions of mucous membrane are destroyed by ulceration, viz. the effusion and organization of lymph, and the formation of an organized cellular membrane. The newly-formed tissue, however, has none of the properties of a mucous membrane, and never performs the func- tion of secretion. The cicatrix is generally white, contracted, and is neither endowed with villosities nor follicles. We have examples of the healing or cicatrization of mucous membrane in ulcera- tion of the throat, bronchia, and urethra; and in the follicular ulceration which accompanies some forms of fever, and also in ulceration of the mu- cous membrane of the stomach, or of the colon in dysentery. The adhesive inflammation of blood-vessels is exemplified in wounds, or when a ligature is ap- plied to an artery or vein. Effusion of lymph takes place both within the canal and on the sur- face of the vessel: this fluid becomes organized and finally transformed into a firm fibro-cellular web, which becomes closely connected with the internal and external tunics, and thus obliterates its canal. The fibrine of which the plug is com- posed is also organized, and may be even injected, showing the distinction between this substance and a clot of blood. A similar process takes place in inflammation of veins, which we have shown to be more sus- ceptible of adhesive inflammation than arteries ; and that adhesive inflammation of this system of vessels frequently occurs, and gives rise to impor- tant and often dangerous diseases. In nervous tissue, adhesive inflammation is ob served in the reparation of various lesions of the brain and nerves, though pathologists are generally agreed that regeneration of the cerebral and ner- vous pulp never takes place. The process of adhesive inflammation of the cerebral tissue is ex- emplified in the obliteration of apoplectic or he- morrhagic cysts, in which, according to Rochoux. 784 INFLAMMATION. the appearance of the effused blood differs accord- ing to tne duration of its effusion. When death ensues quickly, at the end of three or four days for example, it is in the form of soft blackish clots : after a month or six weeks it becomes firmer, assumes a deep brown colour, and resembles the blood of aneurismal tumours. At a more remote period it becomes still more compact, and of a pale red colour, bordering on ochreous matter; and lastly, it is entirely absorbed. Around the coagulum a layer of lymph is effused, which be- comes organized and transformed into a cellulo- fibrous cyst, which separates the clot from the cerebral substance. When the coagulum becomes completely absorbed, the cyst gradually contracts, till its walls approximate, and finally adhere by thin bands of cellulo-fibrous tissue, which in some cases cross the cyst in various directions, so as to connect its opposite sides at these intersecting points. In many instances, however, the cyst re- mains open and is filled with a turbid fluid. In wounds or laceration of nerves, the divided extremities of the cord are united by lymph, which is gradually transformed into firm fibro- cellular tissue. From experiments which have been made with the view-of ascertaining whether the true nervous pulp be regenerated, it is now generally admitted that such reproduction does not take place, the substance of the cicatrix not being capable of transmitting nervous impressions. When muscular tissue is divided or destroyed, the reparation is not effected by the regeneration of muscular substance, but by very firm fibro-cellular tissue. This newly-formed substance becomes more firm according to the extent to which the extremities of the muscle are separated. When this is considerable, the intervening substance be- comes almost ligamentous, but never acquires either the appearance or properties of muscular fibre. When solution of continuity or loss of substance of fibro-cartilaginous tissue (cartilage or ligament) takes place, the structure becomes swollen, in- flamed, and softened ; to which succeed effusion and organization of lymph, which is in process of time converted into dense fibro-cellular tissue; but it is in many respects dissimilar to the primary or original tissue. The adhesive inflammation of bone is effected first by the effusion of lymph from the periosteal and medullary arteries, softening and swelling of fractured extremities of the bone, the subsequent organization of their lymph, and its successive transformation, first into fibro-cellular tissue, then into a semi-cartilaginous substance, on the surface of which there are subsequently deposited a num- ber of points of osseous substance. These points of ossification cohere, and form a thick irregular soft bony callus. The thinner parts of this callus are gradually absorbed, the solid bony substance alone remaining; and by the further absorption of the softer osseous particles, the medullary and cancellated structure of the bone becomes ulti- mately formed. [It has been generally supposed, that the pro- .•■esses of granulation and suppuration, which are attended with much local inflammation, and con- •titutional disturbance, when the surface is large, fcre the only means by which an open wound can be filled up. Occasional instances, have, however, occurred, in which large wounds have closed under the clot of blood by which they were at first covered, without any suppuration or other symptom of inflammation; and in these it has been found, that the new surface much more nearly resembles the ordinary one, than the cicatrix do^s, which follows granulation. Dr. Macartney (op. cit.) terms this the modelling process, and regards it to be precisely analogous to that which ii concerned in the ordinary process of growth, and in the reproduction of whole parts, which takes place in the lower animals without inflam- mation. The most effectual means of promoting this kind of reparative process, and of preventing the interference of inflammation, vary according to the nature of the injury. The exclusion of air from the surface, and the regulation of the tem- perature, would appear to be the points of most importance. Dr. Macartney insists also on the constant application of water dressings. (Carpen- ter, op. cit., §§ 602 and 603.)] 3. Suppuration.—Inflammation may also ter- minate in suppuration or the formation of a fluid termed pus. Various opinions have been enter- tained as to the mode in which this fluid is pro- duced. The older writers ascribed it to the breaking down of the solids, and the changes subsequently induced in extravasated blood ; some regarded it as the effect of putrefaction of the serum or of the chyle, while others imputed its formation to the wasting or melting down of the fat. In mo- dern times the generally received opinion is, that pus is separated from the blood by a peculiar ac- tion of the blood-vessels of an inflamed part, analogous to that of secretion; but in what way this fluid is elaborated is as little understood as the mode by which the various secretions are formed from the parent streams. It would appear, from experiments made on this subject, that pus is formed by a gradual conversion of the coagulable lymph into this fluid. For a detailed account, however, of this process, the physical and chemi- cal character of pus, as well as its mode of forma- tion in different tissues and organs, we beg to refer to the articles Abscess and Suppuhatiox, and to the section of this article, Theory of In- flammation. 4. Mortification.—Mortification, or the complete death of a portion of the body, although produced by various causes, is not an unfrequent termina- tion of inflammation, though it is a more frequent consequence of acute than of chronic inflamma- tion. The terms gangrene, mortification, and sphacelus, have been used synonymously by many writers. Dr. Thomson has proposed to employ the term gangrene to express that stage of morti- fication which precedes the death of the part; and sphacelus, to denote its complete death or mortifi- cation, the circulation and sensibility being com- pletely destroyed. When gangrene occurs as the effect of inflam- mation or other causes, or arises spontaneously, it is announced by a change of colour, sensibility, and temperature in the inflamed part. The bright red colour of inflammation is replaced by a deep purple, livid, or blue appearance, which soon passes into a dark brown or black; the affected part INFLAMMATION. 785 becomes insensible to the acdon of stimuli, while at the same time its temperature is diminished. It loses also the dense elastic feel which it had ac- quired during the inflammatory state, and becomes soft and flaccid ; and if the mortification occur in the skin, the cuticle is raised in vesicles (phlyctenae) which are filled with a yellow or bloody serum. A putrid odour begins soon after to be exhaled, which increases with the severity of the other symptoms, the progress of which is sometimes rapid, at other times more slow. The complete death of the part is announced by a great decrease of temperature, a total loss of sensibility, and consequently cessation of pain, and a crepitous sensation produced by the pressure of air as a consequence of putrefaction. It is also known to anatomists, that the structure of a sphace- lated part is so completely changed that an injec- tion cannot pass into the vessels. When mortification occurs in external parts, recovery frequently takes place even under the most unpromising circumstances. In internal or- gans it is almost invariably a fatal lesion. The symptoms which denote mortification in parts of the body important to life are, sudden cessation of pain, remarkable depression of the powers of the system, with symptoms referable more to the ty- phoid than the inflammatory character; there is great restlessness and uneasiness, but not arising from pain ; the countenance becomes anxious, the features shrunk, and the aspect wild and cada- verous ; the pulse small, rapid, and irregular; hic- cup, followed by delirium and cold sweats, precedes the fatal issue. We have already stated that mortification is more frequently induced by acute than by chronic inflammation. It is, however, important to bear in mind, that the death of parts is not always to ta explained either by the degree or duration of nflammation. In certain epidemics, and in some conditions of the system, a state of local vascular excitement, amounting to little more than conges- tion, is followed by sphacelus of the affected parts. This is seen in the throat during the prevalence "f malignant scarlatina, and in some forms of ery- sipelas : in malignant, eruptive, and typhoid fevers too, the inflammation produced in those parts of ^e body subjected to pressure or friction frequent- ■y terminates in gangrene. There are few parts of the body which are not abject to gangrenous inflammation. Inflamma- don of the brain, though subject to all the changes consequent to inflammation, rarely if ever termi- nates in gangrene, though its membranes have been found in a mortified state after external inju- ries. There are certain tissues, however, in which inflammation is more apt to terminate in gangrene than in others. Nature seems also to have en- dowed the vascular system with a remarkable power of resisting mortification. Surgeons have frequent opportunities of witnessing large blood- vessels exposed, and apparently in a sound state, when the surrounding structures are completely destroyed by gangrene or ulceration. It is well known that in gangrenous parts no hemorrhage follows the division of the sphacelated parts, or even an incision made several inches above the boundary between the dead and living parts. This s owin" to the arteries being filled with a coagu- Voi..°II.-99 3a* lum of blood, which adheres to the inner surface of the vessels so firmly as to resist the impulse of the blood when they are divided. In one instance, related by Mr. O'Hallason, no bleeding followed the removal of a limb, though the incisions were made four inches above the seat of gangrene: and Dr. Thomson saw, in a case of mortification of the thigh, a coagulum of blood in the external iliac artery, extending as high as the origin of this vessel from the aorta. On thel other hand, we observe that inflamma- tion more readily passes into gangrene in some tissues and organs than in others. It is observed more frequently, as a consequence of inflamma- tion, in the skin and cellular membrane, in the organs of digestion and respiration, than in other parts of the body. Mortification takes place also more rarely, and makes slow progress in muscular, ligamentous, and tendinous structures. Besides the occurrence of mortification from in- flammation and other external causes, it may arise, without previous inflammation, from the introduc- tion of acrid poisons, from ligklning, or the near approach of cannon-balls, or from animal poisons, such as that of the viper, cobra di capello, or the rattle-snake. Mortification takes place not only as an effec* of inflammation, and from the other circumstances just enumerated, but as an idiopathic disease. This form differs in some respects from that aris- ing from the causes alluded to, and has been dis- tinguished by the term dry gangrene, from the dry appearance of the mortified part, the skin, cel- lular tissue, muscles, tendons, and ligaments, be- ing hard and dry, and showing no tendency to putrefaction. It generally occurs in the lower ex- tremities ; and from the, arterial trunks being al- most invariably ossified, it has been supposed that this form of gangrene arises from this state of the blood-vessels. It is a remarkable but well-ascertained fact, however, that dry gangrene may be also produced by eating unsound rye. The rye-plant or rye-corn (secale cereale of Linnaeus) is used in some coun- tries, particularly in the north of Europe, as an article of food, and also affords, by distillation, an ardent spirit. Bread made from rye is less nu- tritive but more aperient than any other kind. This grain is liable to a morbid growth, more par- ticularly when great heat succeeds to heavy rains. It is a black curved excrescence, not unlike the spur of a fowl, which grows on the spike, and is sometimes found in such quantities as to form nearly one fourth of the produce of the rye. It is called secale cornutum, or the cockspur in rye. In France it is known by the name of the ergot (siegle ergote). This diseased growth is attri- buted to the destructive operation of an insect which perforates the rye-corn and destroys its parenchyma. Unsound rye has a singular effect on the hu- man body : viz. lassitude, weakness of the extrem- ities, intoxication, and periodic convulsive move- ments. This state, which has been called raphania, or convulsiones cerealiae, continues from a few days to several months. It is stated by Dodard and other writers, that persons who used rye-bread containing a consider able quantity of the diseased grain were 'iable to n 786 INFLAMMATION. gangrenous affection of the extremities, attended with little fever, inflammation, or pain, though the affected limb became dead, and separated from the body. The limb became at first cold and insensi- ble, and in the progress of the disease dry, hard, and withered. For a full account of this curious subject, the reader is referred to Dr. Thomson's work on inflammation. Mortification may, when it is slight, terminate, 1. by resolution ; 2. by adhesion ; 3. by ulcera- tion ; 4. by sphacelus, or the death of the part, the last being by far the most frequent termination. (See Mortification.) 5. Ulceration.