ti THE STUDY OF MEDICINE. BY JOHN MASON GOOD, M.D. F.R.S. F.R.S.L. ** 7 j— MEM. AM. PHIL. SOC. AND F.L.3. < E.P JU£KARY surgeon sen awi's «frc£ SU. MAY 291900 noioi. :\ IN FIVE VOLUMES. VOL. I. FIFTH AMERICAN EDITION. REPRINTED FROM THE LAST LONDON EDITION, GREATLY IMPROVED AND ENLARGED. PRINTED BY J. & J- HARPER, FOR COLLINS AND HANNAY, COLLINS AND CO., AND O. A. ROORBACH, —PHILADELPHIA, JOHN GRIGG, TOWER AND HOGAN,—BOSTON, RICHARDSON & LORD, AND HILLIARD, GRAY, LITTLE, & WILKINS. 1827, SIR HENRY HALF>RD, BART. M.D. F.R.S. F.A.S. PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON, PHYSICIAN TO THE KLNG ; THIS WORK is INSCRIBED AS A TRIBUTE OF GRATITUDE AND FRIENDSHIP. AUGUST VI, MDCCCXXII. ADVERTISEMENT TO THE SECOND EDITION. In obeying the call for a second edition of the present work at so early a period, the author cannot avoid expressing his gratitude to the Profession for the favourable opinion with which it has thus crowned his humble labours in the field of medical science. He has en- deavoured to avail himself of the remarks which have been made upon them, as well in private as in public, as far as he has felt it to be practicable or advantageous; and he trusts that the additions which have hence been introduced into the work will be found, in no small degree, to augment its value. From various quarters he has been pressed to take a further notice of foreign professional writers of the present day than is contained in the first edition; and although he has already been afraid of bein°- charged with too much display in the use of learned names and authorities, and has, as much as possible, contented himself with giving general results, and correspondent suggestions without a refe- rence to their respective sources, except where the authorities seemed to be called for, he has now complied with the request as far as the nature of the work will allow. He begs, however, to observe that as The Study of Medicine is offered to the world, not as a record of authorities, or a compila- tion of professional opinions, but as an original and systematic survey of the healing art as a science, so far, at least, as the author has been able to understand it himself, his chief motive in making refer- ences on any occasion to other writers, has been merely to obtain from them such coincidence or illustration as the subject progres- sively discussed may seem to require. Yet from the wider circulation of the work, beyond the shores of our own country than he had ventured to anticipate, he candidly confesses that he feels/ himself, in some degree, called upon to extend its range of observation propor- tionably; so as to give some further insight into the chief opi- nions and modes of practice of the Continent, in concurrence with those of our own country. To such chief opinions, however, it is still necessary to restrain the survey; since, so exuberant and multi- farious is the foreiern medical press, that, without such a limit, the vl ADVERTISEMENT. present pages would be doubled in extent, and loaded with specu- lations that are little worth recording. Yet, though narrowed by such a curb, the requisite analysis and amalgamation of matter which have demanded the author's attention for this purpose, have furnished him with no small degree of labour, as the reader may easily perceive by observing that there are few pages in the present edition which have not undergone some change in their arrangement, for the purpose of introducing the materials thus selected ; while, in some places, they have been partially re- modelled for thirty or forty pages in succession. Other subjects, moreover, and these not few in number, have been retouched, and, in various instances, enlarged upon : particularly several of the diseases of hot or remote climates; partly, indeed, from valuable documents in the archives of the Army Medical Board, forming a rich and almost inexhaustible repository of important facts and practical information, which the author would rejoice to see given in periodical communications to the public ; and to which his attention has been particularly pointed by his eminent friend the Director-general. For examples of gleanings derived from this source the reader may turn, among other places, to the concluding remarks on cholera spas- modica;* to the observations on the hebetude of syphilitic action in the West Indies, and the comparative insusceptibility of the consti- tution to its power in that quarter ;t to those on the advantage of en- campments in yellow fever ; J and to those, also, on the progress and general nature of beribery.§ Upon the subject of dysentery, too, some additional notice has been demanded in consequence of the im- portant information respecting this disease, furnished since the Author's first edition, by the Reports of the Dublin Hospitals. And, in like manner, the interesting experiments and their important re- sults, which have lately been communicated respecting the nerves, as well as various other physiological researches, have called for oc- casional notice in the physiological proems. A regard is also paid to various subjects of no ordinary moment which have arisen into notice, or been originally started since the period of the preceding edition, or which had, at that time, incidentally escaped attention. Professor Thomson's learned and interesting inquiry, concerning " The varieties of Small-Pox," though anticipa- ting the first publication of the present work by a few months, was too late for notice in its proper place when the Author had the honour of receiving a presentation-copy. He has here, however, fulfilled the promise he then made, of paying it due attention as soon as the present edition should afford him an opportunity. And, in so doing, he has also entered into a consideration of the late Dr. Willan's elaborate speculations on nearly the same subject, published posthu- mously by his learned relative Dr. Ashby Smith. And he has, in like manner, launched somewhat more fully into the question of those * Vol. I. t Vol. III. t Vol. ti. § Vol. IV ADVERTISEMENT. VII tbrms of disease which appear most nearly related to syphilis; and how far the latter may be advantageously treated without mercury. The growing attention which the diseases of vision are still obtaining in our own country, whether dependent upon sensorial or inflamma- tory action, has not passed unheeded in the distinct genera paropsis and ophthalmia; while the still agitated question respecting qua- rantine, and especially as it relates to the contagion of plague, has induced the Author to enter considerably more at large into the his- tory, laws, and natural limits of this last exanthem. The subjects that are strictly original, and which could not con- veniently, or not at all, be introduced into the former edition, are about ten or twelve, of which the following are, perhaps, the chief: I. That singular and destructive inflammation which occasionally takes place, with symptoms of low fever, on dissection with a punc- tured or abraded hand--ERYTHEMA ANATOMICUM.* II. That form of -Marasmus which has lately attracted a good deal of attention, under the name of anaemia—marasmus Anhomiia. 111. The Mila- NOhis of M. Breschet. IV. That lateral distortion of the st ine— Entasia Rhachybia, which has of late become a subject of exten- sive and still advancing discussion. V. The MOLLITIES CEREBRI Of M. Rochoux ; and VI. A peculiar species of trichosis, here named sensitiva, pointed out to the Author by the learned editor of the Edinburgh Medical and Surgical Journal; each of which is now, for the first time, allotted a place in a nosological classification. And to these may be added a summary account of JVl. Laennec's stethos- cope, and method of mediate auscultation ; with occasional notices of several of the new and active forms of medicine which have re- cently been introduced into our own country irom the French phar- macologists. As the volumes of the prior edition were all bulky, it has, hence, been found necessary to add to their number ; though the author has felt great reluctance upon this subject, and has endeavoured to keep them as much as possible within due bounds. And he has the satis- faction to find that, as the greatest part of the new matter appertains to what, in the former impression, constituted the second volume, he has been able to accomplish his design by dividing this alone into two volumes, and adding a little to the paging of the rest. * Since this part of the work has been printed, the author has to acknowledge a commu- nication of not less than ten distinct cases of the same, obtained for his use by the friendly exertion of the Director-general of the Army Medical Board from different Military Hos- pitals and other Establishments throughout the kingdom. On a future occasion he will readily avail himself of these valuable notices ; but at present he can only observe that they fully confirm the general view here offered, while they exhibit almost every variety, and ter- mination of the disease: in one or two examples, indeed, running into a chronic form of most pitiable suffering; sometimes enduring for two, three, or four years, and, in one in- stance, for upwards of fen; in the course of which, organ after organ has become the prey of this monster-malady, till the unhappy individual, who is himself the historian of his own case, has, at this moment, to weep over a contraction of the arm, shoulder and knee-joint, and a total loss of the testicle on the affected side, with an irreparable wreck of his general health; the virulence of the complaint not being yet destroyed, and still threatening further dilapidations. vm ADVERTISEMENT. The only point of importance, hitherto suggested to him which he has found a difficulty in acceding to, is that of introducing generally a description of the appearances offered by diseases on dissection. Wherever such appearances are strictly pathognomic and can throw a steady and intelligent light on the nature and treatment of a malady he has endeavoured to give them : but he has declined to do so upon any other occasion for the following reasons. First, because the present is not designed to be a sepulcretum, or work on morbid anato- my , and would have been swelled to nearly double its extent if such a connexion had been allowed. And, next, because, however valuable an expert practice in dissection may be to a student in the field of anatomy, in a pathological point of view its developements, except where strictly applicable and illustrative, will more frequently perplex than instruct him. They will rarely give him any informa- tion concerning the elementary or chemical changes that have taken place in the animal fluids; and may lead him, in a thousand instances, to mistake effects for causes, the result of symptoms or accidents for that of idiopathy, even in morbid changes of structure. The truth is, as M. Fodere has justly observed, that by far the greater number of diseases are the products of disordered vitality before they become organic: and when, at length, they assume such a character, it is as a consequence rather than as a first moving power. On which account this distinguished pathologist is disposed to place but little reliance on the scalpel; and to think very lightly of all the busy dissections and operative experiments that are at this moment going forward in France, whether upon living or dead animals.* Perhaps this is considerably to undervalue such attempts ; but let their im- portance be what they may, it belongs rather to the province of morbid anatomy to follow them up and illustrate them, than to such a work as the present; except in the class of cases already provided for, in which they may, unquestionably, be turned to an account of great moment, and made productive of an abundant harvest. * Lecons sur les Epidemies, et 1'Hygiene publique, faites a la Faculte de Medicine de Strasbourg. Par Fr. Emm. Fodere. 8vo. Paris, 1822. PREFACE TO THE FIRST EDITION The object of the present work is to unite the different branches of medical science, which, when carried to any considerable extent, have hitherto, by most writers, been treated of separately, into a general system, so that the whole may be contemplated under a single view, and pursued under a common study. These branches are the following : I. Physiology, or the doctrine of the natural action of the living principle. II. Pathology, or the doctrine of its morbid action* III. Nosology, or the doctrine of the classification of diseases IV. Therapeutics, or the doctrine of their treatment and cure, All these are of high, if not of equal* importance. As it is impossible for a workman to set about restoring a machine to order* with any rational hope of success, without knowing the full extent and nature of the injury it has sustained, so is it equally impossible for him to acquire this knowledge unless he has also a knowledge of the structure of the machine, and has studied its several parts methodically, and in reference to the bearing which one part has upon another. It is this advantage of the study of one part in relation to an- other that constitutes, or should constitute, in the art of medicine, the basis of a nosological arrangement ; for by grouping dis- eases, not arbitrarily, but in the order of connexion in which they make their appearance in different functions, and the organs on which those functions depend, it is almost impossible to obtain an insight into the nature of any one disease belonging to such groups, without obtaining some insight into the nature of the rest, or tracing out some of the laws of morbid action which are common to the whole. Vol. I.—% ",V preface. If it be convenient to concentrate the diseases of the nervous department into one division, as has been attempted by many no- sologists, and ably accomplished by Dr. Cullen, it is to be lamented that the same principle has not been allowed to pervade the whole of the nosological plan; and that the diseases of the other chief departments of the animal frame have not been concentrated in the same way, instead of being scattered as we too often find them, over different divisions of a classification that is itself perpetually shifting from one ground of arrangement to another : which in one division, as in the Synopsis of Dr. Cullen, by far the best of his day, is derived from the temperature of the body ; in a second, from its anatomical structure ; in a third, from its chemical depravities; and in a fourth, from its topography : thus offering us in each division a new principle, and one that has no common clew, or analogy with the rest. It was the hope of obtaining a clearer and more connected me- thod than had hitherto been studied in the schools of medicine, that induced the present author to turn his attention to this subject many years ago, and at length enabled him to submit to the public a System of Nosology founded entirely on a physiological basis, in which the diseases of the respective functions of the animal frame are connected in classes derived from those functions, and follow each other in the order in which physiologists have usually treated of them. It was not, however, from a mere hope of obtaining a more exact and comprehensive synopsis of diseases that the author was induced to undertake this new arrangement, but with a view of employing it as a text-book for the collateral branches of the Art of Healing already adverted to, as soon as he should find leisure to enter upon them, and to which no other synopsis he was acquainted with seemed equally adapted. This work was published in the beginning of 1817, under the title of a " Physiological System of Nosology, with a corrected and simplified Nomenclature ;" and the favourable opinion which has been formed of it; its adoption as a text-book in various medical schools of high reputation in our own country, and on the Conti- nent ; the application which has been made to the author by some of the oldest and most established lecturers of this metropolis to print a syllabus of its classification for the purpose of lecturing from ; and above all the approbation which the Royal College of Physicians has bestowed upon it, by permitting it to be dedicated to that leanied body, after having been circulated amidst the Fellows of the College, under an express order of the late President, for an examination of its contents by every individual at his own house, are, he trusts, a sufficient apology for his adhering to his original intention, and taking this system, instead of any other, as the ground- work of the ensuing arrangement. i-AEFAtE, XI It is not necessary in the present place to enter into a minute explanation of the subordinate parts of this system, nor of the oc- casional changes in medical nomenclature which are to be found in it: and