—When a solution of continuity follows as an immediate consequence of inflamma- tion, the morbid process by which it is effected is called ulceration. Previous to the time of Hunter, ulceration was supposed to be produced by the corrosive power of the fluids of the part in which the diseased ac- tion occurred. This celebrated pathologist, how- ever, demonstrated satisfactorily that the solution of continuity was not affected by the acrimonious quality of the fluids, but by the action of the ab- sorbents, the removal of parts or tissues by these vessels constituting the ulcerative process. He designated the formation of an ulcer by simple loss of substance, ulcerative absorption,- and when the solid parts covering abscesses, aneurisms, and deep-seated tumours, in their progress towards the surface, were gradually removed by ulcera- tion, he applied the term progressive absorption. Dr. Thomson has proposed to distinguish the separation of dead or mortified parts by the term disjunceive absorption ; but this appears to be an unnecessary refinement of medical terminology. Ulceration may occur as a consequence of every degree or kind of inflammation, not only in soft parts, such as skin, mucous membrane, brain, lung, liver, &c, but also in the texture of bone, in which structure the ulcerative process is termed caries. Indeed, we find that all textures of the body are susceptible of ulceration. " We see this exemplified," Mr. Lawrence observes, "when mor- tification has attacked an entire limb, and when the separation takes place by a natural process. Suppose, for instance, that the foot and lower part of the leg were mortified, and that the mortifica- tion stop in the middle of the leg, we find that the skin, the cellular membrane, the fascia, the muscles and tendons, blood-vessels, nerves, and even the bone itself, are all penetrated by the pro- cess of ulceration." (Lectures on Inflammation.) Another familiar illustAtion of the progress of ulceration is observed in the progressive absorp- tion which takes place in an internal aneurismal tumour, in which we find the sac of the aneuris- mal adhering to the parts with which it comes in contact, but after forming an intimate bond of union, the mass is gradually though slowly re- moved by the process of absorption ; even the bone which intervenes between the external surface and the aneurism being finally absorbed. It is this removal, Dr. Thomson remarks, of one texture after another, first the sac of the aneurism, then the pleura costalis, then muscles, bones, cel- lular substance, and cutis, layer after layer, that Mr. Hunter wishes to express by the term pro- gressive absorption—a term sufficiently expressive of the general phenomena which it exhibits, and of the gradual and successive disappearance of the parts which cover abscesses, aneurisms, and tu- mours, in their constant and uniform progress to the skin. In this process the adhesive inflamma- tion precedes the outward progress of the aneu rism, and limits, as in phlegmon, the extent of the swelling, and, as it were, directs it to the surface of the body. (Lectures on Inflammation.) The occurrence of ulceration is much more fre- quent in some textures than in others, depending on the degree of vascularity of the part which it affects. It is observed also to be a more frequent effect of chronic than of acute inflammation. The skin appears, of all other tissues, to be most sus- ceptible of ulceration. Mucous membranes, cel- lular tissue, bones, and articular cartilages, come next in order. Fascia, ligamentous structure, and tendons, are the least liable to ulceration. Hence, as Dr. Thomson states, when abscesses form un- der ligamentous or fibrous fasciae, we find that they are long in getting to the surface, and that they seldom arrive at this by the shortest and most direct road, but usually by passing through some texture or organ that is more susceptible of being absorbed. It is important to remark, however, that inflam- mation of the same tissue, apparently the same in kind, degree, and duration, will temvnate at one time in ulceration, and at another pass off without producing solution of continuity. The importance, therefore, of ascertaining those circumstanres which influence the termination of inflammation in ul- ceration must be obvious. 6. Induration.—This effect of inflammation is frequently observed. When it follows acute in flammation, it depends on the presence of fluid effused into the tissue of the inflamed part, when it takes place as an effect of chronic inflam mation, it is more frequently produced by the presence of various solid products to which th. process gives rise. Induration is most generally observed in soft spongy cellular organs, as the brain, cellular membrane, lungs, &c, but morp frequently in the two latter tissues, in which the induration subsequent to inflammation is often very considerable, and produces remarkable altera tion in their structure. 7. Softening.—An opposite state, that of soft ening, is not an uncommon effect of acute inflam mation. Although it is observed to take place in all tissues, it most frequently occurs in the sub- stance of the brain, mucous membranes, and cellular tissue. As this subject is one of great practical importance, and has of late been very fully investigated, it will be fully considered under the article Softening. 8. Hemorrhage. — Inflammation is often fol- lowed by hemorrhage. ' The effusion of blood may take place from almost every tissue and organ in the body, but more frequently from those parts which are covered with mucous membranes. The various circumstances under which hemor- rhagic effusions, as a consequence of inflamma- tion, take place, will be found under the article Hemorrhage. Treatment. — From the serious and often fatal effects of inflammation, it is of the greatest importance to endeavour to subdue the symptoms INFLAMMATION. 787 on their first appearance, that those terminations The abstraction of blood from the system is more or effects we have been considering, some of which have a dangerous and often fatal tendency, may be prevented. The necessity for the adoption of prompt measures is more especially necessary, when the inflammation is seated in an organ essen- tial to life, in which the changes of structure fre- quently go on with great rapidity, so as either permanently to injure the function of the part, or to destroy life. Thus, when inflammation attacks the brain, lungs, heart, or intestines, or when it occurs in parts the organization of which is so delicate that the inflammatory action speedily de- stroys the structure and functions, as, for example, the retina or iris, the ear, or the larynx, the most energetic treatment should be adopted on its very first appearance. Another reason for the imme- diate employment of suitable measures in inflam- mation even in parts which are less essential to life, is, that when the blood-vessels become unduly especially necessary in inflammation of important organs, as of the brain, pulmonary and abdominal viscera, in which diseases it forms the principal means of cure. It is generally found that inflammation of serous membranes requires larger losses of blood than when the parenchyma or substance of an organ is inflamed, and that, on the other hand, inflammation of mucous surfaces is less under the control of general bleeding; in such cases the local is preferable to the general abstraction of blood. The propriety or necessity for general blood- letting being determined, the question as to quan- tity requires consideration. For this there cannot obviously be any fixed or determinate rule, as it must depend on the importance of the organ in- flamed, the intensity of the inflammation, its du- ration, and the peculiar circumstances which each distended for any length of time, they contract case presents. When an organ important to life with difficulty, and thus give a greater suscepti bility to recurrence of the inflammatory action, or, in other words, a predisposition to relapse. Before commencing the treatment of inflamma- tion, if any obvious exciting cause exist, it is pro- per to endeavour to remove it, and also to avoid every circumstance which can tend to keep up local or general excitement. The object to be kept in view in the treatment of inflammation, is to effect resolution. This is, in some instances, the natural and spontaneous solution of the disease, though in the majority of instances it is induced by measures which tend to subdue the local and constitutional excitement. It is necessary, in estimating the probability of ac- complishing such a desirable termination, to con- sider the duration of the inflammation, since we can only hope to bring about resolution in the more early stages. Even although the measures employed prove inadequate to this end from the duration of the symptoms before their application, still the severity or extent of the termination which may have ensued may be materially less- ened by the judicious employment of means cal- culated to subdue inflammatory action. The remedies by which the symptoms of in- flammation are removed, have been termed anti- phlogistic treatment, that is, remedies against in- flammation. We have seen that the capillaries or vessels, which in the natural state admit only the colourless part of the blood, become so en- larged during inflammation as to admit red blood, and from their being thus surcharged, are inade- quate to carry on the circulation. We have also seen that with this local congestion the vascular system throughout the body sympathizes, giving rise to symptomatic fever, during which the blood, being impelled with unnatural force, increases the distension and obstruction in the capillary circu- lation. These circumstances at once show the necessity of bloodletting, as the principal means of removing inflammatory diseases. In all cases of active inflammation, but more especially when the constitutional symptoms are severe, general bleeding is to be employed, with the object of diminishing the quantity of blood, and at the same time, of abating the force and frequency of the action of the heart and arteries. is inflamed, and if there be no special circum- stances to forbid copious bloodletting, the effect produced on the symptoms is a matter of greater moment than the quantity of blood abstracted. The too common practice of prescribing a cer- tain number of ounces of blood to be drawn from a vein in an acute disorder is most reprehensible. The disease may yield to the abstraction of a few ounces of blood, or a much larger quantity than was at first anticipated may be necessary. Hence the obvious advantage of the physician superin- tending the bloodletting he prescribes, in all cases of emergency. Every practitioner must have seen cases in which, though he had imagined a mode- rate bleeding (sixteen to twenty ounces) would have cut short the disease, a very considerable quantity of blood has been lost before an impres- sion was made on the symptoms. In one case of pericarditis which lately fell under o ir observation, in which, after the disease had been nearly sub- dued, a recurrence of the symptoms took place with redoubled violence, according to usual custom twenty ounces of blood were ordered to be drawn from the arm. From the urgency of the symp- toms, however, we superintended the operation. No relief of the pain was obtained after twenty, thirty, forty, and fifty ounces were abstracted. When sixty had been taken away, tbe patient ex- claimed, " I now feel relieved." This large bleed- ing was neceissary as a means of relief from most acute suffering. Besides the quantity abstracted, the rapidity with which the blood flows has an important influence on the symptoms. The blood should be drawn from a large orifice, that a de- cided impression may be at once made on the dis- ease ; for which purpose, in cases of inflammation of a vital organ, a vein in both arms may be opened, and the blood allowed to flow till there is an approach to syncope, which may be favoured by placing the patient in the erect posture, where- by the flow of blood to the heart and upper parts of the body is retarded. It is incredible the quan- tity of blood which some patients have lost before inflammation of an internal organ has been sub- dued. The late Dr. Gregoiy used to relate in his lectures the case of a young woman who lost two hundred and thirty ounces of blood in the space of a few days, before an attack of pleurisy wis 768 INFLAMM ATION. overcome. Such large bleedings, however, are seldom necessary. The effect of bloodletting, more especially if carried to approaching syncope, in lessening in- flammation, may be observed by comparing the state of the conjunctiva in acute ophthalmia, be- fore and after the patient has been freely bled. The distended and tortuous vessels are no longer visible, and for some time after the conjunctiva often remains as pale as in its natural state. The same effect is produced on internal organs, and those structures which are not visible. It is seldom that a single bleeding is sufficient to subdue active inflammation, even when carried to a sufficient extent. The disease may for a time appear subdued, but when the system rallies, when reaction succeeds to the depression consequent on a profuse bleeding, the symptoms reappear some- times with the same intensity as at first, but more generally in a mitigated form, and require a repe- tition of the bleeding. We have sometimes seen the abstraction of a few ounces of blood, when the pulse was beginning to rise, indicating the period of reaction, give a final blow to the disease. Hence, in active inflammation, we are disposed to recommend, an hour or two after the first bleed- ing, the bandage to be re-applied, and a small quantity of blood (eight or ten ounces) to flow from the orifice. Even with this precaution the symptoms in many cases return, and therefore it is necessary to consider those circumstances which indicate the necessity of the further abstraction of blood, and the extent to which it should be carried. 1. There are some particular symptoms from which an indication as to the further loss of blood may be taken. We have observed that, the effect of inflammation in an organ is to disturb seriously its functions; hence, when the natural function of an inflamed organ is restored, it is a true crite- rion of the cessation of the inflammation. When, however, the function of the part is only partially restored, or if, after being completely recovered, it again become disturbed, it is a sure proof that the inflammatory action is still lurking, and may, on the application of a trivial exciting cause, be again called into its former activity. Under such cir- cumstances the further abstraction of blood will be necessary. 2. Another symptom requiring consideration as to the propriety of repeated bloodletting, is pain. In the early stage of inflammation It is more or less acute, but generally mitigated or removed by venesection; and when a moderate bleeding pro- duces partial or complete cessation of pain, it proves that the inflammation has not made great progress. In other cases the relief from pain is less instantaneous or considerable, but takes place gradually with corresponding abatement of the other symptoms, and is often completely removed by local bleeding and counter-irritation. If, how- ever, the pain be only partially mitigated, or its removal be of short duration, or after having been completely removed, it recur, announcing the re- newal of inflammation, there can be no hesitation about the necessity of further depletion. Again, we find that when acute passes into chronic inflammation, the pain abates, and ulti- mately entirely ceases, which may lead to the im- pressim that the inflammation has been extin- guished. Acute pain not unfrequently supervenes in such cases, and announces the conversion of chronic into acute inflammation, requiring a repe- tition of bloodletting and other measures for its reduction. It is necessary, however, to remark that young practitioners are too often deceived in the expecta- tion of acute pain in inflammatory diseases. We have already seen that when inflammation is al- lowed to proceed and to assume the chronic form, the pain abates, and at length finally ceases. In many of the phlegmasiae there is no pain, even when intense inflammation is going on. This is more especially the case in inflammation of the parenchyma of organs ; in the brain, for example, in which most active diseases may be proceeding even to a fatal termination without any indication of pain. If, however, the symp- toms be analyzed, abundant proofs will be given of the existence of serious inflammatory disease. Again, in pneumonia or inflammation of the pul- monary tissue, there is often no pain, the disease being indicated by cough or embarrassed respira- tion, and the crepitating sound of the breathing; or in cases of latent pneumonia, by the stethoscopic phenomena alone. Even in the advanced or chro- nic stage of inflammation of serous membranes, the pain abates or entirely subsides, while slow and insidious inflammation is going on. Were the practitioner to overlook such symptoms, and to imagine that in the absence of local pain inflam- mation did not exist, the life of his patient might be sacrificed; 3. The pulse has from the remotest antiquity furnished an indication of the propriety of blood- letting, and of the necessity for its repetition in acute diseases. In the phlegmasiae the pulse is increased in frequency, and in volume or strength; and in inflammation of serous membranes it ac- quires more or less hardness, wiriness, or tension. The object of bloodletting is to reduce these states of the pulse, more especially the hardness, and in proportion as this is accomplished, the operation is beneficial; so that when we fail in removing this hardness of the pulse by profuse bleedings, the issue of the case is seldom doubtful. It is necessary, however, to bear in mind that in cases in which large losses of blood have been sustained, the reaction is often accompanied with a he- morrhagic throb or jerking of the pulse. We have often seen bloodletting prescribed for this state of the pulse, and observed that it invariably increased by the depletion; the crassamentum of the blood, at the same time, becoming progressively smaller at each bleeding. In these cases there is exhaustion with excessive reaction—a condition of the circulation which tends to impel the blood in inflamed parts, so that bloodletting proves indi- rectly a stimulating rather than an antiphlogistic measure when employed under such circum stances. The state of the pulse alone, however, without reference to the general symptoms, is not always a safe criterion of the necessity for bloodletting. We find in many inflammatory diseases that the pulse does not exceed the average frequency or strength observed in health, so that were the prac- titioner to withhold his lancet solely because the pulse deviated little if at all from its natural state, INFLAMMATION. 