which a close attention to correctness and simplicity seemed to render indispensable. All these are fully illustrated in the Pre- liminary Dissertation to the volume of Nosology, which the author is desirous of having regarded as a part of the general design. An alteration in the distribution of one or two of the diseases, as originally laid down, may be noticed by an attentive eye in the present volumes. They are changes which have been made out of deference to the opinions of others, or from a maturer conside- ration of the subject by the author himself: but, upon the whole, they are too few and of too little importance to render it necessary to indicate them in the present place. A pretty active spirit of physiology will be found to pervade the entire work ; but the author has, beyond this, availed himself of the advantage which his arrangement so readily allows, of pre- fixing to every class a summary of the most important laws and interesting discoveries of physiology that relate to, or can elucidate the subjects which constitute its scope. And he has occasionally enriched the dissertation by a glance at the more striking analogies of the animal, and even of the vegetable world at large, wherever they could add to the illustration. In the pathological department, if the reader meet with an occasional developement of new principles, a question as to several that have been long before the public, or a further extension of many that are well established, the author trusts that whatever doc- trines are advanced will, at least, be found true to themselves and form a digested system operating in accordance through the entire work, in what way soever they may be affected by future investi- gations. He trusts, it will also be found that nothing is neVly started for the mere sake of novelty, or controverted from a mere love of disputation : and that whenever it has been his misfortune to differ from high authorities which have preceded him, he has done it with the candour which should peculiarly characterize a liberal profession. His main object has been to explain to the student the different subjects that pass before him, and to illustrate them by analogies, instead of confining himself to a dry and wearisome his- tory of morbid symptoms and operations. In therapeutics the author has allowed himself a liberal range, and has, occasionally, introduced, into his Materia Medica sub- stances that are highly esteemed abroad, though little valued or even known at home, or that seem without reason, to have fallen into temporary disrepute. There are some practitioners who think that all the articles which are of real use in the cure of diseases lie within a small compass, and may be learnt without burthening the memory. This remark may be allowed to those who are limited Ml PREFACE. to a portable dispensary, as in travelling, or on ship-board; but when uttered under other circumstances it savours less of wisdom than of indolence, If the pharmacopoeias of former times were too voluminous, and were occasionally loaded with medicines of trifling importance, the lopping and topping that must hereupon ensue, would make a destructive inroad upon their boundaries, and take from them much that is good as well as something that can be spared. We may easily, indeed, substitute one medicine for an- other, but it is very rarely that we can hereby obtain an integral re- presentative ; a remedy possessing not only the general, but the par- ticular qualities of that whose place is supplied, so as to be equally adapted to the exact state of the disease or the express character of the idiosyncrasy. Sir George Baker was engaged as reasonably and scientifically in examining into the virtues of the cardamine pratensis or lady's smock, as Dr. Stoerck in proving, upon his own person, the violent powers of coh'hicum and stramonium. A com- mon fate has, indeed, attended the whole of these experiments. From attracting and concentrating the attention of the public, the medicines to which they were directed became equally over-valued; were employed upon all occasions ; pioduced frequent disappoint- ment ; and gradually fell into disuse. The colchicum has been fortunate enough to ascend once more to its full zenith of popu- larity ; many efforts have been made on behalf of the stramonium ; and the cardamine, though at present Jess successful than either of the others, still holds in abeyance its post in the established phar- macopoeias, waiting for some lucky trial to bring it once more into general esteem. A work erected upon scientific principles should know nothing of these accidental reverses, and still less of the varying, and too often capricious taste of the day. To judge by the sentiments of some writers, the reputation of the bark seems at present on the wane, while the seeds of the croton Tiglium, after a long neglect, are again rising into notice. In the remedial part of the present work the author has endeavoured to allow to every medicine its jwoper value, as far as he has been able to estimate it, whatever may have been the era of its credit; and as there can be no stronger ground for the study of botany, oryctology, or chemistry than the advantage they afford to the art of healing, and as these aie pro- vinces cultivated in our own day by almost every one, he has felt himself called upon by the general voice of the times to range with some latitude over the medicinal stores afforded by art and nature, and to discriminate the respective properties of each, rather than to limit himself to a few leading productions, or to refer to the whole under the general divisions of stimulants, sedatives, and ca- thartics, or whatever other names may serve for a medicinal classifi- cation. \t is this, indeed, that softer all must chiefly constitute the The- PREFACE. XUl rapia, or Practice of Medicine, to which every thing else, though of the utmost moment, is but introductory. " The First Lines" of Dr. Cullen when read as they were delivered, in con- nexion with his " Treatise on the Materia Medica," constitute the most important course of instruction that has ever, peihaps, been laid down and completed by the same individual. But for this pur- pose they must be read together, though they were not published together, nor for the express design of forming a contemporaneous study : for it is a singular fact that the First Lines of the Practice of Physic, though full both of mind and of matter, of elaborate axioms and theoretical principles, contain little of what the title suggests; while the Treatise on the Materia Medica, without making any pretensions to the subject, is altogether a practical work, replete with practical principles and founded upon a practical investigation. Whatever may be the theory or the practice advanced in the en- suing volumes, the author will generally be found to leave nothing upon trust; but to support or illustrate his assertions by authorities which he has endeavoured to give, with some degree of copious- ness, from ancient as well as modern times : so as to render the work in a certain sense a summary of the general history of medi- cine in most ages and countries. To the labours of our own countrymen, however, he professes to be chiefly indebted for his supplies : to the illustrious dead and to the illustrious living : to all of whom he has conscientiously en- deavoured to do justice, even where he has been under the mis- fortune of differing from any of them in opinion. With the former he can have no controversy; and, with the latter, he has taken the most gratifying means of avoiding it, and at the same time of adding considerably to the value of his work, by submitting to the most distinguished of them, and especially to those with whom he has the honour of a personal acquaintance, the successive sheets of the work, while passing through the press, that contain a notice of their respective opinions or publications ; with a request that they would correct any incidental mis-statement, or communicate any valuable hint that may since have occurred to them on the subject. It would occupy too much space to enumerate all the individuals to whom the author has been indebted for assistance of this kind : but there are several whose names the public ought to be made ac- quainted with as adding, in no ordinary degree, to the authority of the work itself. He has, in the first place, to return his very grateful thanks to the President of the Royal College of Physicians, without whose fostering encouragement his health and strength, considerably en- croached upon by the laborious and unremitting study with which it has been necessary to prosecute the subject, would hardly have held out to its close: and who has not only taken the trouble of XIV PREFACE. examining the sheets that relate to his own valuable labours, but of watching the progress of the work generally, and of perusing many parts of it as they have issued from the press. He has next to offer his acknowledgments to his highly distinguished and venerable friend Dr. Perceval, of Dublin ; who has been so kind as to favour him with a valuable manuscript series of notes, in the form of a running commentary, upon the entire volume of Nosology, in illus- tration of its definitions or opinions; the whole of which will be found embodied into the present work, with a reference to the real author in every instance. To the liberality of Sir James M'Grigor he is indebted for important assistance on several occasions, and particularly for his munificent offer of a free and facilitated access to all the medical documents of the army, addressed to him as Di- rector-General. To his kind friend Sir John Webb he is also largely indebted for similar assistance from the Ordnance Department, and particularly in respect to the subject of plague, upon which he has proved himself to be so perfectly conversant. The kindness of Dr. Baillie can never be erased from the author's memory, but he has particularly to thank him on the present occasion for reviewing the article on spasmodic stricture of the rectum as well as several others, which, without his previous labours, would not perhaps have been found in the present work, or have been found but very im- perfectly. To Dr. Latham he is under obligations on various ac- counts ; but, in the present work, he is especially indebted to him for his friendly revision of the article paruria mellita or diabetes. The volumes will display abundant instances in which he has de- rived assistance from the comprehensive mind of Sir Gilbert Blane, but the friendliness with which he has consented to furnish him with a description of his own case, in a very singular and obstinate attack of prurigo, and to revise the statement when printed, demands an especial acknowledgment. To Dr. Bree the author is indebted for perusing the article on asthma, and his very liberal opinion on the same. To Dr. Young for a like attention to that on phthisis, and the valuable hints with which his opinion was accompanied. To Dr. Cooke, whose friendship he has experienced in many im- portant instances, he is under a similar obligation for perusing, and in a few instances, correcting the account of apoplexy and palsy: and to his excellent and judicious friend Dr. James Johnson, for various hints concerning tropical diseases, and a perusal of some parts of the present volumes in which they are treated of. The author has entered with a considerable degree of fulness into the different modifications of diseases, in order to adapt the work to foreign climates and stations as well as to domestic prac- tice : for a system of medicine to be complete should be of universal application. To render it such, however, it is seldom necessary to do more than to follow up the common diseases of a country into their respective varieties : for the general laws of the morbid action PREFACE. XV of the living principle are as permanent and universal as those of its natural action, and a really new species of disease is, perhaps. as much a phenomenon as a really new species of plant or animal. We see all these infinitely diversified by accidental circumstances, and particularly the circumstances of habit and climate ; but the specific outlines are still preserved, and we are still capable of re- ducing them, under every disguise, to their proper relations, and of assigning them their proper posts. From a few non-descript skele- tons occasionally found in the bowels of the earth, and particularly from the interesting museum of such established by M Cuvier at Paris, we have reason to believe that a few species of animals have totally disappeared ; as we have also, from the classifications of re- cent naturalists compared with those of earlier times, that a few species are now in being which had no existence in remote ages. And in like manner, whilst a few species of diseases are now no longer to be found which are described by earlier writers, a few seem to have supplied their place, which are comparatively of mo- dern origin. Yet, upon the whole, the march of nature is but little interfered with in either case ; and hence the prognostics and aphorisms of Hippocrates, the medical histories of Aretaeus and Galen, of Rhazes and Avicenna, and the natural histories of Aris- totle and Pliny, are transcripts of animal life in our own day, as well as in the times in which they were severally composed ; and form important subjects of modern as it is well known they did of ancient study. The extensive family of fevers and spasmodic af- fections are, in the main, the same now as they are represented in the most ancient writings that have descended to us ; the plague of Athens, as described by Thucydides, we shall find in the ensuing pages to be the prototype of what still occasionally takes place in Egypt and along the Barbary coast; and even the leprosy of the Levitical law, so minutely described by Moses, will be found, when the passage is closely and accurately rendered, still to retain its hold in the East, and to exhibit even the very same modifications as are noticed by the Hebrew legislator, and have been interme- diately assigned to it by Celsus. TABLE CLASSIFICATION. CLASS I. CCELIACA. DISEASES OF THE DIGESTIVE'FUNCTIONS. ORD. I. ENTERICA. AFFECTING THE ALIMENTARY CANAL. GEN. I. ODONTIA. Misdentition. SPEC. 1. O. DENTITIONIS. Teething. 2. DOLOROSA. Tooth-ache. 3. STUPORIS, Tooth-edge. 4. DEFORMIS. Deformity of the Teeth. 5. EDENTULA. Toothlessness. 6. INCRUSTANS. Tartar of the Teeth. 7. EXCRESCENS. Excrescent Gums. GEN. II. PTYALISMUS. Ptyalism. SPEC. 1. P. ACUTUS. Salivation. 2. CHRONICUS. Chronic Ptyalism. 3. INERS. Drivelling. GEN. III. DYSPHAGIA. Dysphagy. SPEC. I. D. CONSTRICTA. Constrictive Dys- Vol. I.—3 SPEC.2. D. ATONICA. Atonic Dijsphagy. 3. GLOBOSA, Nervous Quinsy. UVULOSA. Uvular Dysphagy. LINGUOSA. Lingual Dys- phagy. 4. 5. GEN. IV. DIPSOSIS. Morbid Thirst, SPEC. 1. D.AVENS. Immoderate Thirst. 2. EXPERS. Thirstlessness. GEN. V. L1MOSIS. Morbid Appetite. SPEC. 1. L. 3. 4. AVENS. Voracity. EXPERS. Long Fasliiig. PICA Depraved Appetite. CARD1ALGIA. Heart-bum. Wa- ter-brash. Car- dialgy. FLATUS. Flatulency. EMESIS. Sickness. Vomit- ing. DYSPEPSIA, Indigestion. xvm TABLE OF CLASSIFICATION. [CL I.-OR. Ii GEN. VI. COLICA. Colic. SPEC. 1. C. ILEUS. lleac Passion. 2, RHACHIALGIA. Colic of Poitou. Painters Colic. 3. CliiARIA. Surfeit. 4. FLATULENTA. Wind Colic. o. CONSTIPATA. Constipated Colic. 6. CONSTRICTA. Constrictive Colic. GEN. VII. COPROSTASIS. Costiveness. SPEC. 1. C. CONSTIPATA. Constipation. 2. OBSTIPATA. Obstipation. GEN. VIII. DIARRHOEA. Looseness. SPEC.l. D.FUSA. Feculent Looseness. 2. BILIOSA. Bilious Looseness. 3. MUCOSA. Mucous Looseness. 4\ CHYLOSA. Chylous Looseness. 5. LIENTERIA. Lientery. 6, SEROSA. Serous Looseness. 7. TUBULARIS. Tubular Looseness. 8. GYPSATA. GypseousLooseness. GEN. IX. CHOLERA. Cholera. SPEC.l. C. BILIOSA. Bilious Cholera. 2. FLATULENTA. Wind Cholera. 3. SPASMODICA. Spasmodic Cholera. GEN. X. ENTEROLITHS Intestinal Concretions. SPEC.l. E.BEZOARDUS. Bezoar. 2. CALCULUS. Intestinal Calculus 3. SCYBALUM. Scybalum. GEN. XL HELM1NTHIA. Worms. SPEC.l. H.ALVT. Alvine Worms. 2. PODICIS. Anal Worms. 3. ERRATICA. Erratic Worms.. GEN. XII. PROCTICA. Proctica. SPEC.l. P. SIMPLEX. Simple Proctica. 2. SPASMODICA. Spasmodic Stric- ture of the Rec- tum. 3. CALLOSA. Callous Stricture of the Rectum. 4. TENESMUS. Tenesmus. 5. MARJSCA. Piles. 6. EXANIA. Prolapse of the Fundament. ORD. II. SPLANCHNICA. AFFECTING THE COLLATI- TIOUS VISCERA. GEN. I. ICTERUS. Yellow Jaundice. SPEC. 1. I. CHOLCEUS. Biliary Jaundice. 2. CHOLOL1TH1CUS. Gall-stone Jaun- dice. 3. SPASMODICUS Spasmodic Jaun- dice CL. II.-0K. I.] TABLE OF CLASSIFICATION. Xl> SPEC. 4. I. HEPATICUS. Hepatic Jaundice. 5. INFANTUM. Jaundice of In- fants. GEN. II. MEL^NA, Melena. SPEC.l. M. CHOLCEA. Black, or Green Jaundice. 