789 a serious or often fatal error would be committed. In such cases the degree of pain or other local symptoms of inflammation must regulate the practice. We very lately found it necessary to abstract once and again a considerable quantity of blood from a patient with abdominal inflamma- tion, whose pulse did not reach the ordinary average frequency. In this case it was discovered afterwards that the ordinary quickness of pulse did not exceed sixty. Again, in the early stages of inflammation of the brain, the pulse seldom exceeds the natural standard, or is often even slower than usual, though it is generally observed to rise after bloodletting. The state of the local symptoms, therefore, is always a more safe crite- rion of the propriety of adopting active measures in inflammatory diseases than either the pulse or the general symptoms. 4. The appearance of the blood, when drawn, will frequently, in conjunction with other symp- toms, afford assistance as to the propriety of further abstraction. We do not think that the buffy coat, which has been regarded as a test of the presence of inflammation, should much influence the decision, as we find it occasionally wanting in inflammatory diseases. When, however, the blood on cooling exhibits the buffy coat, more especially when it is tenacious, the crassamentum firm, the pulse wiry or corded, and the pain un- subdued, it may be confidently predicted that the flammation is not subdued, and therefore more blood may be safely and advantageously taken. In the advanced stages of inflammation in persons whose powers are feeble, or when blood has been repeatedly abstracted, though the blood still exhi- bits the buffy coat, it is soft, and the coagulum loose. It appears, indeed, from the experiments of Prevost and Dumas, that when blood has been repeatedly abstracted, the red particles are dimin- ished in number; and were we to judge from the gradual diminution of the fibrine, it would seem that this principle is also lessened. This appear- ance of the blood shows that inflammation still exists, but that no advantage will be derived from further bloodletting. 5. A most important circumstance, which it is necessary to consider in the treatment of inflam- mation by bloodletting, is the period or duration of the disease. If the sy mptoms have been allowed to go on without any effort being made to subdue them, it is vain to expect the same results from the vigorous use of the lancet, as in the more early stage. Profuse bleeding has less influence on the local disease than on the general powers ; so that when inflammatory disease has slowly but steadily increased in an enfeebled habit, while at the same time the insidious approach of the symp- toms has been overlooked, the patient has a better chance from the judicious employment of modified antiphlogistic measures, of which a moderate bleeding may often form part. 6. It is almost unnecessary to state that the quantity of blood extracted in inflammation must, with other circumstances, have reference to the age of the individual. The diseases of infancy generally of the inflammatory kind; but it is r difficult to open a vein in infants. In such cases one or two leeches may be applied to the back of the hand or foot, and the bleeding after- are very wards encouraged by warm fomentations, or im- mersing the limb in tepid water. In the older infant, the number of leeches must be increased according to age. In some instances the leeches may be applied to the neighbourhood of the in- flamed organ; as by this mode of abstracting blood the local symptoms are not only more speed- ily arrested, but the general symptoms, with which every form of acute infantile disorder is almost invariably accompanied, are reduced. In childhood, greater advantage is often derived from venesection than in infancy; indeed the ac- tive forms of disease at this period of life are too often overlooked, the practitioner being satisfied with the local detraction of blood, while the bolder measure of venesection is required. It is true that blood is less easily drawn from the veins of the arm in children, but there is ample resource in the jugular, from which any quantity may be taken by a little adroitness on the part of the surgeon. The period of life when bloodletting is most required, and produces the most decided effects, is from manhood to middle age, when the powers are vigorous. After the middle age the powers decline, and the system is less able to contend with active disease, and the remedies necessary for its removal. While at the one period bloodletting may be car- ried fearlessly to the required extent, the practi- tioner must be more cautious when he is contend- ing with acute disease at an advanced age. 7. Physicians often derive useful information from observing the prevailing type of diseases. In idiopathic fevers more especially, this knowledge is almost indispensable for the safe conduct of the case. The same observation is applicable to the treatment of inflammation, in which there is often a material difference in the intensity of activity of local and constitutional symptoms, as well as of the power of the system to bear large losses of blood. The most palpable illustration of this is the different types of fever which accompany puerperal or child-bed fever, which is well known to require different treatment according to the pre- vailing character of the epidemic. 7. Much has been said about the influence of temperament in determining the treatment of in- flammatory diseases. The diseases of the san- guine temperament have been supposed to be of a more acute character, and to require a more active mode of treatment, than the melancholic or ner- vous. Greater weight, we apprehend, has been given to this notion than experience has warranted. Were the acute disorders of those of the melan- cholic temperament to be treated on this idea, serious errors would undoubtedly be often com- mitted. The fact seems to be that persons of the sanguine temperament are more predisposed in general to acute or inflammatory diseases, and consequently are more frequently the subjects of them than those of the melancholic, bilious, or nervous; but when inflammation has ance taken place, there is less difference as to its intensity, from the constitution or temperament of the indi- vidual, than has been usually imagined. [Recent researches into the constitution of the blood in various diseases have led M. Andral to infer, (Hematologic Pathologique, p. 123, Paris, 1843, or Amer. edit, by Drs. J. F. Meigs and A. J Stille, Philad. 1844.) that when once the blood 790 INFLAM has commenced producing an excess of fibrin, a certain time is required before this disposition is exhausted ; or in other words, the process, he thinks, is self-limited. Still, he is of opinion, that at the earliest period, when the solid is merely congested, and the fibrin of the blood is scarcely above its healthy proportion, the advancement of the disease may be arrested by bloodletting, and in certain cases it may be cut short. The arrest of the blood in the veins of the ex- tremities, hxmostasis, has been employed by Pro- fessor Nathan R. Smith, and by Dr. T. H. Buck- ler of Baltimore, (Maryland Medical and Sur- gical Journal, March, 1843,) as a sedative agent to relieve inflammatory engorgement in parenchy- matous organs, or inflammations of membranous tissues; to remove hyperaemia, and to restore the balance of the circulation ; as well as to prevent hemorrhage resulting from either rupture of ves- sels, transudation of blood, or from wounds inflicted upon blood-vessels. If a bandage be applied around a limb sufficiently tight to arrest the venous circu- lation completely, and at the same time allow the arteries to pulsate, the blood within the distended veins is cut off, as it were, from the general circu- lation ; a depletory effect is, in this manner, in- duced ; and if the arrest of the venous circulation be practised on all the extremities at once, the skin becomes relaxed; the force of the action of the heart and arteries is weakened ; and if the liga- tures be applied when the heart and arteries have been deprived of a portion of the ordinary amount of blood, owing either to anaemia or to bleeding, so that the vessels are partially empty, it is found, according to Dr. Buckler, that the exhalants of the skin pour out the most copious perspiration ; that the patient complains of a light feeling about the head, of weakness, and sickness of stomach; and if the carotids be pressed upon, they are dis- covered to be scarcely pulsating, and all the phe- nomena of syncope are found to take place. Possessed of such powers, haemostasis may be found a valuable agent in the treatment of the phlegmasiae more especially; and it has been urged upon the notice of the profession by Dr. Buckler. " Haemostasis," he thus forcibly ex- presses himself, " accomplishes what no other known remedy is capable of doing. It puts syn- cope under our control, both as to duration and degree. It is capable of exerting, under given conditions, a more powerful control over the circu- lation than the lancet, antimony, or digitalis; and controls the heart's action without exhausting the vital forces, or giving rise to the ill consequences which the protracted use of most of the sedative agents is likely to do. And, finally, haemostasis, in the hands of judicious practitioners, must prove the means of saving an incalculable amount of blood,—to say nothing of the incredible benefits which would be derived from its adoption by those Sangrados of our art, who bleed empirically in all conditions, and who, in many cases, like the fabled vampire, suck the living current until the vital powers are spent."] We have been considering hitherto those cases ot inflammation in the treatment of which gene- ral bloodletting is required. It is not, however, always necessary to take blood from the system, he topical abstraction being often sufficient to ac- IATION. complish the cure. Cases also frequently occur in which the loss of even a small quantity of blood from the system is followed by considerable incon- venience and exhaustion, though the same amount of blood abstracted locally is followed by excellent effects. This mode of bloodletting may, therefore, be employed 1, when the amount of inflammation is trivial; 2, when the powers of the patient are too weak to admit of general bloodletting; 3, when the active stage of inflammation has been allowed to pass over, and is therefore little under the control of general bloodletting; 4, as an aux- iliary to general bloodletting, when further loss of blood from the system is deemed unnecessary. Moreover the local abstraction of blood may be often so managed as to secure the advantage of a general bleeding. Thus, when blood is taken from the temporal artery or from the jugular vein in diseases of the brain, the quantity may be so re- gulated as to obtain this double advantage: hence the preference given to this mode of bloodletting in acute diseases of the brain. With regard to the mode of abstracting blood locally, cupping is preferable to leeching in all cases in which it can be employed. The blood is more rapidly abstracted, and the quantity more nicely regulated. There are regions of the body, however, to which cupping-glasses cannot be applied; under such circumstances re- course must be had to leeches in suitable numbers. Another powerful antiphlogistic measure in the treatment of inflammation is the exhibition of purgative medicines, which not only remove accu- mulated secretions, but, according to the class of purgatives employed, produce, by their action on the intestinal exhalants, a powerful derivation from the circulating system. Hence great advantage is derived from a combination of cathartics, which may be administered in suitable doses and at longer or shorter intervals, according to the indi- cation to be fulfilled. By active purging the general powers may be very much lowered ; so much so, indeed, that mild cases of inflammation often y ield to the exhibition of purgatives alone, though the more sure and effica- cious practice is to employ at the same time other antiphlogistic measures, more especially bloodlet- ting, general or local, according to circumstances. There is another principle on which the bene- ficial operation of cathartics may be explained, viz. that of revulsion. When a powerful medicine of this class is exhibited, a copious secretion from the surface of the alimentary canal takes place: the sudden removal of so much fluid from every part of the system not only lessens the quantity of liquids in the diseased as well as the healthy parts of the body, but in the general determination to the bowels, the irritation has been supposed to be diverted from the local inflammation to the in- testines. We apprehend, however, that the bene- fit derived from free purging in inflammation u more owing to the abstraction of fluid, than to the revulsion which may be induced. The employment of purgatives is more appli- cable to some forms of inflammation than to others. The circulation in the brain is readily affected by purgatives, as is evident from the pale- ness of the countenance, and the syncope induced INFLAMMATION, 791 by active cathartics. Hence in all cases of cere- bral congestion and inflammation, purging ought never (unless under special circumstances) to be omitted. In threatenings of relapse, the exhibition of purgatives often supersedes the necessity for local or general bloodletting ; and from the inti- mate sympathy which exists between the intes- tines and brain, the necessity of attending to the proper regulation of the bowels in the stage of convalescence from acute diseases of this organ must be apparent. In thoracic inflammation, purgatives form part of the antiphlogistic treatment. Experience, however, shows us that they are less efficacious in this than in some other forms of inflammatory disease ; and, therefore, when there is evidence of pulmonary inflammation, more reliance is to be placed on the general and topical abstraction of blood than on the exhibition of purgatives ; and when there is gastro-intestinal complication, they are to be rigidly withheld. Since the morbid states of the alimentary canal have been so thoroughly investigated, practitioners are more guarded in the exhibition of purgatives in the treatment of abdominal inflammation. It is necessary to sweep out the bowels once or twice by some active aperient in the commencement, except when the mucous membrane is the seat of inflammation. It is a great source of anxiety with many practitioners to procure the free action of the bowels in peritonitis, which ted the late Dr. Saunders to remark, in his lectures on peritonitis, that the best mode of opening the bowels is by the lancet; a practical precept in which we perfectly agree, as there can be no question of the mis- chievous effects arising from irritating the bowels by cathartics at a time when it is most important that every source of disturbance be averted. When the peritoneal inflammation is subdued, the bowels are readily opened by comparatively mild aperients: indeed, this soluble state of the bowels is a tolerably sure criterion of the sub- sidence of the peritonitis. Much harm is also often done by injudiciously irritating the bowels after the inflammatory symptoms have disappear- ed ; and we have many times traced the recurrence of enteritis to the constant irritation of the bowels by purgatives administered with the object of simply effecting their evacuation, which may be at all times ensured by emollient glysters, or a small quantity of castor-oil. If it be necessary to be cautious in the employ- ment of purgatives in peritonitis, it is more par- ticularly so in inflammation of the mucous mem- brane of the intestines, which is not only a very common primary disease, especially in children, but a frequent complication of other acute disor- ders. It is unnecessary, however, to do more than to allude to this subject in this place, as it has been already fully and ably discussed. (See En- teritis and Gastro-Enteritis.) Mercury is a remedy of considerable power in arresting inflammation, either in conjunction with bloodletting, or in cases in which the loss of blood is deemed inexpedient. The beneficial effect of this medicine is best exemplified in the treatment of iritis, in which disease its power of controlling inflammation and in preventing the effusion of lymph, or, when effused, of effecting its absorp- tion, are quite, perceptible. Another illustration of the powers of mercury in checking the progress of inflammation is observed in inflammation of the larynx and trachea, in which organs, from their delicacy of structure, serious consequences often arise when the inflammation is not speedily arrested. There can be little question that it exerts a similar influence over inflammation of internal parts, and appears to have a peculiar power in arresting or controlling the action of the