2. CRUENTA. Black Vomit. GEN. III. CHOLOLITHUS. Gall-stone. SPEC.l. C, QUIESCENS. Quiescent Gall- stone. 2. MEANS. Passing of Gall- stones. GEN. IV. PAR ABYSM A. Visceral Turgescence. SPEC.l. P.HEPATICUM. Turgescence of the Liver. 2. SPLENICUM. Turgescence of the Spleen. 3. PANCREATICUM. Turgescence of the Pancreas. 4. MF.SENTERICUM. Turgescence of the Mesentery. 5. INTESTINALE. Turgescence of the Intestines. 6. OMENTALE. Turgescence of the Omentum. 7. COMPLICATUM. Turgescence com- pounded of va- rious organs. CLASS II. PNEUMATICA. DISEASES OF THE RESPIRATORY FUNCTIONS. ORD. I. PHONICA. AFFECTING THE VOCAL AVE- NUES. GEN. I. CORYZA. Running at the Nose. SPEC.l. C. ENTONICA. Entonic Coryza. 2. ATONICA. Atonic Coryza. GEN. II. POLYPUS. Polypus. SPEC. 1. P. ELASTICUS. Compressible Po- lypus. 2. €ORIACEUS. Cartilaginous Po- lypv*;. GEN. III. RHONCHUS. Rattling in the Throat SPEC.l. R/STERTOR. Snoring. 2. CERCHNOS Wheezing. GEN. IV. APHONIA. Dumbness. SPEC. 1. A. ELINGUIUM Elingual Dumb- ness. 2. ATONICA. Atonic Dum b ncss. 3. SURDORUM. Deaf Dumbness. GEN. V. DYSPHONIA. Dissonant Voice. SPEC 1. D.SUSURRANS. Whispering Voire XX TABLE OF CLASSIFICATION. |_cL- »I'~0R- » SPEC. 2. D PUBERUM. Voice of Puberty. 3. 1MMODULATA. Immelodious Voice. GEN. VI. PSELLISMUS. Dissonant Speech. SPEC.l. P. BAM B ALIA. Stammering. 2. BLvESITAS. Misenunciation. ORD. II. PNEUMONICA. AFFECTING THE LUNGS, THKIR MEMBRANES, OR MOTIVE POWER. GEN. I. BEX. Cough. SPEC. 1. B. HUMIDA. Common or hu- mid Cough. 2. SICCA. Dry Cough. 3. CONVULSIVA. Hooping- Cough. GEN. II. LARYNGYSMUS. Laryngic Suffocation. SPEC. 1. L. STRIDULUS. Stridulous Con- striction of the Larynx. GEN. III. DYSPNCEA. Anhela'ion. SPEC.l. D.CHRONICA. Short-breath. SPEC.2. DEXACERBANS. Exacerbating An- helation. GEN. IV. ASTHMA. Asthma. SPEC. 1. A. SICCUM. Dry or JVervous Asthma. 2. HUMIDUM. Humid or Com- mon Asthma. GEN. V. EPHIALTES. Incubus. SPEC. 1. E. VIG1LANTIUM. Day-Mare. 2. NOCTURNUS. JYight-Mare. GEN. VI. STEBNALGIA. Suffocative Bi e ist-pang. SPEC.l. S. AMBULANTIUM. Acute Breast-pang. 2. CHRONICA. Chronic Breast- pang. GEN. VII. PLEURALGIA. Pain in t e Side. SPEC.l. P.ACUTA. Stitch. 2. CHRONICA. Chronic Pain in the Side. CLA§S III. H^EMATICA. 3. DISEASES OF THE SANGUINEOUS FUNCTION. ORD. I. PYRECTICA. FEVERS. GEN. 1. EPHEMERA. Diary Fcvtr. SPEC.i. E. MITIS. Mild Diary Fever SPEC. 2. E. ACUTA. AculeDiary-Fever^ SUDATORIA. Suveating Fever. CL. HI.-OR. II.] TABLE OF CLASSIFICATION. XXI GEN. II. ANETUS. Intermitting Fever. Jlgue. spec.i. aIquotidtanus. Quotidian Ague. 2. TERTIANUS. Tertian Ague. 3. QUARTANUS. Quartan Ague. 4. ERRATIC US. Irregular Ague. 5. CO iPLi: ATUS. Complicated Ague. GEN. III. EPANETUS. Remittent Fever. SPEC. l. E. MITIS. Mild r*emittent. 2. MALIGNUS. Malignant Re- mittent.* 3. HECTICA. Hectic Fever. GEN. IV. ENECIA. Continued Fever. SPEC.l. E.CAUMA. Inflammatory Fe- ver. 2. TYPHUS. Typhous Fever. 3. SYNOCHUS. Synochal Fever. ORD. II. PHLOGOTICA. INFLAMMATIONS. GEN. I. APOSTEMA. Jtposteme. SPEC.l. A. COMMUNE. CommonAposteme. 2. PSOATICUM. Psoas Abscess. 3. HEPATICUM. Abscess of the Liver. * a Autumnal Remittent. 6 Yellow Fe- ver, y Burning Remittent. 6 Asthenic Re- mittent. SPEC. 4. A. EMPYEMA Lodgment of Mat- ter in the Chest. 5. VOMICA. Vomica. GEN. II. PHLEGMONE. Phlegmon. SPEC.l. P COMMUNIS. CommonPhlegmon. 2. PARULIS. Gum-boil 3. PAROTIDEA. Parotid Phlegmon. 4. MAMMiE. Abscess of the Breast. 5. BUBO. Bubo. 6. PHI M OTIC A. PhimoticPhlegmon. GEN. Ill PHYMA. Tuber. SPEC.l P. HORDEOLUM. Sty 2. FURUNCULUS. Boil. 3. SYCOSIS. Ficous Phyma. 4. ANTHRAX. Carbuncle. GEN. IV. IONTHUS. Whelk. SPEC.l. I. VARUS. Stone-pock. 2. CORYMBYFER. Carbuncled Face, Rosy Drop. GEN. V. PHLYSIS. Phlysis. SPEC. 1. P. PARONYCHIA. Whitloiv. GEN. VI. ERYTHEMA. Inflammatory Blush. SPEC.l. E.CEDEMATOSUM. Edematous Erifthe- xxn TABLE OP CLASSIFICATION. [CL. III.-OR IL SPEC. 8. E. ERYSIPELATOSUM. Erysipelatous Ery- thema. 3. GANGRENOSUM. Gangrenous Ery- thema. 4. VES1CULARE. Vesicular Erythe- ma 5. ANA TOM! CUM. Erythema from Dissection. 6. PERN O. Chilblain. 7. INTERTRIGO. Fret. GEN. VII. EMPRESMA. Visceral Inflammation. SPEC.l. E. CEPHALITIS. Inflammation of the Brain.* 2. OTITIS. Ear-ache. 3. PAROTITIS. Mumps. 4. PARISTHMITIS. Quinsy. 5. LARYNGITIS. Inflammation of the Larynx. »6. BRONCHLEMM1TIS. Croup. 7. PNEUMONITIS. Peripneumony. 8. PLEURITIS. Pleurisy. 9. CARDITIS. Inflammation of the Heart. 10. PERITONITIS. Inflammation of the Peritonaeum. 11. GASTRITIS. Inflammation of the Stomach. 12. ENTERITIS. Inflammation of the Bowels. 13. HEPATITIS. Inflammation of the Liver. * a Brain Fever. 6 Acute Dropsv of the Head. SPEC, 14. E. SPLENITIS. Inflammation of the Spleen. 15. NEPHRITIS. Inflammation of the Kidneys. 16. CYSTITIS. Inflammation of the Bladder. 17. HYSTER1TIS. Inflammation of the Womb. 18. ORCHITIS. Inflammation of the Testicles. GEN. VIII OPHTHALMIA. Ophthalmy. SPEC.l. O TARAXIS. Lachrymose Oph- thalmy. 2, IRIDIS. Inflammation of the Iris. 3. PUR I LENTA. Purulent Oph- thalmy. 4. GLUTINOSA. Glutinous Oph- thalmy. 5. STAPHYLOMA. Protuberant Eye. 6. ECiROPIUM. Everted Eye-lid. 7. ENTR >PIUM. Inverted Eye-lid. GEN. IX. CATARRHUS. Catarrh. SPEC. 1. C. COMMUNIS. Cold in the Head or Chest. 2. EPIDEMICUS. Influenza. GEN. X. DYSENTERIA. Dyseniery. SPEC. I. D. ACUTA. Acute Dysentery. 2. CHRONICA. Chronic Dysentery. CL. III.-OR. IV.] TABLE OF CLASSIFICATION. XX1U GEN. XI. BUCNEMIA. Tumid Leg. SPEC. 1. B. SPARGANOSIS. Puerperal Tumid Leg-. 2. TROPICA. Tumid Leg of hot climates. GEN. XII. ARTHROSIA. Articular Inflammation. SPEC.l. A.ACUTA. Acute Rheumatism 2. CHRONICA. Chronic Rheuma- tism 3. PODAGRA. Gout. 4. HYDARTHRUS. White-swelling. ORD. III. EXANTHEMA- TICA. ERUPTIVE FEVERS. EXAN- THEMS. GEN. I. ENANTHESIS. Rash Exanthem. SPEC.l. E.ROSALIA. Scarlet Fever. 2. RUBEOLA Measles 3. URTICARIA Nettle-rash. GEN. II. EMPHLYSIS. Ichorous Exanthem. SPECIE E. MILIARIA. Miliary Fever. 2. APTHA. Thrush. 3. VACCINIA. Cow-pox. 1. VARICELLA. Water-pox. 5. PEMPHIGUS. Vesicular or Blad- dery Fever. r. ERYSIPELAS. St. Anthony sFire. GEN. Ill, EMPYESIS. Pustulous Exanthem. SPEC. 1. E. VARIOLA. Small-pox. GEN. IV. ANTHRACIA. Carbuncular Exanthem. SPEC. 1. A. PESTIS. Plague. 3. RUBULA. Yaws. ORD. IV. DYSTHETICA. CACHEXIES. GEN. I. PLETHORA. Plethora. SPEC.l. P ENTONTCA. Sanguine Plethora. 2. ATONICA. Serous Plethora. GEN. II. HEMORRHAGE*. Hemorrhage. SPEC 1. H. ENTONICA. Entonic Hemor- rhage. 2. ATONICA. Atonic Hemorrhage. GEN. III. MARASMUS. Emaciation. SPEC.l. M.ATROPHIA. Atrophy. - 2. ANHiEMIA. Exsanguinity. 3. CLLV1ACTEKICUS. Decay of Nature. 4. TABES. Decline. 5. PHTHISIS. Consumption. GEN. IV. MELANOSIS. Melanose. SPEC.l. M.TUBERCULARIS. Tubercular Mela- XXIV TABLE OF CLASSIFICATION. [CL. III.-OR. IV. GEN. V. STRUMA. Scrophula. SPEC. 1. S. VULGARIS. King's Evil. GEN. VI. CARCINUS. Cancer. SPEC. 1. C. VULGARIS. Common Cancer. GEN. VII. LUES. Venereal Disease. SPEC. 1. L. SYPHILIS Pox. 2. SYPHILODES. Bastard Pox. GEN. VIII. ELEPHANTI- ASIS. Elephant-Skin. SPEC. 1. E. ARABICA. Arabian Elephanti- asis. Black Le- prosy. 2. ITALICA. Italian Elephanti- asis. 3. AS> iJRIENSIS. Asturian Elephan- tiasis. GEN. IX. CATACAUSIS. Catacausis. SPEC. 1. C. EBRIOSA. Inebriate Cata- causis. GEN. X. PORPHYRA. Scurvy. SPEC.l. P.SIMPLEX. Petechial Scurvy. SPEC. 2. P. HEMORRHAGICA. Land Scurvy. 3. NAUTICA. Sea Scurvy. GEN. XL EXANGIA. Exangia. SPEC 1. E.ANEURISMA. Aneurism. 2. VARIX. Varix. 3. CYANIA. Blue-skin. GEN. XII. GANGRENA. Gangrene. SPEC.l. G. SPHACELUS. Mortification. 2. U.'ilLAGSNEA. Mildew-mortifica- tion. 3. NECROSIS. Dry Gangrene. 4. CARIES. Caries. GEN. XIII. ULCUS. Ulcer. SPEC.l. U. INCARNANS. Simple healing Ulcer. 2. VITIOSUM. De[/raved Ulcer. 3. SINUOSUM. Sinuous Ulcer. 4. TUBKRCULOSUM. Warty, excrescent Ulcer. 5. CARIOSUM. Carious Ulcer. CL. IV.-OR. II.] TABLE OF CLASSIFICATION. xxr CLASS IV. NEUROTICA. DISEASES OF THE NERVOUS FUNCTION. ORD. I. PHRENICA. AFFECTING THE INTELLECT. GEN. I. ECPHRONIA. Insanity. Craziness. SPEC. 1. E. MELANCHOLIA. Melancholy. 2. MANIA. Madness. GEN. II. EMPATHExMA. Ungovernable Passion. SPEC. 1. E. ENTONICUM. Impassioned Ex- citement. 2. ATONICUM. Impassioned De- pression. 3. INANE. Hare-brained Passion. GEN. III. ALUSIA. Illusion. Hallucination. SPEC .1. A.ELATIO. Sentimentalism-Mental Extra- 2. vagance. HYPOCHONDRIAS. Hypochondrism. Low Spirits. GEN. IV. APHELXIA. Revery. SPEC. 1 A. SOCORS. Absence of Mind. 2. INTENTA. Abstraction of Mind. 3. OTIOSA. Vol. Brown-Study. I.-—4 GEN. V. PARON1RIA. Sleep-Disturbance. SPEC. 1. P. AMBULANS. Sleep-walking. 2. LOQUENS. Sleep-talking. 3. SALAX. Night Pollution. GEN. VI. MORIA. Fatuity. SPEC.l. M.IMBECILIS. Imbecility. 2. DEMENS. Irrationality. ORD. II. iESTHETICA. AFFECTING THE SENSATION. GEN. I. PAROPSIS. Morbid Sight. SPEC. 1. P. LUCIFUGA. Night-Sight. 2. NOCTIFUGA. Day-Sight. 3. LONGINQUA. Long-Sight. 4. PROPINQUA. Short-Sight. 5. LATERALIS. Skew-Sight. 6. ILLUSORIA. False-Sight. 7. CALIGO. Opake Cornm. 8. GLAUCOSIS. Humoral Opacity. 9. CATARRACTA. Cataract. 10. SYNIZESIS. Closed Pupil. 11. AMAUROSIS. Drop Serene. 12. STRABISMUS Squinting. XXVI TABLE OP CLASSIFICATION. [CL. IV.-OR. Ill GEN. II. PARACUSIS. Morbid Hearing. SPEC.l. P.ACRIS. Acrid Hearing. 2. OBTUSA. Hardness of Hear- ing. 3. PERVERSA. Perverse Hearing. 4. DUPLICATA. Double Hearing. 5. ILLUSORIA. Imaginary Sounds. 6. SURDITAS. Deafness. GEN. III. PAROSMIS. Morbid Smell. SPEC.l. P.ACRIS. Acrid Smell. 2. OBTUSA. Obtuse Smell. %. EXPERS. Want of Smell. GEN. IV. PARAGEUSIA Morbid Taste. SPEC.l. P.ACRIS. Acrid Taste. 2. OBTUSA. Obtuse Taste. 3. EXPERS. Want of Taste. GEN. V. PARAPSIS. Morbid Touch. SPEC.l. P.ACRIS. Acrid Sense of Touch or gene- ral Feeling. 2. EXPERS. Insensibility of Touch or gene- ral Feeling. % ILLUSORIA. Illusory Sense of Touch or gene- ral Feeling. GEN. VI. NEURALGIA. JVerve-ache. SPEC. 1. N. FACIEI. Nerve-ache of tlie Face. 2. PEDIS. Nerve-ache of the Foot. 3. MAMMiE. Nerve-ache of the Breast. ORD. III. CINETICA. AFFECTING THE MUSCLES. GEN. I. ENTASIA. Constrictive Spasm. SPEC.l. E.PRIAPISMUS. Priapism. 2. LOXIA. Wry Neck. 3. RHACHYBIA. Muscular Distor- tion of the Spine, 4. ARTICULARIS. Muscular Stiff- joint. 5. SYSTREMMA Cramp. 6. TRISMUS. Locked-jaw. •7. TETANUS. Tetanus, 8. LYSSA. Rabies. Canine Madness. 9. ACROTISMUS. Suppressed Pulse. GEN. II. CLONUS. Clonic Spasm. SPEC.l. C. SINGULTUS. Hiccough. 2. STERNUTATIO. Sneezing. 3. PALPITATIO. Palpitation. 4. NICTITATIO. Twinkling of th? Eye-lids. L. IV.-OR. IV.J TABLE OP CLASSIFICATIOS XXVll SPEC. 5. C. SUBSULTUS. Twitching of the Tendons. 6. PANDICULATIO. Stretching. GEN. III. SYNCLONUS. Synclonic Spasm. SPEC. 1. S. TREMOR. Trembling. 2. CHOREA. St. Vitus's Dance. 3. BALLISMUS. Shaking Palsy. 4. RAPHANIA. Raphania. 5. BERIBERIA. Barbiers. ORD. IV. SYSTATICA. AFFECTING SEVERAL OR ALL THE SENSORIAL POAVERS SIMULTANEOUSLY. GEN. I. AGRYPNIA. Sleeplessness. SPEC.l. A. EXCITATA. Irritative Wake- fulness. 2. PERTESA. Chronic Wakeful- ness. GEN. II. DYSPHORIA. Restlessness. SPEC.l. D. SIMPLEX. Fidgets. 2. ANXIETAS. Anxiety. GEN. III. ANTIPATHIA. Antipathy. SPEC.l. A. SENSILIS. Sensile Antipathy. % INSENSILIS. Tnsensih Antipa- thy. GEN. IV. CEPHALEA Head-ache. SPEC. 1. C. GRAVANS. Stupid Head-ache. 2. INTENSA. Chronic Head-ache. 3. HEMICRANIA. Megrim. 4. PULSATILIS. Throbbing Head- ache. o. NAUSEOSA. Sick-head-ache, GEN. V. DINUS. Dizziness. SPEC.l. D. VERTIGO. Vertigo. GEN. VI. SYNCOPE. Syncope. SPEC. l. S. SIMPLEX. Swooning. 2. RECURRENT Fainting-fit. GEN. VII. SYSPASIA. Comatose Spasm. SPEC. 1. S. CONVULSIO. Convulsion. 2. HYSTERIA. Hysterics. 3. EPILEPSIA. Epilepsy. GEN. VIII. CARUS. Torpor. SPEC.l. C.ASPHYXIA. Asphyxy. Suspend- ed Animation. 2. ECSTASIS. Ecstasy. 3. CATALEPSIA Catalepsy. 4. LETHARGUS. Lethargy. 5. APOPLEXIA. Apoplexy. G. PARALYSIS, Palsy. XXViii TABLE OF CLASSIFICATION. [CL. Y.-OR. CLASS V. GENETICA. DISEASES OF THE SEXUAL FUNCTION. ORD. I. CENOTICA. AFFECTING THE FLUIDS. GEN. I. PARAMENIA. Mis-menstruation. SPEC. 1. P- OBSTRUCTIONS. Obstructed Men struation. 2. DIFFICILIS. Laborious Men- struation. 3. SUPERFLUA. Excessive Men- struation. 4. ERRORIS. Vicarious Men- struation. 5. CESSATIONIS. Irregular Cessa- tion of the Menses. GEN. IL LEUCORRHCEA. Whites. SPEC.l. L. COMMUNIS. Common Whites. 2. NABOTHI. Labour-show. 3. SENESf EN riUM. Whites of Ad- vanced Life. GEN. III. BLENORRHCEA. Gonorrhcea. SPEC. 1. B. SIMPLEX. Simple Urethral Running. 2. LUODES. Clap. 3. CHRONICA. Gleet. GEN. IV. SPERMOR- RH(EA. Seminal Flux. SPEC.l. S. ENTONICA. Entonic Seminal Flux. 2. ATONICA. Atonic Seminal Flux. GEN. V. GALACTIA. Mislactation. SPEC. 1. G. PREMATURA. Premature Milk- flow. 2. DEFECTIVA. Deficient Milk- flow. 3. DEPRAVATA. Depraved Milk- flow. 4. ERRATICA. Erratic Milk-flow. 5. VIRORUM. Milk-flow in Males. ORD. II. ORGASTICA. AFFECTING THE ORGASM. GEN. I. CHLOROSIS. Green • Sickness. SPEC. 1. C. ENTONICA. Entonic Greenr Sickness. 2. ATONICA. Atonic Green Sickness. GEN. II. PR(EOTIA. Genital Precocity. SPEC.l. P. MASCULINA. Male Precocity. CL. V.-OR. III. J TABLE OF CLASSIFICATION. Xxi.X SPEC. 2. P.FEMININA. Female Precocity. GEN. III. LAGNESIS. Lust. SPEC. 1. L. SALACITAS. Salacity. 2. FUROR. Lascivious Mad- ness. GEN. IV. AGENESIA. Male Sterility. SPEC. 1. A. IMPOTENS. Male Impotency. 2. DYSPERMIA. Seminal-Mis-emis- sion. 3. INCONGRUA. Copulative Incon- gruity. GEN. V. APHORIA. Female Sterility. Barrenness. SPEC. 1. A. IMPOTENS. Barrenness of Im- potency. 2. PARAMENICA. Barrenness of Mis- menstruation. 3. IMPERC1TA. Barrenness of Ir- respondence. 4. INCONGRUA. Barrenness of In- congruity. GEN. VI. ^DOPTOSIS. Genital Prolapse. SPEC. 1. A. UTERI Falling down of the Womb. 2. VAGINA. Prolapse of the Vagina. 3. VESICA. Prolapse of the Bladder. 4. COMPLICATA. Complicated Ge- SPEC. 5. A.POLYPOSA. Genital Excres- cence. ORD. III. CARPOTICA. AFFECTING THE IMPREGNA- TION. GEN. I. PARACYESIS. Morbid Pregnancy. SPEC. 1. P. IRRITATIVA. Constitutional de- rangement of Pregnancy. 2. UTERINA. Local derange- ment of Preg- nancy. 3. ABORTUS. Abortion. GEN. II. PARODYNIA. Morbid Labour. SPEC.l. P. ATONICA. Atonic Labour. 2. IMPLAST1CA. Unpliant Labour. 3. SYMPATHETICA. Complicated La- bour. 4. PERVERSA. Preternatural Pre- sentation. 5. AMORPHICA. Impracticable La- bour. 6. PLURALIS. Multiplicate La- bour. 7. SECUNDARIA. Sequential Labour. GEN. III. ECCYESIS. Extra-uterine Fetation. SPEC. 1. E. OVARIA. Ovarian Exfeta,- tion. 2. TUBALIS. Tubal Exfetation. 3. ABDOMINAL! S. Abdominal Exfe- VXX TABLE OF CLASSIFICATION. [CL. VI.-OR. II, GEN. IV. PSEUDOCYESIS. Spurious Pregnancy. SPEC. 1. P. MOLARIS. Mole. SPEC. 2. P.INANIS. False Conception. CLASS VI. ECCRITICA. DISEASES OF THE EXCERNENT FUNCTION. ORD. I. MESOTICA. AFFECTING THE PARENCHYMA. GEN. I. POLYSARCHIA. Corpulency. SPEC. 1. P. ADIPOSA. Obesity. GEN. II. EMPHYMA. Tumour. SPEC. 1. E. SARCOMA. Sarcomatous Tu- mour. 2. ENCYSTIS. Encysted Tumour. 3. EXOSTOSIS. Bony Tumour. GEN^. III. PAROSTIA. Mis -ossification. SPEC. 1. P. FRAGILIS. Fragility of the Bones. 2. FLEXILIS. Flexility of the Bones. GEN. IV. CYRTOSIS. Contortion of the Bones. SPEC.l. C. RHACHIA. Rickets. 2. CRETINISMUS. Cretinism. GEN. V. OSTHEXIA. Osthexy. SPEC.l. O. INFARCIENS. Parenchymatous Osthexy. SPEC. 2. O. IMPLEXA. Vascular Osthexy. ' ORD. II. CATOTICA. AFFECTING INTERNAL SUR- FACES. GEN. I. HYDROPS. Dropsy. SPEC. 1. H. CELLULARIS. Cellular Dropsy. 2. CAPITIS. Dropsy of the Head. 3. SPINiE. Dropsy of the Spine. 4. THORACIS. Dropsy of the Chest. 5. ABDOMINIS. Dropsy of the Belly. 6. OVARIL Dropsy of the Ova- ries. 7. TUBALIS. Dropsy of the Fal- lopian Tubes. 8. UTERI. Dropsy of the Womb. 9. SCROTI. Dropsy of the Scro- tum. GEN. II. EMPHYSEMA. Inflation. Wind-Dropsy. SPEC. 1. E. CELLULARE. Cellular Inflation. 2. ABDOMINIS. Tympany. CL. VI.-OR. III.] TABLE OP CLASSIFICATION. XXXI GEN. HI. PARURIA. Mis-micturition. SPEC.l. P.INOPS. Destitution of 2. RETENTIONS. Stoppage of Urine. 3. ST1LLAT1T1A. Strangury. 4. f MELLITA. Saccharine Urine. Diabetes. 5. INCONTINENT Incontinence of Urine. 6. INCOCTA. Unassimilated Urine. 7. ERRATICA. Erratic Urine. GEN. IV. LITHIA. Urinary Calculus. SPEC.l. L.RENALIS. Renal Calculus. 2. VESICALIS. Stone in the Blad- der. ORD. III. ACROTICA. AFFECTING THE EXTERNAL SURFACE. GEN. I. EPHIDROSIS. Morbid Sweat. SPEC.l. E.PROFUSA. Profuse Sweat, 2. CRUENTA. Bloody Sweat. 3. PARTIALIS. Partial Sweat. 4. DISCOLOR. Coloured Sweat. 5. OLENS. Scented Sweat. 6. ARENOSA. Sandy Sweat. GEN. II. EXANTHESIS. Cutaneous Blush. SPEC.l E, ROSEOLA. Rose-rash. GEN. III. EXORMIA. Papulous Skin. SPEC. 1. E. STROPHULUS. Gum-rash. 2. LICHEN. Lichenous-rasJi. 3. PRURIGO. Pruriginous-rash. 4. MILIUM. Millet-rash. GEN. IV. LEPIDOSIS. Scale-Skin. SPEC. 1. L. PITYRIASIS. Dandriff. 2. LEPRIASIS. Letyrosy. 3. PSORIASIS. Dry-Scall. 4. ICTHYIASIS. Fish-Skin. GEN. V. ECPHLYSIS. Blains. SPEC. 1. E. POMPHOLYX. Water-blebs. 2. HERPES.* Tetter. 3. RHYPIA. Sordid Blain. 