capilla- ries, and of preventing those changes from taking place which are so destructive to the organization of inflamed tissues. In other instances, when the inflammation has assumed a chronic form, and consequently is little if at all under the influence of any form of bloodletting, mercury may be em- ployed with the most decided advantage. The quantity in which it is administered must depend on the violence of the inflammation and the organ that is affected. It is in some cases necessary to bring the system more rapidly under its influence than in others; for instance, in inflammation of the iris, the larynx, or of the trachea. Therefore, after general or local bleeding, two grains of calo- mel, or five of the hydrargyum cum creta may be given every alternate hour till there be some decided amendment in the symptoms. In dis- eases of less urgency, the same quantity may be given at more distant intervals, every four, six, or eight hours, according to circumstances. When the mercury produces purging, it must be com- bined with opium; or, if opium be improper, some of the ordinary astringents—catechu, kino, or chalk may be employed. Some physicians recommend much larger doses of mercury—ten, fifteen, or even twenty grains of calomel at once, and do not hesitate to repeat these enormous doses at short intervals. We confess we have never seen any case of inflammation which, if curable at all, resisted the more moderate doses we have advised. In the inflammatory diseases of hot climates, which run their course with frightful speed, the rapid introduction of mercury after venesection seems to be the only chance of saving life. In the acute diseases of temperate climates, however, most practitioners prefer the smaller doses, repeated at longer or shorter intervals according to circumstances. Though mercury is capable of arresting the progress of inflammation when exhibited alone, it is often more successful when combined with opium. This is more especially necessary when there is much suffering from pain. As a general principle, opium is inadmissible in inflammation, until the excitement has been re- duced. That it is a stimulant has been proved by most carefully-conducted experiments on the lower animals, as well as by observation of its effects on the human body both in health and disease. We have just adverted to the exhibition of calomel and opium in the treatment of inflamma- tion. The notice of the profession was, many years ago (1783), first directed to the efficacy of this combination in the treatment of inflammatory diseases by Dr. Robert Hamilton, of Lyme Regis. He acknowledged that the practice was first sug gested from the favourable accounts he had re ceived from a navy surgeon of the treatment oV r92 INFLAMMATION, hepatitis by mercury. He adopted the hint, and found the practice successful in the hepatic in- flammation which frequently accompanies the bilious, intermittent, and remittent fevers of this country. He soon, however, found it necessary to add opium to relieve pain, which happily most effectually answered that purpose. The success of this mode of treating hepatitis induced Dr. Hamilton to conclude, that it would prove equally so in every form of internal inflammation. He first prescribed calomel and opium in peripneu- mony, and was successful in a large proportion of cases, and under a variety of circumstances. The cases of pleuritis, enteritis, and child-bed fever, in which it was employed, also speedily vanished. The efficacy of this combination in arresting internal inflammation led to its employment in acute rheumatism and in gout; and Dr. Hamilton had the satisfaction of seeing these diseases also give way most readily under its use. The follow- ing is a summary of Dr. Hamilton's mode of pre- scribing it. After bleeding and evacuating the bowels, a pill containing from five to one grain of calomel and from one to a quarter of a grain of opium according to the age and powers of the pa- tient, was directed to be administered every six, eight, or twelve hours, according as the intensity of the inflammation and aspect of the disease required,—plentiful dilution with barley-water or any weak tepid beverage being at the same time enjoined. When there was much fever, with dry parched skin, tartar-emetic and sometimes cam- phor were added ; this combination had the effect of determining powerfully to the skin, and pro- moting the action of the kidneys and bowels. After three or four pills taken in the course of twenty-four hours, the symptoms were evidently relieved ; in other twenty-four, the disease gave way and soon terminated. If, however, there was no abatement of the inflammatory symptoms in the first twenty-four hours, more blood was ab- stracted, the calomel and opium given more fre- quently, and continued till the force of the disease was subdued. It was remarked that when the mercury induced much sweating and purging, the salivary glands did not become soon affected ; but it was not un- common to observe the patient greatly relieved, though the mercury did not affect the mouth, or produce any visible evacuation, except a slight increase of urine or insensible perspiration. The mercurial plan was almost invariably suc- cessful when employed early in the disease ; but when adopted in the later stages, its efficacy was more uncertain, though when the mercurial action could be induced on the salivary organs, the re- covery was more sure. Counter-irritation was at the same time adopted when necessary. With regard to the allegation that, as the calomel had been combined with other powerful medicines, the beneficial effects might with greater probability be ascribed to them than to the mer- cury, Dr. Hamilton states, that though he always regarded the opium as of the most essential service in relieving pain, and that the tartar-emetic and campho; have sometimes contributed to the cure, he haj often seen cases in which tartar-emetic, ?.amphor, and opium had been for some days em- ployed without affording the smallest relief; but on the addition of calomel, the symptoms gave way in a very short time ; the amendment seemed in many cases, indeed, to take place as the sali- vary glands became affected. (Duncan's Medical Commentaries, vol. ix.) Subsequent experience has amply confirmed fhe practical deductions of Dr. Hamilton as to the efficacy of calomel and opium in the treatment of inflammatory diseases. This combination forms an admirable auxiliary to the use of the lancet in internal inflammation ; and when the period for bloodletting has passed over, gives the patient the best chance of recovery. Neither this nor any other remedy, however, must be permitted to interfere with bloodletting in active inflammation, Mercury may assist in con- trolling inflammation and render less bleeding necessary, but is in itself inadequate to subdue it. It is, in the first place, necessary to break the force of the disease by venesection, and afterwards to exhibit mercury, care being taken not to push this remedy too far, as it has been observed that its specific effects take place very readily when large quantities of blood have been abstracted. When the inflammation has passed into the chronic stage, which precedes alteration of struc- ture, mercury is the best, often the only mode of removing it. Many physicians consider that in active inflam- mation the administration of opium alone, after a full bleeding, is followed by the most happy effects, especially in irritable habits. We have often in our practice, as well as in that of others, witnessed its efficacy. After bleeding the patient to approaching syncope, having regard to the effect rather than to the quantity abstracted, the reaction which generally follows a large bleeding may often be prevented by two grains of solid opium, or a draught containing one grain of pure acetate or muriate of morphia, administered when the faintness is disappearing. The heart's action is thus controlled, while the nervous system is tranquillized; so that the patient enjoys an inter- val of refreshing sleep, from which he often awakes with a soft skin and freedom from pain. In many cases this practice, with a moderate cathartic, is sufficient to arrest the inflammatory disease. If, however, after an interval of three or four hours, the symptoms return, with hot skin and wiry pulse, the bloodletting must be repeated, and two grains of opium with three or four of calomel given as before. It may in these in- stances be advisable to administer afterwards a few doses of this combination in smaller quanti- ties—two grains of calomel with half a grain of opium at intervals of three or four hours. This practice has been strongly recommended by the late Dr. Armstrong who emphatically said of Dr. Hamilton's treatment, that " it deserves to be written in tetters of gold, on account of its great practical utility." In a paper written by this physician in the Transactions of the Asso- ciated Apothecaries, entitled " On the Utility of Opium in certain Inflammatory Disorders," he recommends the more early and free use of opium, evidently considering that the great advantage arises from the administration of the opium alone. He advises, after bleeding to approaching syncope, three grains at least of good opium, to be given INFLAMMATION. 793 in the form of a soft pill; and that strict quietude be enjoined, in order if possible to procure steep. In some instances, Dr. Armstrong found a smaller quantity of solid opium sufficient; but the dose was made equal by a portion of laudanum, which in highly irritable habits is preferable, because the sedative influence of the opium is thus more speedily procured. On some occasions, where a great quantity of blood has been lost in irritable persons, a large dose has been given after vene- section, never however beyond five grains of solid opium, nor a drachm of the tincture at once. The effects of opium thus administered, ac- cording to Dr. Armstrong, are to prevent a sub- sequent increase in the force or frequency of the heart's action, and a recurrence of pain, while it induces a tendency to quiet sleep and copious general perspiration. Dr. Stokes has recently brought this subject before the profession in an excellent practical paper* in the first volume of the Dublin Medical Journal, written chiefly with the view of pointing out the advantage to be derived from the adminis- tration of opium in peritonitis, occurring under circumstances where bloodletting cannot be em- ployed. The cases alluded to are—1. peritonitis arising from the escape of faecal matters into the peritoneal cavity, through a perforating ulcer of the intestine ; 2. peritonitis arising from the burst- ing of an abscess into the serous cavity, or from rupture of the intestine, induced by external vio- lence ; 3. peritonitis occurring after the operation of paracentesis in delicate subjects ; 4. low typhoid peritonitis occurring after delivery. In these cases of peritonitis, the rapid sinking of the vital powers renders bloodletting and the usual treatment in common peritonitis inadmis- sible ; the indications are to support the strength o.f the patient as far as circumstances permit, and afterwards to endeavour to prevent the further effusion in the peritoneal cavity, by inducing organization and adhesions of the effused lymph. For this latter purpose, Dr. Stokes thinks opium in large doses pre-eminently calculated. This practice was first suggested from the successful treatment, by liberal doses of opium, of two cases of peritonitis after tapping, and of another from the effusion of purulent matter into the cavity of the belly. Dr. Stokes gives several cases in illus- tration of this plan of treatment. In the first he was unsuccessful, which he ascribes to the exhi- bition of purgatives, from his mind being warped by an early and unfounded prejudice as to the necessity of evacuations from the bowels. In another, after a moderate leeching, a grain of solid opium was given every hour without indu- cing the slightest affection of the brain, though the patient took, in the course of eight days, one hundred and five grains of opium, exclusive of opiate injections, administered with the object of checking a severe diarrhcea which set in for three or four days. Dr. Stokes has subsequently treated cases of common peritonitis with opium, where bleeding was inadmissible, and has had no reason to change * Clinica. reservations on the Exhibition of Opium in larLe doses in certain eases of disease, by William Stokes8, MU one of the Physicians to the Meath Hos- pital. Vor. II—10t 3b his high opinion of its powers; and further pro- poses it as a remedy in cases of rupture of the bladder and uterus, in peritonit:s after paracentesis, or succeeding to the operation for strangulated hernia, and in pneumo-thorax from pulmonary fistula. The favourable results of the treatment of in- flammation of the serous membranes by opium, has led Dr. Stokes to employ it in the same con- dition of the mucous membrane, and under similar depressing circumstances. In a very interesting case of severe gastric fever, in which the abdomi- nal symptoms ultimately became alarming, from the supervention of severe diarrhcea, which every day threatened death from exhaustion, a grain of opium was ordered every hour, when the patient seemed in articulo mortis: this was continued for the first twelve hours without inconvenience, but with the effect of procuring refreshing sleep. Next day the remedy was repeated in the same dose every second hour; and from this time the improvement was rapid, and ended in final re- covery. Liberal doses of opium seem also to have had an excellent effect in a case of phagedenic ulcera- tion of the throat. We have seen the most asto- nishing results from large doses of opium in sloughing phagedenic ulceration, occurring in connection with syphilitic symptoms in broken-up constitutions, such as is frequently observed in the lowest order of prostitutes. Dr. Stokes has drawn the following conclusions on this subject : — 1. that in cases of recent in- flammation of serous and mucous membranes, where depletion by bloodletting or o her anti- phlogistic measures is inadmissi'>!r, and the system in a state of collapse, the exhibition of opium has a powerful effect in controlling the disease; 2. that under these circum^thiices the remedy may be given in very large doses, with great benefit and safety ; 3. that its > ill ct, then, is to raise the powers of life and reinove the local disease ; 4. that the poisonous effects of opium are rarely observed in these cases; the collapse and debility of the patient appearing to cause a tole- rance of the remedy. Acute pain may sometimes render the exhibi- tion of opium necessary, even in the acute stage of inflammation. When the pain is so excessively violent as to constitute the most prominent symp- tom of the disease, and has resisted full depletion and other active remedies, its continuance tends greatly to aggravate the inflammatory action, and may even induce a fatal prostration of the vital powers. Under these circumstances, the subjuga- tion of the pain becomes the most pressing indi cation, and this is to be effectually accomplished by the administration of opium in doses of from one to two and even three grains. This plan of treatment has proved eminently beneficial in severe cases of peritonitis, of sciatica and acute rheuma- tism affecting the heart. In those cases attenued with extreme pain, two grains of opium may be given at first, and one grain every hour until the pain has subsided. It is necessary that the dose should be increased in proportion to the violence of the pain, and that the remedy be cautiously continued, until it has made a decided impression upon the nervous system, in order to procure th* f94 INFLAMMATION. relief intended. It is well known that very large doses of opium are well tolerated when the ner- vous svstem is much excited : but to guard against any injurious effect of this remedy on the brain, a cold lotion may be applied to the forehead, or if necessary to the whole scalp. There is another condition of the system in which opium is extremely beneficial, viz. in ex- haustion from loss of blood. There are some in- dividuals who do not bear bloodletting well even when it is necessary ; in other cases, blood may be abstracted under mistaken views of the nature of the disease, or it may happen that more blood has been taken away than the symptoms either warranted or required. In those cases of exhaustion arising from the effects of loss of blood, opium, with nourishment and cordials, is the best plan of restoring the patient. There are some inflammatory diseases in which opium cannot with advantage be prescribed. In inflammation of the brain, it is a doubtful remedy even after the more active symptoms have been reduced. Indeed, in all acute diseases in which the brain is primarily or secondarily affected, the exhibition of opium requires great circumspection. It not unfrequently happens that when the more urgent symptoms of cerebritis have been overcome, the path-nt continues restless and wakeful, with a cool skin, soft clean tongue, and rapid soft pulse. These symptoms are often decidedly