4. ECZEMA. Heat Eruption- GEN. VI. ECPYES1S. Humid Scall. SPEC.l. E. IMPETIGO. Running Scall. 2. PORRIGO.f Scabby Scall. 3. ECTHYMA. Papulous Scall. 4. SCABIES. Itch. GEN. VII. MALIS. Cutaneous Vermination. SPEC.l. M.PEDICULI. Lousiness. * y Shingles. S Ring*worm. t * Scalled-head. XXXil TABLE OP CLASSIFICATION. [CL. VI.-OR. III. SPEC. 2. M.PULICIS. Flea-bites. 3. ACARI. Tick-bite. 4. FILARI.E. Guinea Worm. 5. (ESTRI Gad-fly bite. 6. GORDII. Hair Worm. GEN. VIII. ECPHYMA. Cutaneous Excrescence. SPEC.l. E. CARUNCULA. Caruncle. 2. VERRUCA. Wart. 3. CLAVUS. Corn. 4. CALLUS. Callus. GEN. IX. TRICHOSIS. Morbid Hair. SPEC.l. T. SETOSA. Bristly Hair. 2. PLICA. Matted Hair. 3. HIRSUT1ES. Extraneous Hair, SPEC. 4. T. DISTRIX. Forky Hair. 5. POLIOSIS. Gray Hairs. 6. ATHRIX. Baldness. 7. AREA. Areated Hair. 8. DECOLOR. MiscolouredHair. 9. SENS1TIVA. Sensitive Hair. GEN. X. EPICHROSIS. Macular-Skin. SPEC. 1. E. LEUCASMUS. Veal-Skin. 2. SPILUS. Mole. 3. LENTICULA. Freckles. 4. EPHELIS. Sun-burn. 5. AURIGO. Orange-Skin. 6. PtECILIA. Pye-balled-Skin. 7. ALPHOSIS. Albino-Skin. ♦ *♦ CLASS I. Vol. I.—5 / CLASS I. C(ELIACA. DISEASES OF THE DIGESTIVE FUNCTION. ORDER I. ENTERICA. DISEASES AFFECTING THE ALIMENTARY CANAL. II. SPLANCHNICA. DISEASES AFFECTING THE COLLATITIOU6 VISCERA, CLASS L PHYSIOLOGICAL PROEM The first class of diseases that call for our attention, upon the General physiological arrangement proposed in the present work, consists of AedkeMes those which primarily affect, or commence in, the digestive organs, of the elm. and impede the digestive function. I say primarily affect or com- mence in these organs, because the same parts may be affected in a secondary manner, by sympathy or induction, in consequence of diseases that originate elsewhere, and which on this account do not belong to the present class. Of these, numerous examples will oc- cur to us as we proceed. Now in order to obtain a clear idea of the nature of the diseases Digestive before us, it is necessary to have a distinct knowledge of the organs org which are the seat of them, and of the functions which they em- brace. To follow up this inquiry into a very minute detail, is the joint province of anatomy, physiology, and animal chemistry : and a finished practitioner must derive his information from these three sources collectively, pursued through an extent of many volumes. But for the purpose immediately before us, it may be sufficient to concentrate the subject, and to present a general and connected view of those parts of it which directly relate to the organs appro- priated to the digestive process, constituting the field of diseases which the present class is designed to comprehend. There is no animal function that displays a greater diversity of Biffestiye means for its performance than that of digestion ; and perhaps the only point in which animals of all classes agree upon this subject, is in the possession of an internal canal or cavity of some kind or other, into which the food is introduced, and prepared for nutrition; an agreement which may be regarded as one of the leading features by which the animal structure is distinguished from the vegetable. Let us, then, in the first place, trace this cavity as it exists in man and the more perfect animals; and next observe the organs that are supposed to be auxiliary to it, and the powers by which it ac- complishes its important trust. The alimentary cavity in man extends from the mouth through Aal^en,ary the whole range of the intestinal canal; and hence its different parts are of very different diameters. In*the mouth, where it commences, it is comparatively wide; it contracts in the esophagus ; then again widens to form the stomach, and afterwards again contracts into the tube of the intestines. This tube itaelf is also of different diameters a6 PHYSIOLOGICAL PROEM. in different parts of its extent; and it is chiefly on this diversity ot magnitude that anatomists have established its divisions. Its general length is five or six times that of the man himself; and, in children, not less than ten or twelve times, in consequence of their diminutive stature- In some animals it is imperforate, the dross of the food being rejected by the mouth. It is so occasionally in birds, and fishes ; perhaps in the medicinal leech (hirudo sanguisuga, or mcd,i- cinalis); though Cuvier,* in opposition to the assertion of Dumerilt and others, contends that this has a very small open anus. In zoophytes it is almost uniformly imperforate. In man himself it is sometimes found imperforate on birth, with a preternatural outlet to supply the place of an anus in some neigh- bouring part or organ, as the bladder, in which case the feces have been discharged by the urethra; the vagina; the navel; or the groin. The most extraordinary instances of accommodation of this kind which I have ever met with in the collections of medical curiosities, is that of a girl who, from birth, was imperforate both in the anus, and meatus urinarius; in fact in the whole division of the vulva : and who to the age of fourteen, when the account was written, had regularly discharged her urine by the breasts after the manner of milk, and her feces by a natural vomiting or rejection from the sto- mach.}; Reiaivoex- Generally speaking, the extent of the digestive cavity bears a re- ^"mentury6 lation to the nature of the aliments by which the individual is design- cavity. et| to be nourishe(i. The less analogous these aliments are to the substance of the animal they are to recruit, the longer they must remain in the body to undergo the changes that are to assimilate them. Hence the intestinal tube of herbivorous animals is for the most part (for we still meet with exceptions) very long, or in par- ticular portions very capacious ; in various kinds very complicated. and often double or triple. Thus in the horse the large intestines; are of an enormous size, and dilated into sacculi, while the coecunj is as capacious as the stomach. In the ruminant animals the stomach is not only peculiarly complicated, but often, as in the rain, twenty- seven times the length of the body. Carnivorous animals on the contrary have a short*and straight canal; the food on which they feed, being already of their own nature, and containing a larger quan- tity of nourishment in a less bulk ; and hence demanding a smaller proportion of time and space to become fit for use. In this respect man maintains a medium between the two. His digestive canal is less spacious or complex than that of most mammals that feed on grass alone, yet more so than that of most Omnivo- mammals that feed on a diet of their own nature. Man is hence TfThe'hiT-" omnivorous ; and is capable of subsisting on an aliment of either man stom- Sort; and from the nature of his digestive, as well as of various other organs, is better qualified for every diversity of aliment and climate than any other animal. Thus many nations in a savage state live almost, perhaps altogether, on frtiits and roots ; as those of the vam, beet, and potatoe, the bread-fruit-tree, bread-nut (brosimum alicas- * Lecons d' Anat. Comp. Sim. iv. p. 141. t Zoolo&ie Ajiatomifptc, p. 29?, I Samml. Medi- served upon this, and has divided the proper membranes of the proper** animal frame into three kinds, serous, mucous, and fibrous. The seroug"'"'8, first forms a common external coating for the viscera, whether sub- stantial or hollow; it is possessed of few nerves, and is lubricated - by a perpetually ascending halitus. The second or mucous mem- Mucous, branes form an internal coating to the large tubes and hollow viscera, mostly connected with the skin at their extremities, as the mouth, nostrils, esophagus, and intestines ; the cavities of the urinary and the uterine systems. They are enriched with numerous nerves, and are loaded with minute glands in their structure, which secrete a muculent fluid with which the interior surface of the organs is constantly moistened. The third or fibrous division of membranes Fibrous belongs to another set of organs than those before us, and consists * Phil; Trass. Sir E. Home, 1602, part I. and IT 4U PHYSIOLOGICAL PROEM. of the dura mater, which lines the skull, the membranous expansions of the muscles, the capsules of the joints, and the sheaths of the tendons. Manduca- The solid materials of the food are first masticated and moistened in the mouth and fauces, except when they are swallowed whole ; and, in this state, are introduced into the stomach, by whose action they are converted into a homogeneous pulp or paste, which is called chyme; they are then in this pultaceous form introduced into the duodenum, and by an additional operation, transmuted into a fluid, for the most part of a milky appearance, denominated chyle ; in which state they are absorbed or drank up voraciously by thousands and tens of thousands of little mouths of very minute vessels, which are sparingly, if at all found in the stomach, but which line the whole of the interior coating of the^ small intestines into which the stomach empties itself, and where they are excited by the flow of the fluid to Ucteais. the act of absorption. These vessels constitute a distinct part of the lymphatic system. From the milky appearance of their contents they are known by the name of lacteals : they anastomose or unite together gradually, and at length terminate in one common trunk, denominated the thoracic duct, which conveys the different streams thus collected from the alimentary canal, as well as from other parts of the body, to> the sanguiferous system to be still further operated upon by the action of the heart and lungs. Chymifac- T' e means by which the food is broken down into a pulp, after being received into the stomach, are various. In the first place, the muscular tunic of the stomach acts upon it by a slight contraction of its fibres ; and, in connexion with a certain degree of pressure derived from the surrounding organs, produces, so far as this cause operates, a mechanical resolution. Secondly, the high temperature maintained in the stomach by the quantity of blood contained in the neighbouring viscera and sanguiferous vessels, gives it the benefit of accumulated heat, and so far produces a concoctive resolution. And thirdly, the stomach itself secretes and pours forth from the mouth of its minute arteries a very powerful solvent, which is by far the chief agent in the process, and thus effects a chemical resolution. chiiifac- In this manner the moistened and manducated food becomes converted into chyme. It then passes into the duodenum, and becomes mixed with the secretions poured into this organ from the pancreas, the liver, and the substance of the duodenum itself, and subject to their action ; and hence its conversion into chyle. Chyle. Chyle, therefore, is obviously a very complicated fluid, and con- sists of the dissolved materials of the food and the juices poured forth from the salivary glands, the stomach, pancreas, duodenum, and liver. The several proportions of these juices have been vari- ously estimated, though there can be no doubt that the general ag- gregate amounts to considerable more than the bulk of the aliment which they hold in solution. General The whole process of digestion, therefore, as it occurs in the Higestfonf numan fabric, to which the description now given chiefly applies, consists of three acts, manducation, or chewing, chymifaction, and chylifaction. The entire course is generally run through in about PHYSIOLOGICAL PROEM. 41 three hours ; and under certain states of the system, to which I shall advert presently, almost as quickly as the food is swallowed. The most important of these three acts is that of chymifaction, or the part contributed by the stomach itself; and while this is taking place both orifices of the organ are closed, and a degree of chilliness is often felt over the body, and particularly in persons of a weakly habit, in consequence of the demand which the stomach makes upon it for an auxiliary supply of heat to assist in the process which is taking place. M. Magendie's experiments induce him to calculate, that a dog, upon an average, forms about six ounces of chyle every hour; to which no colouring matter in the intestines imparts a hue.* " The drink" says Mr. Cruickshank, " taken into the stomach of JJ^*^, a man, may be two pounds in twenty-four hours : the saliva swal- of the al- lowed may be one pound in the same period; the gastric juice, ^Ces. another; the pancreatic juice, another. The bile poured into the intestines, Haller supposes, about twenty ounces, besides the fluid ■ secreted through the whole length of the internal surfaces of the intestines."! The intestinal secretion here alluded to, was estimated by baron Haller at eight pounds in the twenty-four hours : but M. Blumen- bach regards this estimate as extravagant.J There are many substances which are so hard and intractable as glances? to sustain the action of the digestive organs without any other change than that of being softened or otherwise partially affected, instead of being entirely subacted, and reduced to chyme or chyle. Such especially are the seeds of plants : and it is well worth observ- ing, though it has not yet been noticed by physiologists, that while birds or other animals derive from this kind of food a very valuable nutriment, notwithstanding its passing through them without being completely digested, the seeds themselves that are thus acted upon, derive also a reciprocal benefit in many instances; and are here- by rendered more easily capable of expanding in the soil into whieh they are afterwards thrown as by accident, and have their produc- tive power very greatly increased. The olive-tree has, till of late j^f"1^ years, only been raised in the south of France by cuttings, or wild rearing plants obtained from the woods. It was remarked by an attentive o]lveSl inhabitant of Marseilles, that when produced naturally, it is by means of kernels carried into the woods, and sown there by birds which had swallowed the olives. By the act of digestion, he fur- ther observed, these olives are deprived of their natural oil, and the kernels hence become permeable to the moisture of the earth ; the dung of the bird at the same time serving for manure, and perhaps the soda which the dung contains, by combining with a portion of the oil that has escaped digestion, still further favouring germination. Following up this fact, a number of turkeys were made by the ex- perimenter to swallow ripe olives, the dung was collected containing the swallowed kernels, the whole was placed in a stratum of earth, * Precis de Physiologie, vol. ii. 155. t Cruickshank, Anat. of Absorb. Vessels, p. 106. X Institut. Pbysiol. Sect, 'xxvii. p. 410. Vol. J.—6 At PHYSIOLOGICAL PROEM. and frequently watered. The kernels thus treated vegetated easily: and a number of young plants were procured. And in order to produce upon olives an effect similar to that experienced from the digestive power of the stomach, a quantity of them were afterwards macerated in an alkaline lixivium ; they were then sown, and proved highly productive. Vegetation Most of the plants found on coral islands, and in various other Cy°a^imai places, are propagated by the same means of passing through the dejections, digestive canal; and it is probable that the seeds of many of them are equally assisted by the same process. And even when they are completely disorganized and digested, the material'to which their refuse is converted, and which combined with the animal secretions that accompany it, is called dung, very powerfully contributes, as every one knows, to render the soil productive. So that, in the wisdom of Providence, animal digestion and vegetable fructification are equally dependent on each other, and are alternately causes and effects. Early hypo- Considering the comparatively slender texture of the chief di- c«n?nS°he gesting organ, and the toughness and solidity of the substance it po\m.VC overcomes, it cannot appear surprising, that mankind should, at different times, have run into a variety of mistaken theories in ac- counting for its mode of action. Empedocles and Hippocrates supposed the food to become softened by a kind of putrefaction. Galen, whose doctrine descended to recent times, and was zealously supported by Grew and Santarelli, ascribed the effect to concoction produced, like the ripening and softening of fruits beneath a sum- mer sun, by the high temperature of the stomach from causes I have just pointed out. Pringle and Macbride advocated the doc- trine of fermentation, thus uniting the two causes of heat and pu- Irefaction assigned by the Greek writers: while Borelli, Keil, and Pitcairn resolved the entire process into mechanical action, or tritu- ration ; thus making the muscular coating of the stomach an enor- mous mill-stone, which Dr. Pitcairn was extravagant enough to con- ceive ground down the food with a pressure equal to a weight of not less than a hundred and seventeen thousand pounds, assisted at the same time, in its gigantic labour, by an equal pressure de- rived from the surrounding muscles. Their fuii- Each of these hypotheses, however, was encumbered with insu- perable objections: and it is difficult to say which of them was most incompetent to explain the fact for which they were invented. Boerhaave endeavoured to give them force by interunion, and hence united the mechanical theory of pressure with the chemical theorv of concoction ; while Haller contended for the process of macera- tion ; but still a something else was found wanting, and continued to be so, till Cheselden, in lucky hour, threw out the hint, for at first it was nothing more than a hint, of a menstruum secreted in some part of the digestive system : a hint, which was soon eagerly laid hold of and successfully followed up by Haller, Reaumur, Spallanzani, and other celebrated physiologists: and though Cheselden was mistaken discovery in the peculiar fluid to which he ascribed the solvent energy, namely Wuicf"* the saliva, still he led forward to the important fact; and the gastric PHYSIOLOGICAL PROEM. 43 juice was soon afterwards clearly detected, and its power incontro- vertibly established. This wonderful menstruum, the most active we are acquainted §;"an*tty-£t: with in nature, is secreted, as I have already observed, by the ca- juice. pillary arteries that infinitesimally intersect the cellular texture of the stomach, and decussate each other in their ramifications. Mr. Cruickshank supposes the quantity of the fluid thus secreted to be a pound in every twenty-four hours. Yet the quantity seems to vary very considerably according to the demand of the system, or the state of the stomach itself. In carnivorous birds whose stomachs are mem- branous alone, and consequently whose food is chymified by the sole action of the gastric juice without any collateral resistance, or pre- vious mastication, this fluid is secreted in a much larger abundance : as it is also in those that labour under that morbid state of the stomach which is called canine appetite, and will be distinguished in the present classification by the name of limosis avens; as like- wise when, on recovery from a fever, or after long abstinence, the system is reduced to a state of great exhaustion, and a keen sense of hunger induces a desire to devour food voraciously, and almost perpetually. When pure and in a healthy state, the gastric juice is a thin, £™'f transparent, and uninflammable fluid, of a weak saline taste, and juice. destitute of smell. Generally speaking, it has a near resemblance in its external properties to the saliva, and is neither acid, nor al- kaline ; though in these qualities it seems to vary more or less, not only in animals whose digestive organs are of a different structure from those of man, but even in the same animal under different circumstances. It may, however, be laid down as a common rule that, in carnivorous and graminivorous animals, possessing only a single stomach, this fluid is slightly acid, and colours blue vegetable juices red : in omnivorous animals, as man, whose food is composed of vegetable and animal materials indifferently, it is neutral; and in graminivorous ruminating animals, with four stomachs, and particu- larly in the adults of these kinds, it is slightly alkaline, and colours blue vegetable juices green. This singular secretion has the peculiar property of coagulating milk, as well as all albuminous substances, which it also as com- pletely dissolves ; and hence the milk thrown up from the stomach of an infant shortly after sucking is always found in a curdled state. But the two grand and characteristic properties of the gastric juice, are its astonishing power of counteracting, and correcting putre- faction, and of dissolving the toughest and most rigid substances in nsiturG Of its antiseptic power abundant proofs may be adduced from ^optic every class of animals. Among mankind, and especially in civilized the gastric life, the food is usually eaten in a state of sweetness and freshness : JUIC°' but fashion and the luxurious desire of having it subacted and mellow- ed to our hands, tempt us to keep several kinds, as game and vension for example, as long as we can endure the smell. The wandering hordes of gipsies, however, and the inhabitants of various savage countries, and especially those about the mouth of the Orange Rivr-r 44 PHYSIOLOGICAL PROEM. in Africa, carry this sort of luxury to a much higher pitch ; for they seem to regard a fetor as a perfume, and value their food in proportion as it approaches putrefaction. Now all these foods, whatever be the degree of their putridity, are equally restored to a state of sweetness by the action of the gastric juice, a short time after they have been introduced into the stomach. Dr. Fordyce made a variety of experiments in reference to this sub- ject upon the dog ; and found in every instance, that the most putrid meat he could be made to swallow, was in a very short period de- prived of its putrescency. We cannot therefore be surprised that crows, vultures, and hyenas, who find a pleasure in tainted flesh, should fatten upon so impure a diet; nor that the dunghill should haVe its courtiers, among insects, as well as the flower-garden. The gastric juice has hence been employed as an antiseptic in a variety of cases out of the body. Spallanzani has ascertained that the gastric juice of the crow and the dog will preserve veal and mutton perfectly sweet, and without loss of weight, thirty-seven days in winter ; whilst the same meats, immersed in water, emit a fetid smell as early as the seventh day, and by the thirtieth are resolved into a state of most offensive putridity. Gastric Physicians and surgeons have, in like manner, availed themselves p"oCyeed"me- of this corrective quality; and have occasionally employed the gastric dieinaliy. juice of various animals ; internally, in cases of indigestion from a debilitated stomach ; and, externally, as a check to gangrenes, and a stimulus to impotent and indolent ulcers. I do not know that this practice has hitherto taken place very largely in our own country, but it has been often resorted to on the Continent, especially in Italy and Switzerland, and in many cases with great success. Solvent Yet the gastric juice is as remarkable for its solvent, as for its an- the^astrie ^putrescent property. Of this any industrious observer may satisfy j"ice. himself by attending to the economy of digestion in many of our most common animals : but it has been strikingly exemplified in the ex- periments of Reaumur, Spallanzani, and Stevens.* Pieces of the toughest meats, and of the hardest bones, enclosed in small perforated tin cases, to guard against all muscular action, were repeatedly, by the two former of these physiologists, thrust into the stomach of a buzzard. The meats were uniformly found diminished to three fourths of their bulk in the space of twenty-four hours, and reduced to slender threads ; and the bones were wholly digested either upon the first trial, or a few repetitions of it. The gastric juice of a dog dissolves ivory and the enamel of the teeth ; that of a hen has been found to dissolve an onyx, and diminish a louis-d'or. And it is not many years ago that the handles of several clasp-knives were found half di- gested, and the blades blunted, in the stomach and intestines of a man who had some time before swallowed these substances out of hardihood, and at last died in one of the hospitals of this metropolis fhestomlh Tt is in c?nsequen,ce of this wonderful power that the stomach is to digest sometimes found in the extraordinary action of digesting its own self • itself. ' *^OT ?r;.St"CT»VXPerVnent8' Thich were num«ousand well conducted, see his Dissertatio Physiologica Inaugurahs; or an analysis of it in Edin. Med. Com- ment. vol. v. p. 146. PHYSIOLOGICAL PROEM. 45 and of exhibiting, when examined in dissection, various erosions in different parts of it, and especially about the upper half into which the gastric juice is supposed to flow most freely. It was the opinion of Mr. John Hunter,* however, that such a fact c.. I. SPECIES II. ODONTIA DOLOROSA. TOOTH-ACHE. ACUTE PAIN IN THE TEETH OR THEIR INVOLUCRES. Gen. I. There is often a considerable degree of pain of a particular kind Spec. II. that accompanies the irritation of the last species ; but it is rarely, if ever, of an acute character ; and is rather a sense of soreness about the tooth, than an ache within it: and hence the definitions now offered are sufficiently distinct. causes. Pain of this kind may be produced by various causes, as a catarrh, or cold; an exostosis, or deposit of ossific matter on the sides of a tooth or its socket; a caries or decay ; a peculiar affection of the nerves of the sockets or jaw-bone, acting upon a tooth by contiguous sympathy, and hence not relieved by extracting the tooth that is suspected. It may be produced also by some remote influence, as that of pregnancy, or sordes in the stomach ; by a peculiar diathesis, as that of rheumatism, or scurvy ; or whatever else tends to render the state of the fluids acrimonious, as a long use of mercury ; or by a transfer of action, as in some cases of gout, in which the pain is often most vehement and agonizing ; in various instances has pro- duced convulsions,* and in others delirium ;t or, in the language of the sufferers themselves, has actually driven them mad. In several of these cases, it is obvious, that it occurs as a mere symptom of some other disease ; and can only be cured by a removal of the dis- ease that gives rise to it. The following varieties, however, seem well worth attending to. and will generally be found to result from a primary affection: u, Catarrhalis. From cold. Catarrhal tooth-ache. 0 Cariosa. From decay or caries. Carious tooth-ache y Exostosa. From ossific deposit. Nodose tooth-ache. ^ Nervorum. From irritability of the dental or Nervous tooth-ache. adjoining nerves. a. o. Dolo- Every tooth has an internal cavity which commences at the point larthaiis. of its fang, and enlarges as it ascends into its body. This cavity is Fiom cold. not cellular or rugged, but smooth on its surface : it contains no marrow, but appears to be filled with blood-vessels, accompanied with nerves, which must necessarily be derived from the second and * Velschius, Episa»m. 16. 1 Hochstetter. Dec. ix. Obs. 3. .;l.i.] DIGESTIVE FUNCTION. I oho. i. 61 third branches of the fifth pair, though they have never been dis- Gen. I. tinctly traced. In the interior of this cavity the teeth appear to be ao^v'oio-. peculiarly sensible ; and hence direct or indirect exposure to the rosa Ca- ,, , , tarrhalis. external air ; or, in other words, a carious opening, or a current From cold. of sharp air without such opening, (for the air seems in many in- Caaaes- stances to act through the substance of a sound tooth,) will produce acute pain, and is, in fact, the common cause of tooth-ache. The pain thus produced will sometimes cease very suddenly, and espe- cially upon the application of an opiate, or some acrid essential oil. But the irritation is often communicated to the periosteum of the tooth, and thence to the membrane that lines the socket, which is only a duplicature of it. And hence, the pain will often become permanent from inflammation excited in these tunics, now thickened and tense, and at the same time incapable of relieving themselves by stretching: while, if a rheumatic or gouty diathesis prevail, the pain may become intermittent or periodical. In all these cases, wherever we can trace in the tooth a hole Treatment. opening externally, the readiest and most effectual modes of cure will consist in stopping up the hole, with a metallic or some other substance, so as to defend the tooth from the access of cold ; or in destroying the affected nerve by caustics, or cauteries introduced through the hole itself. The pain may also be occasionally diminished by the application of opium or the more acrid aromatic oils, espe- cially that of cajeput, which is a distillation of the leaves of melaleuca Leucodendron, either directly to the nerve in the tooth, or to the ex- tremity of those nerves in the skin, which are branches of the same pair. These medicines act by exhausting toe sensibility of the nerve: and it is hence that relief is procured by volatile alkalies and rube- facients ; or by a blister behind the ear of the affected side ; by burn- ing the edge of the helix of the ear ; rubbing the cheeks with the ce- rambyx moschatus, which possesses a vesicatory power nearly equal to that of the lytta ; holding brandy or hot water in the mouth ; or infants applying the sedative juices of the lady-bird or coccinella septem- punctata, as well as that of several other insects, to the tooth or gums, after bruising them for this purpose between the thumb and fingers. The root of the peteveria aliacea, a very acrid and even caustic plant, is employed for the same purpose by the inhabitants of Jamaica, who put a small plug of it into the diseased cavity. It is vulgarly called guinea-hen-weed, from the fondness this animal manifests for it in the West Indies.* So the mastication of various other aromatic or stimulating plants will often produce a similar effect, and especially those that at the same time rouse the ducts of the salival glands to increased action, as the bulbs of the alliaceous plants, the root of several of the sese- lis, particularly the seseli vulgare, the common hartwort, or laserpi- tium siler, Linn., which has long been celebrated both as a siala- gogue, and a remedy for the tooth-a :ie. Such masticatories, however, are chiefly of use in the tooth-ache Jf"'icat0" produced by rheumatism, or where congestion has taken place in * Trans. Stockh. Acad. 1644. p. 287. 62 cl. i.] CQ2LIACA. (ord. u Gen. I. the neighbouring parts from inflammation of any other kind. The a aDoio-* sensibility of the nerves may hereby, indeed, be in some degree ex- rosa Ca- hausted ; but it is the evacuation that principally affords relief. And From cold, it is hence that relief is, also, not unfrequently obtained by smoking or chewing tobacco ; and, as. Dr. Cullen conceives, by the use of camphor ;* though it appears probable that both the camphor and tobacco may partly operate by the sedative power they possess. And as errhines promote the same secretion as sialagogues, these have also been frequently employed with considerable success, as well in tooth-aches, as ophthalmias ; in both which cases, however, preparations of asarum, for some reason or other, have generally been found to produce more alleviation than those of tobacco, which is oioum de the basis of our common snuffs. A local application of cantharides dibus. i° powder or ointment is inconvenient: but the tinctura cantharidis may be often used effectually with little trouble ; yet the most ele- gant form of this stimulant for the present purpose, is that of the French Pharmacopoeia under the name of Oleum de Cantharidibus. It is made by digesting for six hours with a gentle heat, one part of powder of cantharides in eight parts of olive oil ;t the oil thus im- pregnated is to be filtered, and is then fit for use. Electricity. Electricity has also been tried, and occasionally with success. r agnetism. Magnetism, however, on the continent., has been a more favourite remedy ; and has, at least, more writers in its recommendation ;J whatever be the actual benefit it may have produced, of which I cannot speak from personal knowledge. Animal magnetism seems at one time, indeed, to have been very extensively employed for this as well as for other severe pains ; and, if we may credit the writers of a century or a century and a half ago, with instant, and specific Animal effect.§ The grand magnetiser of the day was the then celebrated magnetism. Valentine Greatrake, who operated by stroking his hands over the part affected, much in the same manner as Mr. Perkins of America not many years ago employed his metallic tractors.|| And, as strong emotions of the mind are well known to every one to produce a more immediate influence on the tooth-ache than on any other disease whatever, we may readiiy account for the cures hereby produced in some cases. Confident hope is as strong a stimulant as terror; and the latter is well known to operate so generally, that it is a rare fact for a person to be actually suffering pain just before the operation of extraction. stopping The stopping of a carious opening in a tooth should only be opting"8 attempted when there is no pain, for otherwise the pain will be in- creased by the introduction of a foreign body. The substances chiefly employed for this purpose are gum-lac, bees-wax, sealing-wax, tin, lead, and gold. The metals, and especially tin-foil, are among * Mat. Med. Vol. II. p. 304. t Codex Medicatnentarius seu Pharmacopoeia Gallica. Paris, 1818. \ De la Condamine, Journ. de Med. torn. xx?ii. p. 265. Glaubrecht, Diss Ana- lecta de Odontalgia, ejusque remediis variis, prascipue Magneta. Arpent 1766 Teske, Neuer Versucht in Curirung, des Zanschmerzens vermittelst eines Maena- tischen Stahls. Koingsb., 1765-6. ^ 6 Schelhammer. Diss, de Odontalgia tactu sedenda, Jen. 1701 J Stubbes—An account of several mairellous cures performed by the stroking of the hands of Valentine Greatrake. Lond. 1666. 