ameliorated by a full dose of opium. In inflammation of the mucous membranes, which generally terminates by an increased secretion, opium, from its tendency to check this salutary process, should be withheld, unless special circumstances arise to render its exhibition imperative. Of the other remedies of this class, our indivi- dual experience does not warrant us to say much in terms of praise. Digitalis, which was formerly so much extolled for its anti-inflammatory powers, is now rapidly falling into disuse. Though it certainly exerts a peculiar effect on the heart's action, its uncertainty and the length of time which elapses before it produces any decided impression, have tended much to impair the confidence which wa"> at one time reposed in its efficacy in controlling inflam- mation. We have seen it given in very large doses (ten drops every half hour), and though it lowered the frequency of the circulation, it seemed in many instances to exert scarcely any control over the local disease. From what we have per- sonally observed, therefore, we should not feel in- clined to recommend the employment of digitalis as an anti-inflammatory remedy. Colchicum is certainly efficacious in checking gouty and rheumatic inflammation. Some years ago this remedy was much used as a contro-stim- ulant in visceral inflammation, and was by some imagined to be little inferior in power to bloodlet- ting. These sanguine expectations, however, have not been realized, and at present the admin- istration of colchicum is almost entirely confined to the specific inflammation of gout and rheuma- tism, in which cases, we have prescribed a pill containing the acetic extract of colchicum (gr. i.) and extract of hyoscyamus (gr. iii.) every eight Hours, with excellent effects. Among the remedies resorted to with the view of resolving inflammation, antimony has always been held in high estimation. Since its first in- troduction by Paracelsus, antimony has enjoyed more varied reputation in the treatment of acute diseases than any medicine in the Materia Medica, After it had been declared a most valuable remedy in many formidable disorders, it was denounced as a poisonous medicine, and interdicted under very severe penalties by the French Parliament in 1566. In later times, however, it has been again brought into use, and within the last century has been prescribed as a most powerful antidote to almost every form of febrile disease. Various forms and preparations of this mineral have been from time to time introduced, but after repeated trials of theii efficacy only two have been retained. These are the antimonial powder, pulvis antimonialis of the London Pharmacopoeia, and the tartrate of anti- mony and potassa. The virtue of the antimonial powder is not only doubtful, but according to the experience of some physicians it appears to be positively inert, 130 grains having been given by Dr. Elliotson three times a-day without producing even nausea. Dr. Thomson has satisfied himself from experimental investigations that the compo- sition of the antimonial powder, and that of James's powder, which the former was intended to imitate, are totally dissimilar. This excellent pharmaceutical chemist states as the reason, that the antimony in James's powder is in the form of a soluble protoxide, while that in the pulvis anti- monialis of the Pharmacopoeia is in the state of an insoluble peroxide ,- and from the ascertained fact that the more soluble the salts of antimony are, the more certain and powerful is their effect on the living body, the cause of the inertness of the one, and the more certain efficiency of the other, is thus explained. Sometimes the skin becomes moistened, or the bowels gently purged by small doses (two or three grains) of James's powder given every four or six hours. More generally, however, it does not pro- duce any sensible evacuation, the pulse becoming softer, and the skin more cool under its use. It is more efficacious when combined with calomel or blue pill, or occasionally with opium, when there is pain. Thus, after general or local bleed- ing, a pill containing two grains of calomel or blue pill, the same quantity of James's powder, and a quarter or half a grain of opium, may be given every three or four hours with decidedly good effects, every alternate pill being followed by a saline aperient, should the state of the bowels require it. The tartrate of antimony and potassa (tartar- emetic) is the preparation in most general use. It is seldom exhibited as an emetic, as the action of vomiting in inflammatory diseases is deemed pre- judicial, at all events until the general excitement is reduced by bloodletting. Stohl, however, recommended emetics in pneu- monia. We are also told by Laennec, that Riviere vomited his patients in pneumonia with tartar- emetic daily, or every second day ; and that Du- mangin, physician to La Charite, followed this plan, and though he seldom combined bloodletting with it, that his practice was quite as successful as that of Corvisart, who bled much in that dis- INFLAMMATION. 795 ease. Laennec concludes, that in these cases, the good effects of the tartar-emetic are to be ascribed to the derivation exerted on the intestinal canal. This mode of treatment still prevails in many parts of the continent, especially in France, as appears from memoirs which have recently ema- nated from the French press.* From the well known effects of continued nau- sea in depressing the heart's action, nauseating doses of tartar-emetic are frequently administered in inflammation, in conjunction with other anti- phlogistic measures. For this purpose, a quarter of a grain of tartar emetic may be given in solu- tion every two or three hours. The first two or three doses generally produce vomiting, but after- wards constant sickness is the only effect observed. By this mode of administration, the sub-acute forms of inflammation are often resolved, and in feeble habits, when the disease is little under the control of general or local bleeding, this mode of administering antimony is often followed by the most beneficial effects. The more slow or insi- dious forms of pulmonary inflammation, or the progress of tubercular disease may also often be checked by administering antimony in nauseating doses. In still more minute quantities, (one-sixth or one-eighth of a grain every three hours,) tartar- emetic acts as a diaphoretic. This mode of ad- ministering antimony in inflammatory diseases was extolled by Cullen, and his example was fol- lowed by bis pupils. It is seldom, however, pre- scribed alone, but in combination with other remedies of this class, more generally the saline diaphoretics. Antimony has been at times exhibited in very large doses as an anti-inflammatory remedy, more particularly in Italy ; indeed the large doses in which it has been administered by some conti- nental physicians so astonished British physicians, that the accounts inserted in the foreign journals were at first discredited by many, while others supposed that there was a material difference in the chemical composition of the tartar-emetic. It has, however, been proved by chemical analysis that there is no essential difference between the Italian and British preparations, besides that the formula given in the respective pharmacopoeias is nearly alike. The practice of giving large doses of tartar- emetic was revived in Italy by Rasori, who, after embracing and widely disseminating the doctrines of Brown, had an opportunity of witnessing their fallacy in the treatment of an epidemic fever, which broke out at Genoa in the years 1799 and 1800. The application of the Brunonian principles to the management of this epidemic was attended with such fatal results, as to induce Rasori to change entirely his mode of treatment, and to substitute antiphlogistic measures. The practice of contro-stimulus which was pursued consisted in bloodletting, followed by large doses of tartar- emetic, four, six, eight, or more grains being given in the course of the day in any agreeable vehicle. The suc-ess of this treatment was as great as the previous plan had been fatal, and had an impor- tant influence in subverting tlwuntenable theories * Memoire sur les fluxions de poitrine, par Louis Va- lentin, M.D. Clinique Med. de l'Hc'.el Dieu de Rouen. of Brown in the north of Italy. It also induced Rasori to employ the tartar-emetic in other acute diseases, more particularly in peripneumony. From the memoir which he published on this subject, (the translation of which afterwards ap- peared in the Archives Gen. de Med. for 1824,) it appears that after one or more bleedings, or without this evacuation, according to circum- stances, he prescribed twelve grains of tartar- emetic at intervals daily, which was repeated du- ring the night. If the disease had made conside- rable progress, he began with twenty or thirty grains, increasing the dose daily till one or even several drachms were taken in the course of twenty- four hours. The result of this practice in the hands of Rasori was encouraging. Of eight hun- dren and thirty-two cases of pneumonia treated by the tartar-emetic, one hundred and seventy- three only died. It was subsequently prescribed by most of the Italian physicians, some of whom published the results, from which it appears to have been even more successful in their hands. Laennec was induced from these flattering ac- counts to make a trial of it, but at first restricted it to cases of apoplexy. Having occasion some time afterwards, however, to attend two cases of peripneumony in which he thought it inexpedient to resort to venesection, he determined to make trial of the tartar-emetic; both patients rapidly and unexpectedly recovered, so that he was en- couraged to give it in other cases. Laennec did not prescribe it in the large doses recommended by Rasori; indeed his mode of administration is so judicious that it has been generally adopted. The following is a summary of the manner in which Laennec employed the tartar-emetic in the treatment of pneumonia. As soon as the exist- ence of the disease was recognised, and the pa- tient was able to bear venesection, blood was first taken from the arm, unless in cachectic or debili- tated subjects, in which it was deemed advisable to dispense with this evacuation. Immediately after bleeding, one grain of tartar-emetic dissolved in infusion of orange-leaf was directed to be taken and repeated every second hour for six times, after which the patient was allowed to remain quiet for seven or eight hours, if the symptoms were not urgent, or the patient disposed to sleep. If the inflammation had already made considerable pro- gress, the same dose was continued uninteruptedly until there was decided amendment. It was seldom necessary to give a large quan- tity of the tartar-emetic, though in extreme cases as much as a grain and a half, two grains, or two grains and a half, were prescribed at the same in- tervals. Many patients were found to bear these doses of the tartar-emetic without either vomiting or purging being induced: more generally, how- ever, it excited vomiting or purging for the first day, but this effect soon passed off, and the tole- rance (power of bearing the remedy) became esta- blished often within twenty-four hours from the time of its first administration. It was even occa- sionally necessary afterwards to prescribe gentle aperients to keep the bowels open. It was ob- served also that the tartar-emetic was most eifici cious when it did not produce any sensible evacu- ation; and that, although severe vomiting and purging are by no means desirable, the cure of the m INFLAMMATION. inflammation was often very satisfactory, when the stomach and bowels were much irritated by the remedy. This may often be checked by com- bining with the tartar-emetic a small quantity of opium. Laennec recommends the addition of one or two ounces of syrup of poppy to the six doses to be taken in twenty-four hours. We have found the irritation very much allayed by adding the dose of the tartar-emetic to the common efferves- cing mixture, to which a few drops of laudanum may, if necessary, be added. At the end of a few hours, seldom beyond twenty-four, such a decided improvement in the symptoms takes place, that both the patient and the practitioner are encouraged to persevere with the medicine till resolution of the inflammation be effected, when the medicine should be withdrawn gradually by giving it at more distant intervals. It is singular how patients become accustomed to tartar-emetic, when restored to convalescence. Laennec states that when they are taking their usual allowance of food, nine, twelve, or even eighteen grains of the emetic tartar may be taken daily without their being at all aware of any me- dicine being given. This is in opposition to the opinion of Rasori, who considers the tolerance to be owing to the excess of stimulus which exists in the system and produces the disease; consequently, whenever this is destroyed by the contro-stimulant effect of the tartar-emetic, the tolerance, were this theory correct, should cease, which is certainly in direct opposition to our own experience. We have observed in some cases of pneumonia treated by tartar-emetic, that when the patient could bear a grain every second hour, twenty drops of the anti- monial solution produced copious vomiting, show- ing that this medicine is less emetic in large than in small doses. Laennec has detailed shortly the several dis- eases in which the emetic tartar has been found successful in his hands. These were, 1. pulmo- nary inflammation; 2. inflammation of serous membranes, though he did not appear to place great value on its powers in this class of diseases; 3. hydrocephalus ; 4. phlebitis; 5. acute chorea; 6. articular rheumatism; 7. severe ophthalmia; 8. apoplexy ; 9. acute dropsy. No satisfactory explanation has been offered of the mode in which tartar-emetic affects the reso- lution of inflammation. It appears not only to check the progress of inflammation, but to cause the absorption of inflammatory effusions. Laennec affirmed that he had observed, in a case of articu- lar rheumatism, well marked fluctuation of the knee-joint disappear in the course of six hours by the use of this medicine. The value of large doses of tartar-emetic, as a powerful anti-inflamrnatory remedy, is now esta- blished by the united experience of some of the most distinguished British and continental prac- titioners. In our hands, we have seen the most surprising effects produced by it when administered according to the mode proposed by Laennec. We have never found it necessary to exceed twenty grain? in twenty-four hours, and when the remedy is at all likely to be beneficial, this quantity need not be exceeded. There are few cases of inflam- matory disease in the early stage, which do not yield to prompt bleeding, followed by a few doses of tartar-emetic; and in cases which have been so long neglected that the period of bloodletting has been allowed to pass over, it affords the best chance of grappling successfully with the disease. These are the general measures on which our chief reliance should be placed for the removal of inflammation. There are other points of minor importance to be attended to; for example, the thirst is to be allayed by cooling sub-acid drinks, containing lemon-juice, cream of tartar, or a solu- tion of the pulp of tamarinds. It is also some- times expedient to endeavour to diminish feverish heat by the free admission of cool air, by light bed-clothes, and by administering refrigerants, such as citrate of potash, acetate of ammonia, or nitre. These measures, however, are not to divert the attention from the more active remedies. The propriety also of removing every source of irritation is obvious; npt only is the exciting cause to be ascertained, and, if practicable, re- moved, but excitement of every kind must be withdrawn ; hence in visceral inflammation the greatest quietude of body and mind is indispensa- ble. When, therefore, the inflammation is seated in an external part, all use of the organ must be avoided, and such position adopted, as will be least likely to favour the circulation of the blood towards the inflamed part. Every kind of food which has a tendency to excite the circulation must be avoided; the very mildest farinaceous aliment being best adapted, and even this should be given in small quantities at stated intervals. We shall next shortly allude to the local treat- ment of inflammation. In all diseases attended with excitement, the free application of cold is decidedly beneficial. In inflammation of the brain, after depletion, the application of cold evaporating lotions, or bladders filled with pounded ice, not only reduces the morbid heat of the scalp, but diminishes the vas- cular action in the brain. The most powerful mode of applying cold to the head is the cold dash, which we regard as little inferior to blood- letting itself; and when the general powers are too weak to render the abstraction of blood to an adequate extent expedient, it is the most effectual mode of arresting the inflammatory action. In the subacute or chronic form of inflamma- tion of the lung, more particularly in that slow insidious form which attends the formation or pro- gress of tubercles, the local application of cold tends materially to check the progress of tubercu- lar disease. For this purpose the chest is to be sponged daily with vinegar and water, (at first tepid, and afterwards cooled down to the natural temperature,) and after being rapidly dried, the skin should be well rubbed with a coarse towel or flannel. This mode of applying cold has also the advantage of removing or diminishing the sus- ceptibility to cold, which renders the consumptive invalid so liable to returns of the inflammation. In inflammation of the abdomen, cold applications have been recommended by some practitioners. Some years ago Dr. Sutton strongly advocated this practice in peritoneal inflammation, and de- tailed several interesting cases in which the local application of cold was decidedly beneficial. From Dr. Sutton's observations, this practice appears to INFLAMMATION. 