4to. 5 cl. i.] DIGESTIVE FUNCTION. [ord. i. 03 the most useful, as they afford the best guard, and far less frequently* Gen. I. require to be renewed. Yet none of them can be easily retained in fo^o"; cases where the opening is wider at the top than the bottom; and losa c&- although attempts have been made to keep them in the proper situ- Fronfcoid. ation by drilling a small hole through the sides of the teeth, and ri- * vetting a proper pin into the metallic substance, they soon become loose, and admit air, food, and other acrimonious materials. Mr. Fox makes mention of a compound metallic substance that had been recommended to him, as far better calculated to answer the purpose of a permanent plug than any of the preceding. It is, he tells us, obtained by mixing several metals together, which, by the process made use of, become fluid at the temperature of boiling water; on which account it has been called fusible metal. It is FnsiMe supposed that this may in consequence be employed in a liquid n" state, and thus have an opportunity of striking, before it becomes cool, into all the ramifications of the carious part, so as to fill up the cavity completely, and form a fixture not easily to be detached. Whether the substance thus recommended to Mr. Fox were ever tried, he does not inform us, nor does he seem to have been ac- quainted with the proportions or even the kinds of the metals out of which the compound was elaborated. It has often occurred to me, though I have never seen it tried, indissoiu- that some of the drying earths employed as cements by our stone- proposed. masons, and which harden into an indissoluble plate or mass under water, might be used with more success for this purpose than any other substance; especially tufa or tuffwacke, as Schmeisser calls it, and tarras, which are compounds of iron, alumine, silex, and car- bonate of lime. Introduced into the cavity of a carious tooth in the form of soft paste or mortar, they will, easily dry and harden and adhere : and no moisture of the mouth will dissolve them. If these methods should not succeed, we may attempt a cure by Nerve stu- endeavouring to stupefy the nerve of the tooth by a frequent use of destroyed. hot essential oils intermixed with camphor and opium, or we may destroy it directly by a hot iron. And if these methods fail, the only Extraction alternative is extraction, which, however, should never be had re- oushtoo?h! course to till the above plans have been skilfully tried : for first, the pain may proceed from an affection of the socket, and in this case the pain of tooth-drawing will have been incurred for no purpose: and next, a carious tooth, whose nerve has been destroyed or ren- dered torpid, may be"" of very essential service, as well as ornament for many years, perhaps through the whole of life. Yefcif the caries be accompanied with inflammation in the surrounding parts, the tooth should be removed without loss of time; as the mischief may spread and the adjoining teeth be wounded.* In extracting a tooth, a very troublesome hemorrhage will occa- Hemon- sionally follow: sometimes profuse and of long continuance Plater, belreated ° Schenck, and others have, indeed, given cases in which it has proved fatal.! The best ordinary styptic is pressure with an elastic * Manuel du Dentiste, pour l'application des Dents artificielles incorruptibles, &c. Par C. Maury, 8vo. 5 feuilles, Paris, 1826. 7 Plater, Obs. Libr. m. p. 77S. Schenck, Lib. I. Obs. 403.405, p. 99. 64 ci. i.] CCELIACA. [ord. i. Gen. I. substance, as a piece of sponge covered with wax, touch-wood, a of Doio- spunk, or some other spongy boletus, or a dossil of lint dipped in a rosa Ca- strong solution of alum, or sidphuric acid. I was not long ago re- Fronfcoid quested to see a young man, who had been profusely bleeding from the gums and socket of an extracted tooth for five days without ces- sation, and without sleep, till his wan cheeks and faint, emaciated frame seemed to indicate that he had scarcely any blood left in his vessels. He was so weak as to be incapable of rising from his bed or taking food ; and his stools, from the quantity of blood he was perpetually swallowing, had all the appearance of a melaena. On opening his mouth I found it crammed full of hnt wadding, one piece having every hour been added to another, without a removal of the preceding, lest the hemorrhage should be increased, whilst the blood in which the wadding was soaked, and which had remained in the socket and over the gums for so long a period, was becoming gru- mous, putrid, and intolerably offensive. I first removed the whole of this nauseating load from the patient's mouth, and gave him some warm brandy and water to wash it with. I next directed him to take a goblet of negus with a little biscuit sopped in it, a part of which he soon contrived to swallow. The bleeding still continued : but as I had no doubt that this proceeded entirely from a total want of power in the lacerated arteries to con- tract, I applied no pressure of any kind, but prescribed a gargle of equal parts of tincture of catechu and warm water : and I had the satisfaction to find that the hemorrhage diminished almost immedi- ately, and entirely ceased in about half an hour, the mouths of the vessels having recovered their proper tone. °roduS d?w ^ ls no* easy to explam by what means teeth become carious. Out of the body they are indestructible, except by very powerful chemical agents ; and yet in the opinion of many physiologists, they are nearly in the same state in the body as out of it; extraneous substances formed complete at first, without vascularity, growth, or interstitial action, and even destitute of absorbents. In caries of the bones, observes M. Auzebi, the carious part, in consequence of the oscillations of the vessels in the sound part be- low, is thrown off, and gives place to a new growth. While, in the teeth, if the enamel be broken, and a caries commence, the carious part is never thrown off as in the bones, but continues its progress through the parts adjoining ; nor can any remedy we know of pro- duce a separation between the part that is sound and that which is ^terthbe unsound- And we have hence, says he, a proof that there are neither an extrane- fibres nor vessels of any kind in the substance of the teeth, and that o.is body. tney nave a distinct conformation from other bones.* Not widely different was the opinion of Mr. J. Hunter when composing his " Natural History of the Human Teeth," an opinion drawn from the impossibility of injecting them—the perfection in which they are produced at first, and their retaining their natural colour after so long a use of madder as a food that all the other bones of the body have become thoroughly tinged with it. " But they have most * Traite d'Odontalgie, ou l'on presente un systeme nouveau sur 1'origine et la for- mation des dents, &o. Lyons. cl. l.j DIGESTIVE FUNCTION. johp. i. 65 certainly," says he, '-a living principle, by which means they make Gen. I. part of the body, and are capable of uniting with any part of a liv- a 0fPo|o; ing body ; and it is to be observed, that affections of the whole body rosaCa- have less influence upon the teeth than upon any other part of the Fromcoid. body. Thus in children affected with the rickets, the teeth grow equally well as in health, though all the other bones are much affect- ed ; and hence their teeth being of a larger size in proportion to the other parts, their mouths are protuberant." M. Cuvier who has Authorities copied largely from Mr. Hunter, and seems to have adopted all his ^fthrFopi- \lews, has employed the same reasoning ;* and M. De Blainville nUm- has apparently gone beyond both, for he has denied not only a vascu- lar structure, but even a living principle to the teeth; at least to that exterior part of the organ, which, he says, is alone entitled to the name of proper teeth, and which he hence denominates " la partie excretee ou morte."t Admitting the soundness of Mr. Hunter's experiments, and the accuracy of his reasoning, it seems impossible that the teeth, when once perfectly produced in the gums, should ever decay : for no ac- tion of the living principle can occasion a secretion of those chemical agents, which would alone, in such case, be capable of destroying them. It is probable, therefore, that this reasoning is erroneous ; prooabiy that the teeth are vascular, though the art of injection is incapable enlarge as of readily tracing out the vascular structure, and that the colouring particles of madder-root are not sufficiently attenuate to enter their vessels. Mr. Fox however is said to have succeeded in injecting both the external and internal layer of the dental germ, and even Mr. Hunter himself appears to speak with some degree of hesitation in the treatise before us; and in his subsequent treatise " On the Diseases of Teeth," offers observations that seem to show he had at that time embraced a different opinion. In the first essay, indeed, he allows, that " the fangs of teeth are liable to swellings, seem- ingly of the spina ventosa kind, like other bones;" but he immedi- ately adds, that " there may be a deception here, for the swelling may be an original formation." Yet in the second essay, he treats of this swelling as one of the diseases to which the teeth are per- petually liable ; he regards the teeth as subject to the common in- flammation of other bones, and, like other bones, evincing, at times, great sensibility through the entire substance of the organ, as well as in the central cavity itself Nor is it quite certain that the body of a tooth does not occasionally enlarge as well as its fangs; for no- thing is more common than for the space produced by extracting one of the grinders of a healthy adult, to be filled up by an approxi- mation of the two adjoining teeth. Mr. Hunter, indeed, endeavours to account for this, by supposing that each of these teeth has been pressed into the vacancy by the teeth adjoining, in consequence of their want of a proper support in this direction; but in such case there must be some vacuity discoverable between themselves and the teeth which have thus urged them forward. In various instances, the present author has never been able to trace any such vacuity whatever ; and * Diet, des Sciences Medicales, art. Dents. t Nouveau Diet. d'Hist. Naturelles, &c. vol. ix. in verbo. Vol. I.—9 66 cl. i.J CG3LIACA. (ord. i. Gen. I. nas a decisive example to the contrary in the state of his own teeth : a o. Doio-" for having, when a boy of twelve years old, had the second of the rosa ca- bicuspidati extracted, the vacancy hereby produced has been so com- From cold, pletely filled up by the enlargement of the adjoining teeth, that these teeth closely touch, and he is only able to introduce a fine probe be- tween them at the neck, or lowest and narrowest part; while he can introduce nothing between any of the other teeth, which have in no respect given way or separated from each other. Hunter, Cuvier, and Blainville, assert equally that no vessels pass from the side of the socket into the fangs, but M. Lemaine affirms that in the grind- ing teeth of a calf he has seen vessels passing from the cavity of the fang into the periosteum :* and Dr. Blake has added other facts and observations, some of them peculiarly striking, in favour of the common vascularity of the teeth. Possess an There is probably, therefore, some internal action continually action. taking place, though we are not able to trace it very evidently. And it is probable, also, that a caries of the teeth is occasionally produced by some internal cause operating upon and vitiating this action, though there can be no doubt that the chief causes are external. We have already noticed exposure tp currents of cold air, and the medical practitioners of Germany and the north appeal to the oppo-> site extreme of the habitual use of hot aliments as a still more general and mischievous source of the same evil. In the Swedish Amceni- tates Academical we have an elaborate examination of this subject by M. Ribe, who tells us, among other things, that "man is the only animal accustomed to hot foods, and almost the only animal affected with carious teeth." Whence the author takes occasion to con- demn, in an especial manner, the custom of drinking hot tea and coffee. And, in accordance with this remark and recommendation, M. Tillaeus, another celebrated writer in the same interesting jour- nal, tells us from Kahn, in his paper entitled Potus Theai, that the Indians of North America knew nothing of the inconvenience of • carious teeth or debilitated stomachs, till tea was introduced among gefmju'ri-4"tnem- There can be no question that the two extremes of heat and •ms. cold must be greatly, perhaps equally, injurious to the health ; and as little, that the inhabitants of high northern latitudes must suffer more than others from the use of hot aliments, in consequence of the greater coldness of their atmospherical temperature. How far To the abuse of hot beverages as a cause of caries M. De la Salle injurious, adds, the abuse or excessive employment of sugar ; and seems to imagine that these are the two principal means by which teeth are rendered black in their enamel, and carious in their substance.^ Now if sugar act at all, it must be by means of the principle of acidity which is contained in it; and consequently in proportion to the degree of affinity which this principle bears to the earthy matter, or calcareous basis of the teeth and their enamel, beyond that of the acids which enter into their natural composition. And the same may be observed in respect to any other exotic acid whatever. If, then, we examine the composition of teeth chemically, we shall * Traite sur les Dents, 8vo. Paris, 1822. i Vol. rii. Art. 136. Jonrn. de Med. torn. xxsviK appx. p. 399. cl. r.J DIGESTIVE FUNCTION. [ord. i. 67 find that in their structure they consist very largely of phosphate of Gbn. I. lime with a small proportion of animal matter, and a much smaller (Janoio- of carbonate of lime ; and in their enamel, which is altogether ofrosa Ca- the nature of ivory, that they consist almost entirely of phosphate of From cold. lime with a small proportion of animal matter, and a minute trace of fluate of'lime. And admitting that the same decompositions take place in an organized living structure, or a simply organized structure in a living frame, as where the principle of life has no concern, we have next to inquire whether there be any acids that have a stronger affinity for lime than the phosphoric, for it is scarcely necessary to extend our research to the carbonic, since this can never be attacked till the enamel into which the phosphoric so largely enters be decom- posed, and withdraws its protection. Now, by examining the tables of elective attractions we shall find What acids that there are four, and only four, acids that precede the phosphoric affec/the in their affinity for lime; the oxalic, sulphuric, tartaric, and succinic. teeth- And hence, although it is very probable that a tooth sound in itself, and soundly fixed in the gums, is not decomposed by the application of any given substance, as it is out of the body, yet we have daily proofs that that law of affinity in respect to several of these acids actually holds, and that the teeth, while in their living sockets, are greatly injured by their frequent or habitual use. 1 Jiave at this moment a lady under my care, who till of late possessed as sound and fine a set of teeth as can any where be boasted of. From a peculiar delicacy of constitution, however, it has been judged requi- site that she should, among other medicines, use a very large quantity of sulphuric acid. This prescription has been continued for many Sulphuric months, and her general health is considerably established: but acul" owing to her not having taken all the precaution that is requisite to " guard the teeth while swallowing the acid, the pearly enamel is be- coming yellow, and its coating very considerably diminished in thick- ness, so that at the apex of the incisors it is almost as thin as a razor, and is frequently chipping off. Whether, as