797 be peculiarly adapted to the chronic stage of peri- tonitis, when the symptoms are not such as to require bloodletting. (Tracts on Delirium Tre- mens, on Peritonitis, &c. by Thomas Sutton, M.D. 1813.) In external inflammation, the application of cold lotions forms an essential part of the anti- phlogistic measures. For this purpose a solution of acetate of lead, or a lotion consisting of equal parts of the acetate of ammonia, alcohol, and water, may be employed. These may be used cold or tepid, according to the feelings of the pa- tient. Warm applications are often very beneficial in inflammation. The warm bath, by producing a powerful determination of blood to the external parts, is often employed with great advantage, more especially in inflammation of the abdominal cavity. For this purpose the temperature of the water should not be too high, (not exceeding 98°,) a greater degree of heat proving a stimulus, and thus increasing the inflammatory action. The partial application of heat in the form of- fomentations is often a powerful mode of reducing inflammatory action, and at the same time of re- lieving pain. We have an illustration of this in the beneficial effects of the vapour arising from warm water, or the decoction of poppy or hyoscy- amus in ophthalmia, and in various forms of ex- ternal inflammation. Warm fomentations pro- perly applied often prove valuable applications also in internal inflammation. We have often observed excellent effects from them in pulmonary inflammation after general or topical bleeding, and in abdominal inflammation this practice is so beneficial that it is seldom if ever omitted. The different forms of counter-irritation are employed in certain stages of inflammation with great advantage, after the activity of the symp- toms has been subdued. When this has been ac- complished, should there be pain, the application of a sinapism or blister to the neighbourhood of the inflamed organ will frequently remove it, and when the inflammation has passed into the chronic form, the repeated application of blisters is de- cidedly beneficial. Great care, however, should be taken that local stimulants be not applied until the active stage of the disease has been overcome. The principles on which the application of counter- irritants should be employed have been so fully discussed in the articles Counter-irritation and Derivation, that it is unnecessary in this place to go more into detail. We may, however, just advert to the practice of applying blisters when inflammation has receded from a part it had just occupied, and fixed on another organ, as happens now and then in gout and rheumatism. It has been recommended to apply a blister near the seat of the former disease with the view of recalling the inflammation, but we agree with Mr. Lawrence, that it is better to attack the inflam- mation vigorously in its new quarters, than to attempt to entice it back to its old seat. It is scarcely necessary to state, that in deter- mining the measures which may be necessary for the treatment of inflammation, we must bear in \iew the particular circumstances with which it is accompanied, or which may arise in its progress. For example, we are to consider not only its duration, and degree or amount, but the age and constitutional powers of the individual, and the effect of such measures as may have been adopted. When inflammation occurs in a feeble or exhausted habit, (and the local symptoms may in such cases be intense,) the treatment must be less active. Perhaps a small bleeding may be hazarded, but in genera] it will be more safe to trust to local bloodletting, with mercury and opium. It is often necessary in such cases to adopt local antiphlogistic treatment, and at the same time to give general support by anima! nourishment. Even wine may be occasionally required. There is another point of great practical im- portance connected with the treatment of inflam- mation. We frequently observe, after the employ- ment of active measures, that the symptoms though much modified, continue; the general symptoms may even be entirely removed, but the local disease is still perceptible; a degree of passive inflammation or local congestion remains, which a further extension of bleeding or purging infallibly aggravates. This is often observed in ophthal- mia, and did not escape the observation of Hunter. In other instances the measures adopted produce exhaustion accompanied with morbid irritability, which it is often exceedingly difficult to distinguish from inflammation. Both the local and general symptoms will, however, afford some assistance. | The pulse, though quick, will be found soft and compressible, the skin cool, and there is little if any thirst. The local symptoms are slight; then is often very little pain, and when there is, it i. transient. What is to be done under these cir cumstances? Stimuli may reproduce the inflamma tion; bleeding and other depleting measures will aggravate the symptoms. It is most prudent in these cases to try cautiously fluid nourishment, i with a little wine in sago or arrow-root; and ii' the state of the local symptoms admit of local de- traction of blood, a few leeches may be from time to time applied. In short, a combination of treat- ment answers best. In the treatment of congestions of blood — a subject of great importance, though involved in obscurity—we agree with the precepts laid down by Dr. Barlow. If the congestion arise in a ple- thoric habit, it is evident that general antiphlogis- tic measures, more especially bleeding, purging, and abstemious diet must be resorted to. This plan, however, must not be carried too far; it is sufficient to take off the pressure from the circu- lation in order to overcome the plethora. Over- bleeding, from the reaction which follows, and the weakness it induces, brings on this very state. When the local congestion is unaccompanied with general fulness, or when it is the result of irritation, local depletion is to be adopted in pre- ference to the general measures, which are indis- pensable when plethora exists: indeed, as Dr. Barlow has well remarked, general depletion is not only unnecessary but injurious, enfeebling the system, and weakening those efforts by which the congestion would be naturally relieved. (See Con gestion of Blood.) The other measures which in congestive affec- tions may be employed in conjunction with blooa- ! letting, or alone when this evacuation nay be 798 INFLAMMATION. dispensed with, are mild purgatives, diaphoretics, warm bathing, counter-irritation, and low diet. These several measures must be varied, and re- peated more or less frequently according to cir- cumstances. Congestive affections, both of an acute and chronic character, are not unfrequently combined with general debility; and there are cases in which a mixed plan of treatment is often indicated, and the management of which requires generally much tact and caution. The general debility is sometimes the primary cause of the acuteness and persistence of the congestion ; and if such active antiphlogistic remedies be used as increase the. general debility, they will inevitably have the effect of aggravating the local complaint. While, therefore, it may be advisable, in such cases, to keep the local congestion in check by small topi- cal bleedings, counter-irritation, fomentations, poultices, &c. it is often necessary to strengthen the constitution by the use of tonics, generous diet, and change of air. In many cases of chronic congestions in which the blood-vessels are relaxed, the resolution of the congestion is often greatly favoured by the exhibi- tion of tonics and stimulants. We may mention, for instance, the good effects of various tonics in chronic catarrhal affections, and in some other chronic pulmonary diseases. In cases of habitual determination of blood, and of a tendency to attacks of congestion of one particular organ, such as the brain, lungs, &c. bleeding by revulsion (or at a remote distance from the organ affected) occasionally repeated, together with great attention to the regulation of diet, and ' the general management of the system, is found more effectual than depletion in the neighbour- hood of the organ, which often induces an in- a copious eruption of pustules, which greatly re- lieves the chronic forms of inflammation. Some- times a seton, caustic, issue, or the moxa, is em- ployed with great advantage. In all cases of inflammation, whether acute or chronic, the regulation of the diet is of essential importance. In acute inflammation the mildest food only is admissible; in the chronic, nourish- ment may be more freely allowed. Indeed it is often necessary to allow moderate support while local bleeding and other measures are employed. Pure air is of most essential consequence in all acute diseases, and often exerts a most decided influence in the treatment of low kinds of inflam- mation, which it is often difficult to remove in certain localities. The general principles by which the treatment of inflammation is to be regulated having been considered, we proceed to state what is necessary to be done when any of its effects or terminations have taken place. It is necessary, however, to bear in mind, that although the inflammation may have produced either of the morbid changes alluded to, the in- flammatory action may be still going on, so that it is necessary to watch the primary disease, as well as its effects. For example, in pleurisy and peritonitis, the liquid effusion in the pleural or abdominal cavity does not necessarily imply that the inflammation of the pleura or peritoneum has ceased: on the contrary, we almost invariably find it necessary in such instances to combat the in- flammation on which the effusion depends, at the same time that we attempt the removal of the effused fluid. It is not uncommon to observe, that as the local inflammation is reduced, the effu- sion disappears simultaneously, or very soon after: in such cases the effusion does not depend, as has creased disposition to an undue influx of blood, been too generally supposed, on diminished action although it may procure momentary relief. Chronic inflammation differs from acute only in degree. The duration of the disease is of little consequence compared with its intensity. It should also be kept in mind that inflammation which has been for some time in a dormant or chronic state, sometimes becomes suddenly acute, and may require vigorous measures for its re- moval. In the treatment of chronic inflammation, there being no constitutional excitement, general blood- letting is seldom necessary, local bleeding by cup- ping or the application of leeches being generally sufficient, unless there be a degree of feverishness, or the inflammation be seated in an organ over which local bloodletting exerts little control, when the abstraction of a few ounces of blood from the arm is preferable. The bowels are to be thoroughly cleansed by purgatives, and afterwards a general action should be kept up by alterative doses of mercurials with the milder kinds of aperients, such as rhubarb with manna and Rochelle salt. ' Counter-irritation is especially necessary in chronic inflammation. Blisters are less effective than the more severe kinds of counter-irritants, such as tartar-emetic ointment, or a plaster made of equal parts of Burgundy pitch and yellow wax, lo which a scruple or a half-drachm of tartar- sn.etic 'according to the size) is to be added. Ei- ner the tartar-emetic ointment or plaster brings out of the absorbents, but on the increased quantity of fluid which fs effused from the inflamed sur- face. The sudden relief which often follows from bloodletting judiciously employed in cases of acute dropsy is thus explained; and also, how venesec- tion frequently removes dropsical effusion when diuretics in every form and combination have failed. When effusion follows inflammation of a more chronic character, more especially when the _ powers of the individual are low, it becomes a point for consideration how far anj form of blood- letting may be advantageously adopted. In such cases the local abstraction of blood, or other local antiphlogistic measures, may be advantageously combined with such remedies as are calculated to effect the removal of the effused fluid. The va- rious means which "are to be employed, as well as the circumstances which are to regulate their ad- ministration, have been already considered in the article Dropsy, to which we refer. The effusion which takes place as a conse- quence of inflammation of any of the three cavi- ties may proceed to such an extent as to embarrass seriously the functions of the contained organs, and even ultimately to destroy life. This has led to an attempt to evacuate the effused fluid by an opening. Such an operation, however, is not al- ways practicable, as, for instance, in the effusion which is the effect of acute hydrocephalic inflam INFLAMMATION. 799 mation. A few practitioners of more than ordi- nary boldness have, however, ventured on tapping the cranium in chronic hydrocephalus; but though in some recent examples this operation has been successfully performed, we fear the small average proportion of cases in which it has succeeded will scarcely give general encouragement to hazard it. When effusion to a considerable amount takes place in the pleural cavity, there is little hope of deriving any permanent advantage from the em- ployment of internal remedies administered with the view of promoting the absorption of the effused fluid. In such cases the chest has been tapped, and with such favourable results that this opera- tion can no longer be viewed as a hazardous at- tempt, but the only means of saving the sufferer from indescribable suffering and ultimate death. (See Empyema.) When peritonitis terminates in effusion, the effect of evacuating the fluid is doubtful: in many instances the fluctuation is not perceptible during life ; and even were the fluid detected, more benefit is derived from occasional leeching, counter-irrita- tion of the abdomen, mercury, and diuretics. By a steady perseverance in these measures, abdo- minal effusion succeeding to peritonitis has been frequently removed under most unpromising cir- cumstances. When inflammation has terminated in suppura- tion, similar principles must regulate the treat- ment, the extent of purulent formations being often materially diminished by a continuance of measures calculated to abate the inflammatory action. The kind and extent of these measures must depend on the active or passive nature of the local as well as constitutional symptoms, the ob- ject in every case being if possible to arrest, or if this be impracticable, to diminish the extent of the purulent formation, and afterwards to promote either the absorption or evacuation of the matter. If the suppurative process be accompanied by local or general symptoms, as in phlegmonous ab- scess, it is evident that a persistence in antiphlogis- tic measures, including general or local bloodlet- ting if necessary, may be required till the excite- ment is subdued. It is well known also, that a removal of the inflammatory action frequently takes place in an organ after matter has formed, just as acute may supervene on chronic inflam- mation, or as the inflammatory process may be suddenly renewed in a part recently inflamed. The necessity, therefore, of watching the progress of inflammation in organs in which purulent for- mations have occurred, is apparent, though the attention of practitioners, it must be confessed, is too often almost exclusively directed by the local measures which are best calculated to assist the evacuation of the purulent matter. On the other hand, when suppuration takes place in feeble habits, general antiphlogistic mea- sures must be employed with great caution, even though there be evidence of local excitement. In these cases, a moderately stimulant plan of treat- ment, consisting chiefly in nutritious diet, a mod- erate use of wine and tonic medicines, is often more successful; and should the local affection indicate too great excitement, this may be mode- rated by small detractions of blood from the neigh- bourhood of the part, and such other local mea- sures of an antiphlogistic kind as circumstances may require. In short, the practitioner must have in view, on the one hand, not to retard a salutary process, nor, on the other, to increase or renew the action by which the suppuration has been in- duced. When suppuration succeeds to phlegmonous inflammation of the external parts of the body, various topical applications are found useful. Warm applications are most suitable not only from their soothing, but from their supposed power of promoting the process of suppuration. Fomen- tations of simple warm water, or of decoctions of anodyne or emollient substances, are to be fre- quently applied, and the part afterwards covered with a large poultice of bread and water, or of lintseed flour, some contrivance being adopted to prevent the escape of the heat and moisture. These applications are to be frequently renewed, as soon, indeed, as they become cool, the princi- pal benefit being derived from their warmth and moisture. When fluctuation can be detected, whether the purulent matter be collected in a distinct cyst or abscess, or be diffused in the cellular tissue, it be- comes a subject of consideration whether the pus should be evacuated by an opening made into the part, or be allowed to discharge itself by the gradual process of ulcerative absorption or spon- taneous rupture. If the abscess be situated near the surface of the body and at a distance from any important organs, surgical interference may generally be dis- pensed with. There are some circumstances, however, which render it advisable to open ab- scesses as soon as matter can be detected. For example, when the abscess forms in the neigh- bourhood of an organ important to life, such as the larynx or trachea ; near a large joint; in the vicinity of any of the great cavities ; when the matter is deep-seated, or being resisted by an un- yielding texture, becomes diffused among other parts where less resistance is offered, as in abscess beneath the fascia covering muscles, in the sheaths of tendons, or under the periosteal covering of flat [ bones—an early opening should be made for the discharge of the purulent matter. The cavity of the abscess becomes afterwards gradually obliter- ated by the process of granulation and cicatriza- tion, but this stage of the curative process fre- quently requires the attention of the surgeon. The treatment of chronic suppuration differs in many respects from that of the acute. It is often surprising how little constitutional disturb- ance precedes or accompanies these chronic ab- scesses, which have sometimes been Observed to give no indication of their formation, till attention has been directed to an indolent swelling, which on examination is found to contain fluid. They are frequently observed in individuals of an un- healthy constitution, and more especially in those of a strumous diathesis. Hence, in the treatment. the improvement of the general health must form a more prominent feature than even the local man- agement of the abscess. Chronic abscesses evince a great disposition it increase in size, but the matter has a tendency rather to become diffused than to approach the 900 INFLAMMATION. surface, or, as it is termed, to point. The propriety, therefore, of opening them requires, in general, little consideration, though the mode in which this is to be done is a matter of greater nicety. Mr. Lawrence, in his lectures on inflammation, has very clearly pointed out the local and constitu- tional effects which follow when these chronic ab- scesses are opened in the same way as a phleg- monous abscess. If an aperture be made so as to evacuate the matter, and a poultice be afterwards applied, as is the practice in phlegmonous abscess- es, the entrance of the air produces decomposi- tion of the matter ; the surface or cyst of the ab- scess inflames; the purulent secretion is altered, becoming thin, fetid, and very irritating to the parts with which it comes in contact. The con- stitutional disturbance which is thus excited ag- gravates the local disease, which, in its turn, re- acts on the constitutional irritation to such a de- gree as seriously to disturb the general health, and frequently to destroy the patient. The mode of treating chronic abscesses adopted by the late Mr. Abernethy obviates the risk of inflammation of the cyst, and the constitutional effects to which it gives rise. This consists in making a small oblique opening into the abscess so as to allow its contents to escape, the ingress of air being carefully prevented; the aperture is then to be closed, and pressure applied so as to allow of its uniting by adhesion. The object of this practice is to diminish the cavity of the ab- scess, so that, after it has become contracted, it may be again opened, and afterwards treated in the same way as a phlegmonous abscess, and at the same time to obviate the constitutional irritation which arises from exposing the cyst of a large abscess to the action of the external air. This mode of treatment is, however, not inva- riably successful; the cyst often continues to se- crete pus so as to distend the abscess to its former size, or, if it be diminished, a fistulous opening leading to a large cavity remains. In these cases, surgeons have succeeded in producing inflamma- mation and adhesion of the cyst of the abscess by passing a seton through it, or by injecting irri- tating fluids. The general health is to be improved by nutri- tious diet, vegetable or mineral tonics, and resi- dence in a pure atmosphere. The treatment of ulceration must depend on its local or constitutional origin, the acute or chronic character of the inflammation by which it is ac- companied, the causes by which it is induced, and the structure in which it occurs. 1. Ulceration may be strictly a local affection, as when it arises on an external part of the body from an external cause, such as a wound or other kind of injury. In this case the ulceration may be either accompanied with little or no inflamma- tory action, or with considerable local as well as constitutional disturbance. It is evident that in the former, mild local applications, and avoiding exer- cise or use of the part, will speedily effect a cure ; while in the latter, antiphlogistic measures,, even general or local bleeding, must be combined with topical applications. 2. When ulceration arises from constitutional causes, in addition to the local treatment it is ne- cessary to attend to the general health. Thus, when ulceration of an external structure arises from syphilitic, syphiloid, cancerous, scorbutic, or scrofulous diathesis, it is in vain to attempt to heal the ulceration by local measures alone; or should these succeed, the cure cannot be consi- dered permanent until the particular constitutional malady be subdued. 3. Though almost every tissue of the body is liable to ulceration, it occurs more frequently in the skin and mucous membranes. In the former the treatment is often tedious, depending in many instances on the state of health and previous habits of the individual. The local treatment re- quires attention also to the kind and extent of the local inflammation: this is in some cases of an active inflammatory character; in others it is of a low or chronic kind, the one demanding an anti- phlogistic, the other a stimulant plan of treat- ment. It is inconsistent with this outline to enter more minutely on the treatment of ulcers, and as this belongs more properly to the province of sur- gery, we beg to refer to the writings of Home, Lawrence, Thomson, Cooper, Bell, Brodie, and others, for much valuable information on this subject. Ulceration in mucous membranes is more com- mon in some situations than in others, the gastro- intestinal mucous membrane being by far its most frequent seat. We have repeatedly alluded to the latency of gastro-enteritis, and even when it pro- ceeds to ulceration, the symptoms are no less equivocal. Hence arises the uncertainty of any method of treatment except that which tends to arrest inflammation in this tissue. We do not affirm that ulceration of mucous membranes does not cicatrize: this has been demonstrated by the most satisfactory process, not only in genuine cicatrix of ulcers of the stomach and colon, but even in the small intestines. The exhibition of mineral tonics and astringents—sulphate of cop- per, or the superacetate of lead, in combination with opium — in intestinal ulceration have been found successful, though some physicians speak of the more powerful vegetable tonics, sulphate of quinine, strong infusion of catechu or logwood, as equally efficacious. When ulceration occurs in the buceo-pharyn- geal membrane from the syphilitic or syphiloid poison, the treatment must be entirely constitu- tional ; therefore mercury, sarsaparilla, and nitric acid must be given according to circumstances. Phagedenic ulceration of the genital organs re- quires the application of a powerful escharotic, for example, the concentrated nitric acid. We have seen the action of this specific in those cases powerfully assisted by liberal doses of opium, to the extent even of a scruple in the twenty-four hours. Mortification is a frequent termination of in- flammation, but it arises also from a variety of other causes. It is obvious, however, that in this place we can only consider the treatment of that form which is the effect of inflammation, and refer for information as to the measures to be adopted, when it takes place from other causes, to various articles in this work, and to the article Mortifi- cation. The general principles on which the treatment of mortification originating in inflammation is to be conducted, vary according to the circumstances INFLAMMATION. 801 with which it may be associated ; for it is incon- sistent to suppose that one general rule can be applicable to every case that may occur. Dr. Thomson has justly remarked, there can be no general plan of treatment equally suitable to the differences which occur in the seat, form, progress, and state of the disease, nor to the various affec- tions of the general system by which it is invari- ably accompanied. In all cases of mortification there are some cir- cumstances to be considered before any plan of treatment is determined. 1. Mortification, in re- spect to its seat, is distinguished as it affects an internal or an external part. 2. It is necessary to determine whether the mortification arise sponta- neously, (i. e. from some causes connected with the general system, which are not very obvious,"! or whether it originate from some external cause or local injury ; and, 3, whether it be of an acute or chronic character. When inflammation of an external organ ter- minates in mortification, it is almost invariably fatal, the acute inflammation of which it is the effect being often of itself sufficient to destroy life; when it is not, the system is seldom able to with- stand the additional irritation which the mortifica- tion induces. If, therefore, the violence of inflam- mation in an internal organ be likely to terminate in gangrene, the only indication of treatment is to prevent its taking place by active antiphlogistic measures, since it is well known that death almost invariably follows mortification of an internal organ, unless, as very rarely happens, the gan- grenous inflammation has stopped spontaneously, and the mortified parts have separated and been afterwards expelled by a natural outlet. In every disease it is obviously necessary to as- certain and to remove, if possible, its causes ; and this is no less important in mortification. When it arises from inflammation, it is necessary to dis- cover whether this action still continues, or has abated or entirely ceased. If the inflammation still continues, it is proper to ascertain its degree, both as respects the general as well as the local symptoms; for we often find that there is consider- able local action going on, with very moderate ex- citement of the constitution. When the causes and degree of gangrenous inflammation have been ascertained, the object of the treatment to be adopted is to prevent mortification taking place ; or if it have already occurred, to arrest its pro- gress; and if seated externally, to promote the separation of the mortified from the living parts. To fulfil these indications, the measures to be adopted must have reference to the acute or typhoid character of the symptoms. It is scarcely necessary in the present day to state that no reli- ance can be placed in the antiseptic medicines re- commended by the older authors, on the mistaken idea that mortification depended on putrefaction or decomposition of the solids. Their principles of treatment consisted in endeavouring to prevent or arrest mortification by administering, internally md externally, medicines which were known to prevent the decomposition of dead animal matter. These were chiefly the more powerful vegetable and mineral tonics, and various local stimulants, applied to the mortified parts. It is true that in certain states and stages of mortification the same Vol. IL—101 3s measures are in the present day employed, but on very different principles, no one attributing their good effects to a supposed power of preventing putrefaction by their chemical operation, but to their action as general corroborants or stimulants. The practical error committed by those who ascribed the advantages which occasionally re- sulted from the exhibition of these remedies, was not only in the principles on which they were ad- ministered, but in their indiscriminate adoption in every stage and form of mortification, even in cases which originated with acute inflammation. We shall presently show that they have their value even among modern pathologists; and in stating our opinion, we wish to impress on the reader that we are desirous of guarding the inexperienced against erroneous principles of application, rather than against the remedies themselves. In acute mortification, the general and local ex- citement require the adoption of antiphlogistic measures, modified according to circumstances. General bloodletting, if the pulse be full and hard, and there be great local pain and redness, will be necessary, and must be repeated till the pulse be- come soft, and the other symptoms are moderated. The other parts of the antiphlogistic treatment, consisting of purgatives, saline diaphoretics, and abstinence from stimulating food, must be at the same time enjoined. These measures are neces- sary in the early stage of acute inflammation, not only to prevent mortification, but, when it has begun, to check its further progress. The extent to which bloodletting and the other antiphlogistic measures are to be carried, requires nice discrimi- nation, and especially reference to the age, powers, and previous habits of the individual, as well as to the stage of mortification. The pulse in these cases is often a fallacious guide, more especially when the mortification occurs in a vital organ. The practitioner must, therefore, consider rather its particular character with regard to fulness or hardness, than to frequency. If it be soft, though frequent, and if the skin be cool,—moreover, if the individual be of an irritable habit, and some- what advanced in years, the lancet must be with- held, as under such circumstances detraction of blood would increase the irritability of the heart's action, weaken the patient, and favour the pro- gress of the mortification. Such symptoms, which are often mistaken for inflammation, require atten tion to the state of the bowels, the moderate use of opium, the exhibition of mild nourishment, and the moderate use of wine. In other instances the state of the general as well as of the local symp- toms indicates subacute inflammation — a condi- tion intermediate between acute and chronic mortification, requiring a modification of the anti- phlogistic treatment, according to existing cir- cumstances. A full bleeding from the arm may be necessary or advisable, to diminish the velocity and force of the circulation, though, in many in- stances, this may be dispensed with ; local bleed- ing, by the application of leeches at a short distance from the mortified part, purgatives, anti- monials, mercury, and low diet, being generally sufficient to arrest the progress of the mortification. When the treatment adopted has succeeded in abating the inflammation, and when the progress of the mortification is consequently arrested, fur- 802 INFLAMMATION. ther antiphlogistic measures must be suspended, and the powers of the patient reserved for what the system has yet to accomplish—the separation of the mortified from the living parts. In the ex- ternal parts of the body this is indicated by a red line, which shows the boundary of mortification, and, at the same time, that the process has stopped. A certain degree of inflammation is necessary to carry on the separation of the dead from the mortified parts; and if the powers of the system be feeble, it is evident that this salutary process cannot proceed. In this stage the patient must be supported, especially if advanced in years, by animal food, in the form of strong broths or jellies, and in some cases wine and other diffu- sible stimuli may be given, according