she has now no longer an occasion to continue the sulphuric acid, and as the general sub- stance of the teeth is sound, firm, and free from pain, the enamel, at her time of life, may be able to recover its healthy thickness and lustre, remains to be seen. If the principle of life really extend to the teeth and their enamel, and no injurious dehtrifice be in the mean time made use of, nor any mischief derived from sudden exposure to great heat or cold, from the remarks already made on the occasional spreading of the substance of a tooth, it is probable that such an effect may take place. If we apply these observations to the condiment of sugar, we can only infer that this material can have very little effect in destroying the enamel of a tooth. Sugar in itself, though it contain a principle Sugar not of acidity, cannot with propriety be regarded as an acid. It may ^"'d.y *" give forth this principle by fermentation, in which case it will form acetous acid ; or it may give forth the same principle by distillation with nitric acid, when it will form genuine oxalic acid (for that which exists already formed in the oxalis acetosella, or wood-sorrell, is pre- cisely of the *same kind;) and, in this combination, will evince a t)$ CL. I.J <'CELIACA. [OKD. 1. Gek. I. Spec. H, a O. Dolo- rosa Ca- tarrhal. From cold. Caution in the compo- sition of dentrificeg. How a ca- ries ope- rate*. Common to all ages and tempera- ments. stronger attraction for lime than any other acid whatever. But of itself, and without this combination we have no reason to suppose that its action, if there be action at all, can be otherwise than ex- tremely weak. If, in truth, it were a solvent of calcareous matter of any kind, it would first show itself in dissolving, and, consequently, preventing a lodgment of the carbonate, or phosphate of lime, which the salivary glands are so continually secreting, and which is per- petually incrusting on the neck of the teeth in mankind, and separat- ing them from the surrounding gums; and hence sugar would be one of the best preservatives against such an encroachment. But as we do not find that those who use a large quantity of sugar are freer from this excrementitious matter than those who abstain from it altogether, we have again no reason to suppose that it is a solvent of the enamel of the teeth in any degree worth attending to. It will be well to bear these remarks in memory in the composition of dentrifices containing acids of any kind. For the reasons already assigned, the oxalic, sulphuric, and tartaric acids, ought at all times to be sedulously avoided ; and hence cream of tartar which enters so generally into their composition, should in like manner be rigidly- proscribed : while those which have the least chance of doing mis- chief from their very slight affinity for lime, are the citric, benzoic, acetous, and boracic. Yet even these have a stronger attraction than the carbonic acid ; and hence, whenever teeth are deprived of their enamel, or the naked fangs become exposed by a decay of the surrounding gums, these also must in like manner be abstained from. By whatever means a decay or caries of the teeth may be pro- duced, it appears to operate in three different ways ; sometimes commencing in the internal cavity, and working its course outwards ; sometimes commencing outwards, and working its course within : and sometimes by a wasting of the enamel, and consequent denu- dation of the bony part. The first is the least common affection, and is discoverable by an appearance of blackness within the whiter surface of the tooth ; the third is often to be met with ; but the se- cond is the most frequent of the whole ; evincing at its commence- ment, the appearance of an opake white spot through the enamel, which gradually crumbles away about the spot, and thus discloses that part of the body of the tooth which forms the original seat of affection. The disease, by its continuance, converts the spot into a hole, and at length destroys the tooth altogether, or at least down to its neck, unless the pain produced by the morbid progress compel the patient to have it extracted before the disease advances thus far. Caries of the teeth does not appear to be a disease of anv par- ticular age, or temperament, or state of health. It exists "in in- fancy, and in the firmest manhood, as well as in old age. In the last, indeed, the teeth that drop out from absorption of their alveoli are often as sound as when they were first formed : while in child- hood it has sometimes spread from tooth to tooth so extensively and at the same time produced so much torture, that it has been necessary to extract almost every tooth before the sixth or seventh year. Mr. John Hunter hence conceived that a decay of the teeth was rather a disrase of earlv than of advanced life: and that, the ix. t.] DIGESTIVE FUNCTION. |>rd. i. 69 iceth did not become carious after fifty years of age. Mr. Fox, Gen. I. however, observes, that he has met with several persons, who had „ 0 Dolo." not only passed fifty years without having had a caries in this organ, rosaoa- but who had been obliged after having arrived at sixty to have several From cold. teeth extracted in consequence of tooth-ache produced by a caries. In some general diseases of the constitution the teeth seem to pos sess a singular degree of health and even luxuriance. Thus in Pearly gloss phthisis it is almost a proverbial remark, that that white and pearly phthuis.'" gloss of the enamel, which is peculiarly characteristic of soundness, is more than ordinarily clear and bright; while in rickets, in which the whole frame of the bones is shaken, and many of them become soft and spongy, the teeth ascend as firmly and as regularly as if the system were in a state of the most vigorous health. From the structure of the teeth, as just explained, there is no P o. Doi.i- great difficulty in conceiving that, like other bones, they may be l™*, subject to exostoses, or a deposit of ossific matter on their surface, j^'0™ °s«- and particularly on the surface of their roots or fangs, from the se- cretion or conveyance of a larger portion of calcareous fluid than is needful. For however it may be doubted whether the crown or body Teeth pos- of the teeth be possessed of secernents in a mature state, there can ^g,0 sor be no doubt of their possessing absorbents, since we behold their fangs, in very numerous instances, diminished, shortened, and truncated, and sometimes entirely carried away by the activity of absorbents, which it is difficult to conceive can belong to any adjoining organ. And And hence we may lay it down as a general rule, that there is no organ in pos- "hiTseccr^ session of absorbent vessels, which does not at the same time possess nents. secernents so as to maintain a balance of action. All this we might pronounce proleptically: and what we might thus justly anticipate, we find to occur not unfrequently in fact. We find on extracting a tooth that has long been a cause of considerable pain, that the fangs at least are considerably encrusted with a deposit of ossific matter, so as to give it an appearance of that d:S( use which was formerly but most incorrectly denominated a spina ■; ntosa. And on examining the state of the alveoli after death, w: find also that similar morbid apophyses have pullulated occasionally from the face of the alveoli. Wherever such effects occur, whether in the alveoli or the teeth, Symptom*. a considerable degree of pain, and generally an increasing degree mu.-t be the result, from the pressure of the bony projections against the periosteum or alveolar membrane. At first this pain is not quite so acute as in carious or nervous tooth-ache, for the im- prisoned tunic is not at this time in a state of irritation. But by a continuance of the pressure it is soon reduced to this state, when the pain will be as severe as on any other occasion, and far less mitigable. Wherever we can satisfactorily decide upon the cause, and the Treatment. complaint is recent, we may often put a check to it by a free applica- tion of leeches, and the local use of mercurial ointment, or a mer- curial plaster. But in cases of long standing, the only cure is an extraction of the tooth ; for even if the disease be seated in the socket, it will be instantly arrested by this process, as the substance of the socket, no longer of any use, will from this time be in a state of absorption, and be at length entirely removed. TU cl. i.] COZLIACA. [ord. i. Gen. I. There is sometimes, however, a peculiar irritability in the ^noio1-' NERVES OF THE TEETH themselves, or of those parts by which they rosa Nervo- are immediately surrounded, and with which they participate in initabdttym action, that excites the sensation of severe and even agonizing of the den- tooth-ache, without caries or any other concomitant. In this variety ingnerves"* the exact seat of pain is less easily defined than in the preceding ; and there being no black spot or other external mark to direct us to it, the tooth is often mistaken in the continuous sympathy excited, and a sound tooth is extracted in its stead; so that the torture re- mains unabated. And there are instances in which the plan of extraction has been followed up from tooth to tooth without any al- leviation whatever, till the jaw has been entirely divested of its teeth on the disordered side. This is often an idiopathic affection dependent upon a peculiar irritability, from a cause we cannot easily trace, of the nerves sub- servient to the aching tooth or the tunics by which it is covered, or the periosteum, or the fine membrane that lines the interior of the alveoli. But it is more frequently a disease of sympathy, produced by pregnancy, or chronic rheumatism, or acrimony in the stomach in persons of an irritable habit. For this remote or indirect influence it is not difficult to account, when we reflect that the great inter- costal nerve, emphatically called the sympathetic, and connected by ramifications with every viscus of the chest and lower belly, is con- nected also, by its union with a branch of the fifth pair, with the nerves that immediately supply the teeth, and which hence become its indirect extremities. Neuralgia It is still less to be wondered at that the nerves of the teeth taker! iv should often associate in the maddening pain of neuralgia faciei, tooth-ache, or tic douloureux, as the French writers have quaintly denominated it; for here the connexion is both direct and immediate. In con- sequence of this the patient, in most instances, regards the teeth themselves as the salient points of pain (and they may unquestiona- bly be so in some cases), and rests his only hope of relief upon ex- traction, although, when he has applied to the operator, he is at a loss to fix upon any one tooth in particular. Mr. Fox gives a striking example of this in a person from whom he extirpated a stump which afforded little or no relief: in consequence of which his patient applied to him only two days afterwards, and requested the removal of several adjoining teeth which were perfectly sound. This he objected to, and suspecting the real nature of the disease, he immediately took him to Mr. (now Sir) Astley Cooper, who by dividing the affected nerve, produced a radical cure in a few days. Where the pain, therefore, proceeds fijwn sympathy, it is of the utmost importance to trace it home to the organ idiopathically affected, for to this the attention should be chiefly directed. Where it exists as a primary d.sease, it is often of long duration, and diffi- cult removal. Sometimes narcotics, and sometimes stimulants have been found most successful: blisters have occasionally relieved, and the burning of a little cone of moxa behind the ear, more frequently and more effectually. Of narcotics applied locally, hyoscyamus appears to be one of the best. Its seeds may be put to the cheek cl. i.j DIGESTIVE FUNCTION. [ord. i. 71 in the form of a cataplasm ; or their smoke conveyed by a funnel Gen. r. to the tooth itself. In this last form, it will often allay the pain of fo"o£' a carious tooth. Where the pain is remittent or periodical, a free rosaNervo- use of the bark, with change of air has proved most salutary. Frominita- bility of the dental or adjoining nerves. SPECIES III. ODONTIA STUPORIS. TOOTH-EDGE. TINGLING UNEASINESS OF THE TEETH FR03I GRATING SOUNDS OR FRICTIONS. There is sometimes a peculiar sensibility in- the teeth or their Gen. I. sheaths that induces a kind of vibratory pain, in which they are collo- Spec- m quially said to be set on edge ; and that in two ways, as follows :— u. A stridore. From jarring noises. /3 Ab acritudine. From vellicative, or acrid substances. In many cases the teeth sympathize with the ear, on an exposure a. °.- stuP0. to harsh, dissonant, or stridulous sounds, as the grating of a file, Sore.81"" the creaking of a door on its hinges, or of a swinging sign in the Fromjar- street. * sounds. The same effect is produced whenever the teeth are vellicated by & °- StuP°- smooth substances, as a piece of silk or velvet, or exasperated by tudine.' acid or other acrid materials. Fr,om velli" cativo or To explain these effects it is necessary to observe, in the first acrid sub- place, that a close reciprocity of feeling is at all times maintained etances' between the teeth and the tympanum of the ear, by an union of their respective nerves ; as one of the branches of the seventh pair, destined to supply the tympanum, anastomoses with the lingual branch of the fifth, which sends offsets to the teeth: by which means the latter become indirectly an organ of sounds as well as of mastication. It is for this reason, among others, that deaf persons open their mouths to catch up speech they cannot otherwise hear; and that, as already observed, in cutting the wise or adult teeth, the tympanum not unfrequently endures more pain than the gum or membrane by which the tooth is covered ; and, hence, too, the tuner of a musical instrument is often in the habit of applying his tuning- pipe to his teeth, as soon as he has put it into a state of vibration, to determine the more accurately upon its-pitch. Now as the last action is a source of pleasure to the teeth, from Causo ex- the vibrating tone proving agreeable to the ear, we can readily see plamod why tones or sounds of any kind that are hateful to the ear shoulc be hateful also to the teeth. This is the general principle : and it is sufficient to explain why ~,% cl. i.] COSLIACA. [onu.i. Gen. I. an persons are in a certain degree subject to the tooth-edge upon o'stupo1!!' an exposure to the more common causes that produce it. But in Tooth.dgc'. constitutions of a peculiar kind, or where the ordinary association between the two organs has been specially and habitually cultivated, or some early and very powerful impression has been even acci- dentally communicated from the one to the other, it is obvious that the sensation of tooth-edge will be produced far more frequently, and more acutely than in other cases. And it is equally obvious that when in such persons the teeth are in a state of preternatural sen- sibility from any kind of diseased action, or from irritating substances applied to them, as acerb or acid juices, the sensation may become caseac- so acute as to be intolerable. Bartholine has recorded a case in withPhei.ed which the sharpening of a knife so highly excited, not the teeth only, morrhage. but the surrounding gum, that, along with a very sensible jarring of fc the teeth, the last were thrown into a profuse hemorrhage,* being perhaps at this time in an inflamed or irritable state. Sometimes In many instances the power of the imagination alone, from a Fm°4ina- ** long habit of association, is sufficient to call up a very considerable tion. degree of this painful feeling ;t as when we see a knife drawn across a china-plate, though so gently as to produce no sound whatever: and there are instances of persons in a high degree of excitement, who, by this action alone, have been suddenly thrown into con- vulsions. Mode of Where this affection is permanent or very frequent and trouble- treatment some^ and proceefjs from a morbid state of the teeth or their invo- lucres, our attention must be particularly directed to the nature of the cause with a view to its removal: and if the gums be inflamed, spongy, or otherwise irritable, scarification will often be found ser- viceable : and if the disease be seated in the body of the teeth, several of the remedies recommended under the preceding species may have an equally good effect in the present case. If it be a symptom of some other complaint, it can only be removed by a re- moval of the original disorder. Forestus,J Baricelli,§ and other writers assert, tiiat relief may often be obtained by chewing purslane leaves: bm it is a remedy I have never tried. When it is the mere result of an association of ideas, or of great strength of sympathy, with an ear delicately alive to harmony of sounds, it is best cured by an habitual exposure to the cause of affection which gradually blunts the feeling. The grating sound produced by filing a saw was probably at one time harsh and -abhorrent to the ears of the sawyer; but by being inured to it, he at length hears it with in- difference. * Epist. IV. p. 523. t Darwin, Zoonom. sect. xvi. 10. and class ix. 1,2,3. | Lib. xiF. Obs. 9. § Hortas Gentalis, p. 337. wu. i.j DIGESTIVE FUNCTION. {oto. i, ?3 SPECIES 1\ ODONTIA DEFORM1S. DEFORMITY OF THE TEETH. teeth irregular in shape, position, or number, Deformities of the teeth are for the most part produced natu- **Etf. 1- rally and in early life. Either set may be too large or too small, Iow^'to-^ or some of them much larger or smaller than the rest, or they may be duced. irregular in their line of ascent. They may be misplaced by incurva- tions, or procurvation, or obliquity. They may be crowded and confused, or, as has sometimes occurred, be multiplied in crops of double or triple rows.