to the indi- cations. It is necessary to be very cautious, however, that these measures be not adopted too early, or before the inflammatory action be suffi- ciently reduced; and if they seem to renew the inflammatory excitement, they must be adminis- tered in small quantities, or altogether withdrawn, and mild vegetable nourishment substituted. A similar tonic plan of treatment is requisite when the general fever assumes a typhoid type, which it frequently does very early: in these cases the mortification often proceeds with great rapidity, and the only chance of arresting it is by the liberal administration of stimuli, animal nourish- ment, cordials, and wine. From the supposed virtues of the Peruvian bark in preventing or arresting mortification, it is ne- cessary to allude to it more particularly. About a century ago it had acquired considerable reputa- tion for its supposed antiseptic powers, and was extolled as a remedy possessing great power in the treatment of mortification. It is probable, however, that its indiscriminate adoption led to frequent failures; it consequently fell into disre- pute, and its exhibition is now confined entirely to mortification accompanied with typhoid symp- toms, in which other remedies of a stimulant and tonic kind are found useful. It is obviously an improper remedy when there is inflammatory ex- citement, when there is derangement of the sto- mach and bowels, or when the mortification suc- ceeds to inflammation, produced by external injury. When it is indicated, the sulphate of quinine is the best form of administration, in doses of two grains repeated at suitable intervals. When either the bark in powder, infusion, or de- coction, or the sulphate of quinine disagrees, or proves too stimulating, an infusion of some of the lighter vegetable tonics, cascarilla, gentian, or calumbo, may be substituted; to an effusion of either of these an aperient, such as the infusion of rhubarb, may be added, should the state of the bowels require the combination. Opium, when administered in proper cases, is an invaluable remedy in mortification ; it soothes pain, and diminishes the restlessness and irrita- bility with which mortification is so frequently accompanied, and often procures sleep. In the acute stage of mortification, it is improper until the excitement has been subdued; it may then be given at distant intervals in combination with calomel One grain of opium combined with two of calomel in a soft pill may be given every six or eight hours, if there be pain, irritability, and wakefulness; and should this quantity fail to pro- cure steep, two grains of solid opium may be given once, or perhaps twice in the twenty-four hours. This remedy is more especially indicated should spasms or convulsions arise in the pro- gress of the mortification. The late Mr. White, of Manchester, recommended, in spasmodic contrac- tions and convulsions arising during mortification from external injury, large doses of musk and volatile alkali, which he asserted removed the singultus, subsultus tendinum, and convulsive spasms, while at the same time the mortification was stopped. We agree, however, with Dr. Thomson as to the doubtful efficacy of these remedies under the circumstances mentioned by Mr. White, more particularly as this eminent sur- geon candidly confessed he had been disappointed in the effects of this combination, when it was tried in mortification arising from other causes. When mortification on the surface of the body has terminated in sphacelus, the separation of the mortified from the living parts may sometimes be assisted by local applications. In former times, the practice of surgeons was to make incisions or scarifications through the dead down to the living parts, in order to apply stimulating, and, as was supposed, antiseptic substances, such as turpen- tines, balsams, and even essential oils, regardless of the degree of local inflammation which already existed or might be produced by such applications, Mr. Samuel Cooper has very well remarked, that though such things are indeed really useful in preserving dead animal substances from becoming putrid, a very little knowledge of the animal econ- omy is requisite to make us understand that they cannot act in this manner on parts still endued with vitality ; hut on the contrary, that they must have highly prejudicial effects in the cases under consideration, by reason of the violent irritation which they always excite when applied to the liv- ing fibres. Any local application is unnecessary, and often injurious before the mortification has stopped. This, as we have seen, is indicated by a defined red line, which shows the separation of the mor- tified from the living parts : the living portion ad- joining the sphacelus assumes a red colour, ul- cerative absorption commences, by which the mortified are gradually removed from the living parts. The object of local applications is, 1. to soothe the local irritation : 2. to allay any excitement in the part that may arise ; 3. to accelerate the pro- cess of separation when it proceeds too slowly ; and, 4. to correct the fetor. The most soothing application is a common poultice made of stale bread or lintseed flour and water, and in nine cases in ten this forms the best local application in mortification. When the heat of a poultice produces too much irritation, a cold lotion, or if more agreeable to the feelings of the patient, a tepid lotion may be applied by means of one or two folds of linen. It should be remem- bered, however, that while heat increases the lo- cal action, cold, on the other hand, though it at first diminish or repress vascular action, when too long applied produces debility, and may be conse- quently injurious. INFLAMMATION. 803 When it appears expedient to stimulate the liv- ing parts, several local applications are employed hy surgeons. Mr. Lawrence recommends the ni- tric acid, of which from four to ten drops may be added to an ounce of distilled water, and lint moistened in this lotion applied to the part. The pyroligneous acid has also been applied with ad- vantage, more especially in hospital gangrene. A liniment, composed of oil of turpentine and resi- nous ointment in equal proportions, is an excel- lent stimulating dressing in mortification. The mode of applying this liniment is to moisten lint in it when made warm by putting the vessel in which the liniment is contained in boiling water by which it is soon liquefied. The lint soaked in this liniment is to be put on the part, which is to be afterwards covered with a large warm poultice. This dressing may be renewed once or twice a day or oftener, according to circumstances. Various kinds of stimulating poultices have been recommended. The common yeast poultice, prepared by adding to the grounds of stale strong beer, as much bread crumb or lintseed flower as will make a poultice, answers very well: or some surgeons prefer the effervescing poultice, prepared by adding to an infusion of malt as much oatmeal as is necessary to form a poultice, and afterwards mixing with it a table-spoonful of fresh yeast. When the ulceration looks healthy, and the pro- cess of separation goes on satisfactorily, the stimu- lating ingredients in the dressings must be dimin- ished or wholly withdrawn. Dr. Thomson has shown that the ulcerating surface is, in the pro- gress of separation, liable to pass, under every mode of treatment, into the state of a painful and irritable ulcer ; and in this state it may require to be treated with anodyne fomentations, or with poultices made of carrot, turnip, or fresh hemlock leaves. In these cases, as in sores from other causes, the applications require to be frequently changed, which has often a most beneficial effect on the ulceration. With the view of correcting the fetor arising during the process of separation of mortified parts, charcoal has been employed. The common char- coal poultice is made by adding to a common bread and water or lintseed poultice, two ounces of finely levigated charcoal : this application generally de- stroys the fetor arising from the mortified parts. The disinfecting agents which have been lately introduced—the chloride of lime, or of soda—when applied in proper strength to a gangrenous sore, remove very effectually the unpleasant smell, and may, therefore, be employed in conjunction with the other local measures. We distrust, however, the accounts given by the French writers of their power in arresting the progress of mortification ; in our opinion, they are useful only in correcting the fetor, and cleansing a foul sore. When an extremity has become mortified, it is necessary to remove it to save the patient's life. The general rule adopted by surgeons is, to defer amputation until there is decided evidence that the mortification has stopped ; but for information on this important point, we beg to refer to the writings of those surgeons who have discussed the point of practice. It is necessary to advert to the treatment of mortification arising from unequal pressure on those parts on which the body rests, when an in- dividual has been long confined to bed. The parts which are most liable to mortification from this cause are thinly covered with flesh, viz., the sa- crum, hips, scapulae, elbows, and sometimes the cartilage of the ears, and the skin covering the cranium. It takes place more especially in dis- eases attended with debility, as in the advanced stage of continued fever, in the typhoid forms of which there appears to be a tendency to gangre- nous inflammation; it occurs also1 in bad com- pound fractures, in cases of tedious suppuration, and in paralysis; it is much favoured also when the evacuations are passed involuntarily. According to Dr. Thomson there are two forms of disease arising from pressure, which are not always accurately distinguished ; the one is mor- tification ; the other a chafed, excoriated, and ulcerated state of the same parts ; the mortified state, however, being always an indication of a greater degree of weakness. They not unfre- quently occur in the same diseased surface, a part in which a mortified slough or eschar has been formed, passing very readily into ulceration, so that a sore, which at first was small, often acquires in this way a very large size. The treatment depends on the circumstances with which each case is accompanied. When mortification occurs from pressure in the low or typhoid forms of fever, the strength must, as a general rule, be supported, unless special symp- toms arise to render the tonic plan inexpedient. It is important, however, to discriminate the irri- tative fever which the mortification frequently in- duces, after the primary febrile symptoms have nearly or entirely disappeared. When ulcerative or gangrenous inflammation arises in diseases in which the system is less disposed to mortification from failure of the vital powers, as in paralysis, bad compound frac- tures, and long-continued suppurations, there is less necessity for stimulants ; mild nourishment, great attention to cleanliness, and suitable local applications, with attention to relieving the un- equal pressure, forming the best plan of treatment. For the purpose of obviating the unequal pres- sure sustained by those parts on which the body rests, various contrivances have been invented. A soft down pillow, or an air-cushion, may afford temporary relief. The bed invented by Mr. Earle is well adapted for many surgical diseases which require for their cure long confinement in one posture. The frequent failures of these various contrivances, however, led our scientific friend Dr. Arnott to construct a hydrostatic or floating bed for invalids, on the following ingenious principle —that the support of water to a floating body is so uniformly diffused, that every thousandth of an inch of the inferior surface has, as it were, its own separate liquid, so that no one part bears the load of its neighbour; that a person resting in a bath is nearly thus supported; and that, though the pres- sure of the atmosphere on our bodies is fifteen pounds per square inch of its surface, yet because it is uniformly diffused, it is not felt. He also reflected that the pressure of a water-bath of depth to cover the body is less than half a pound per inch, even on the under side, where it is greatest. and similarly unperceived; an 1 therefore concluded, 304 INFLAM MATION. that if a patient were laid upon the surface of a hath, over which a large sheet of India-rubbei cloth (which is quite impermeable to water,) is thrown, the body being rendered sufficiently buoy- ant by a mattress placed under it, the invalid would repose on the face of the water without sensible pressure on any part, and almost as if the weight of the body were annihilated. A bed constructed on this principle and made in the following manner has been found to effect this desirable object. A trough of convenient dimensions (six feet long, thirty-two inches wide, and eleven inches deep, are good common dimen- sions) is to be lined with lead or zinc to make it water-tight; this trough is to be half filled with water, and over it is to be thrown a sheet of the India-rubber cloth as large as will be a complete lining to it if empty. The edges of this sheet are to be touched with spirit-varnish, to prevent the water creeping round by capillary attraction, and to be afteiwards secured, in a water-tight manner, all round to the upper border or top of the trough, the only entrance left being through an opening at one corner, which can be perfectly closed. Upon this dry sheet a suitable mattress is to be laid, and a bed is thus constituted ready to receive its pillow and bed-clothes, and cannot be distin- guished from a common bed but by its surpassing softness or yielding. When an invalid is placed on this bed, the body, being (as is known to swimmers) nearly of (he specific gravity of water, displaces water equal te his own body, in weight as well as in bulk, and is supported as the displaced water would have been. If a mattress of a certain thickness be placed under the body, after the weight of the body has forced two cubical feet (the average bulk of the human body) of that under the level of the water around, he will float with four-fifths of his body above the level, and will sink much less into his floating mattress, than in an ordinary feather-bed. If unusual positions be required, by having the mattress formed of different thickness in different parts, or by placing a compress of folded blanket or of pillow under the mattress in certain situations, any desired position of the body will be easily obtained. The hydrostatic bed does not admit of the per- spiration being carried off, and unless the invalid can leave the bed so as to admit of its being aired daily, like an ordinary bed, it is necessary to adopt a plan of ventilation in order to prevent the per- spiration from being condensed on the water-sheet below. This Dr. Arnott has proposed to effect by placing under the mattress, arranged like the bars of a gridiron, small flexible tubes of copper wire, wound spirally, with their ends open to the atmo- sphere, either directly or through two larger tubes, crossing and connecting their extremities near the ends of the mattress, and then issuing at the cor- ners of the bed from under the clothes. This bed is therefore admirably adapted not only to every disease requiring long confinement to bed, but to cases of fractured bones, palsy, and diseases of the hip and spine. It also allows the patient, when capable only of feeble efforts, tc change his position almost like a person swim- ming, and thus even to take a degree of exercise. It also enables the attendant to dress wounds, apply poultices, or to place vessels under any part of the body, as the elastic mattress may at any part be pushed down, so as to leave a vacant space, without the support being lessened for the other parts. With regard to local applications, when the skin is merely inflamed without excoriation or detachment of the cuticle, the part should be fre- quently bathed with camphorated spirits of wine, or a solution of the acetate of zinc, or with a lini- ment made by triturating equal parts of alcohol and the white of an egg, and afterwards covered with soap cerate spread upon leather. When the skin is excoriated, spirituous applications are im- proper, the mildest emollients — the lin. calcis, simple cerate, or the zinc ointment—are suitable, and, if there be much irritation, an emollient poul- tice may be placed over the dressing. When mortification, terminating in sphacelus, has taken place, a bread-and-water or carrot poul- tice is the best application, and if the separation of the sphacelus proceeds too slowly, a stimulant dressing, such as the resinous and turpentine be- fore mentioned, may be applied for a short time, but it must be removed if it produce pain and irri- tation. When the sphacelus has been completely de- tached, the sore is to be treated as a simple ulcer, the dressings being varied according to the state of the ulcerations. A. T. Adair Crawford. A. Tweedie. [The portion of this article which precedes the initials A. 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