* In all which cases they cannot too soon become a subject of artificial arrangement, which in young persons may accomplish much, and often, by skilful management, not only correct the error of shape or number, but give a proper inclination, not merely to the teeth, as they start from their natural line, but even to.the mis-shapen sockets. Many of these irregularities proceed from a natural excess or de- Calcareous ficiency of the calcareous matter which enters into the structure of excessive or the teeth. This has been sometimes so defective as to leave the deficient- teeth cartilaginous, or possessed of their animal part alone : and in a few cases, as I have already observed, to retard the appearance of even the first or shedding set till ten or twelve years of age. But the opposite extreme is by far the most frequent; and where this exists in a considerable degree, we not only find occasionally all the irregularities already noticed as resulting from plurality, but sometimes a direct symphisis,! or inseparable union between the teeth and their sockets, so that it is impossible to extract them in the case of tooth-ache or any other malady without fracturing the socket: sometimes a perfect continuity or coalition between all the teeth,;!; insomuch, that in one instance the whole was found to constitute a single bone or curb of ivory.§ Then again we sometimes meet with a production of teeth in other parts of the mouth than the gums, and particularly in the palate, of which examples are to be found in Schenck,|| and Boreli,1T as well as in several of the con- tinental journals. Another cause of irregularity in the ascent of the permanent teeth, i^^eoitU is an inaccordance of time or manner in the absorption of the fangs otthofiret of the first Set of teeth, and the protrusion of those of the second ™d stcond * Blocb, Medicinische Bemerkuugen, p. 19. For others! see Nosolog. in loc. t Courtois, Dentiste Observateur. | Bartholin. Hist. Anat. Sent. i. hist. 35. Henkel, Samralung. Med. und Chir. Ammerkungen. vii. N. 16. S Schenck. libr. i. Obs. 412. It Id. Obs. 411. « Cent. ii. Ohs, 81. 'Vol. I —10 74 cl. i.j CXELIACA. [ORD. I. Gbn. I. Set. As the latter fangs are thrown forth, the former, in all cases 0."°^' of regularity, are carried away: and hence the permanent teeth, "}"• pressed forward by the gradual prolongation of their fangs, bear be- oftho^eHh. fore them the mere crowns of the shedding-teeth, and fyid little resistance to their ascent. And here I may again observe, that we have a proof of their existence as well of secernents as of absorb- ents in both sets of teeth. There can be no doubt that the fangs in both sets pullulate from the body of the teeth, but they can only pul- lulate by a process of secretion; and if the body of the teeth possess vessels of secretion, they must necessarily possess vessels of absorp- tion. And, consequently, there ought to be as little doubt that the removal of the fangs is produced by the latter, as that their germina- tion is the work of the former. Now if the fangs of the upper set be not sufficiently carried off, or in other words, the crown of the teeth be not sufficiently detached and set at liberty, as the under set, or any particular teeth in the under set, press forward, the latter must necessarily be thrown out of their proper line, and rise within, or without, or wherever they can force their way. sTni„8et The second set of teeth are also wider than the first; and hence, wider than • i , • <. , • the first with the exception of the bicuspidati, which from this very circum- stance rise under the shedding molares, every single tooth in its, ascent must be opposed to more than a single tooth above it; whence another source of difficulty and often irregularity. In con- sequence of all which, it is rather to be wondered at that we do not meet with more frequent instances of deranged or mis-shapen teeth than actually occur to us. And nothing can be clearer than the necessity of a close and skilful watch over them during the shedding season, so as to remove any of the first set when they form an undue degree of resistance to the permanent, and have a tendency to throw them out of their proper line ; and any of the second set that may exceed their proper number, and, by their surplus, crowd and mis- place the rest. SPECIES V. ODONTIA EDENTULA. TOOTHLESSNESS. LOSS, OR WANT OF TEETH. Gen. I. This is also a very common affection, and offers tjie following Spec. v. varieties: * . u, Peculiaris. From constitutional defect, /3 A vi extrinseca. From external violence. y A carie. From decay. £ Senilium. From old age-. cl. i.] DIGESTIVE FUNCTION. [qbd. i. 75 As the teeth are often produced supernumerously, so are they GEN,*r often naturally deficient in number. This is sometimes the case Toothless-' with the bicuspidati, as it is not uncommon to meet with a person *«"• ej in whom one, two, or more of these have never made their appear- tula Pecu- ance. But it occurs more frequently in the incisors, particularly of p^mcon- the lower jaw: and Mr. Fox refers to an instance in which this stitutionai defect appertained to several individuals of the same family, none of e w' whom had ever cut the incisors of the lower jaw. But the other varieties of cause are more obvious and common : P ,°\Et!en* , . tula a vi being extrinseca. Violence, by which they are suddenly misplaced, or knocked out: £rr°™i ^J. Caries, or inflammation of the surrounding sheaths, by which they ,e"ccp, become loosened in their sockets: and luia * cane. The natural absorption of their sockets in advanced life. From In many instances, therefore, the separated teeth are in a sound a o. Eden- state ; and, in a few instances, where the alveolus is also perfect, {Jjjj},.em" and the tooth has only been out of it for an hour or two, so that its From old living principle has not altogether ceased, it may be* replaced, and Hence sepa- will take a fresh hold and become serviceable for many years; J^g^. though it rarely, perhaps never, forms so firm and permanent an attachment as before the accident which threw it out. Mr. John Hunter extended this mode of supply to a transplanta- ^^Ja" tion of teeth from other persons : and at one time this method also teeth. was carried to a considerable extent of practice. Too much cau- tion, however, cannot be employed in ascertaining the health of the individual by whom the scion-tooth is to be furnished: for it is well known that syphilis, and it seems probable that some other diseases, may be transplanted at the same time. As an instructive case upon Danger of, this subject I may refer to the following, drawn up by Dr. Watson, eluc,dat'd' and inserted in the Medical Transactions.* An incisor tooth of the upper jaw, from an unknown cause, becoming carious in a young unmarried lady about twenty-one years of age, it was extracted, and its place very dexterously supplied by a like tooth from another young woman, who upon examination for the purpose, appeared to be in gopd health. The scion-tooth very rapidly took a firm hold, and soon bid fair to be of great service and ornament. In about a month, however, the mouth became painful, the gums inflamed, dis- coloured, and ulcerated. The ulceration spread very fast, the gums of the upper jaw were corroded, and the alveoli left bare. Before the end of another month the ulceration stretched outwardly under the upper lip and nose, and inwardly to the cheeks and throat, which were corroded by large, deep, and fetid sores. The alveoli soon became carious, several of the teeth gradually dropped out, and at length the transplanted tooth which had hitherto remained firm in its place. About this time blotches appeared in the face, neck, and various parts of the body, several of which became painful and extensive ulcers; a considerable degree of fever, apparently hectic, was ex- cited ; a copious and fetid discharge flowed from the mouth and * Vol. iii. Art. xs. 76 eL, x.j (CELIACA. [oud. i Gen. I. throat which impeded sleep, and the soreness of the fauces prevented o PEden^' a sufficiency of nourishment from being swallowed. tula. The wisest plan would probably have been to have commenced Toothless. from the firgt wkh a mercuriai process before the system was so far debilitated, and the general health so deeply encroached upon, as to render any plan of very little use. An antiseptic course, however, of bark and other tonics was first tried and persevered in till found to be of no service whatever; and calomel pills in an alterative proportion were then had recourse to in their stead. This plan was found to soften every symptom, and totally to eradicate many: but the bowels were soon affected with severe pain and purging ; and the calomel was exchanged for strong mercurial ointment; which, from the present debility of the patient, soon produced a like effect and an effect that could not be corrected by opium. The venomous taint or putrescent tendency, though occasionally driven back, as often rallied, and at length prevailed ; and the patient fell a victim to it in the greatest distress and misery. The person from whom the tooth had been taken, had in the mean time continued in perfect health ; and upon a minute inspection, as well of the sexual organs as of the mouth, evinced not the slightest syphilitic affection. The case is mysterious, and leaves much ground for the imagina- tion to work upon. If it be difficult to conceive it to have been syphilitic, it is more difficult to conceive it to have been any thing else. But the grand lesson to be learnt from it on the present occasion is that of the wariest caution, and a caution amounting almost to a prohibition, in remedying a deficiency of teeth by transplantation. Sueh evils Other cases might be advanced, but it is unnecessary. Mr. John counted for Hunter, partial to his own invention, endeavoured to account for Humeri' most °^ these, upon the principle of local irritation exciting remote evils, or universal sympathy. Yet the cases of mischief have been so severe and numerous that the practice has long fallen into great disrepute, and is now seldom ventured upon. Mere A transfer, however, of the mere crowns or bodies of sound teeth, Bound teeth with the fangs filed off, does not seem to have been productive of ■aiWvbe tne same evil effects; and hence these may be conveniently made transferred, use of, when the body of one or more teeth has been destroyed bv caries, while the fangs have remained sound: for by screwing a piece of gold wire into the crown of the scion-tooth, and boring a hole into the fang of the lost tooth, the former may be made to take a firm hold without any attachment to the adjoining teeth ; and, if due care be taken in the selection, it will make the best match and produce the most perfect supply that human art can bestow. When natural teeth are not employed, the dentist has recourse to artificial teeth commonly obtained from the tusk of the hippopota- mus ; though in order to confer a greater durability, they have of late years been ingeniously formed of a composition of porcelain earth properly modelled and burnt. <-t. 1.1 DIGESTIVE FUNCTION. [oru. i. 7? SPECIES VI. ODONTIA INCRUSTANS. TARTAR OF THE TEETH. THE TEETH INCRUSTED WITH EXTRANEOUS MATTER. The teeth are always subject to be covered over with layers of Gen. I. an earthy material secreted as a constituent part of the saliva, and Spec- VI# denominated tartar. Simple as this substance seems to be, no very clear explanation chemical either of its origin or character has hitherto been given. Accord- ^"tarta^ ing to Professor Berzelius, tartar, when it first settles on the teeth, is mere hardened mucus: ubut during the destruction of the mucus," says he, " we insensibly trace phosphate of lime on the enamel of the tooth, which is sometimes increased to a crust of the thickness of from a fourth to the half of a line : and in this state it contains, besides the phosphate, about a fifth part of its weight of mucus which has been exsiccated in the earthy mass."* Tartar of the teeth, therefore, as far as it has been analyzed, con- sists of concrete or dried saliva, hardened by its own earthy mate- rials. As it flows from the salivary ducts, it is always found most accumulated around those teeth which are situated nearest to their openings. M. Series, indeed, has ventured to assert that this mate- whether rial is secreted by a set of minute and distinct glands, of which he [h^aiiva!" has given an engraving, and then gravely affirms uce tartre n'est done pas un produit de salive."t But till some other anatomist besides himself has met with the same andular structure, it is by no means worth while to relinquish the Liablished belief. In some Varies in persons, however, the saliva is much more loaded with earthy mate- secreted.'113' rials than in others ; for while some have very little trouble in keep- ing their teeth free from this deposit, in others it forms so copiously, that nothing but an unremitted attention will preserve their teeth from being covered with it. While this material continues soft, it has a yellowish appearance; but as it hardens, it changes to a dark brown or black ; and often, in" children, to a dark green. By degrees the teeth lose all their Progress of beauty to the eye, the gums are detached from their respective necks, are irritated and inflamed ; the alveolar processes of the teeth are exposed, absorption takes place, and the teeth become loosened: while the breath is loaded with a disagreeable fetor, from the de- composition of such a mass of aninv . matter. In some cases the accumulation has been so enormous •-:s to cover the whole range of teeth, and unite them into a solid heap.J * Animal Chemistry, p. 62. t Essai sur l'Anatomie et la Physiologie des Dens. Paris, 1817. } Enstachius, Tract, de Dentibus, cap. xx>x. Stoeller Beobacbtungen, &c. N. 3. 78 cl. i.] CG3LIACA. |ow>. », Gen. I. Spec. VI, Odontia Incrustans, Tartar of the teeth. How Pre- vented by habitual attention. Milder acids may be employed. Scaling. Accumula- tion how prevented in India- It is almost superfluous to point out the necessity of attention to prevent so foul a disfigurement. The daily use of a tooth-brush with any of the ordinary tooth-powders will, however, in most cases be sufficient for this purpose. The basis of these powders is of lit- tle importance, provided they contain nothing that may injure the enamel of the teeth. Pulverized fish-shells, cuttle-fish-bone, boles, bark, myrrh, mastic, soot, and charcoal, may be used with equal ad- vantage according to the fancy, and when an odour is wished for, it may be obtained from ambergris or orris-root. It is only necessary to observe, that the powder be innocent in its quality, and impalpa- ble in its reduction. If the tartar yield not to these, we may without mischief add a small quantity of some of the milder acids in order to render it more efficacious. All dentists oppose the use of acids of every kind ; but this is from an inacquaintance with the gradation of chemical affini- ties. I have already observed that there are but four known acids for which the lime of the teeth has a stronger attraction than for the phosphoric with which it is combined; and these four are, the oxalic, sulphurie, tartaric, and succinic. From these, therefore, we ought sedulously to abstain ; but most of the rest may be used very harm- lessly, and will often be found by the friction of a tooth-brush, to dissolve the tartar of the teeth without making the least impression upon their substance. But if the deposit still bid defiance to our exertions, it must be removed by the operation of scaling; and the gums afterwards be washed with some pleasant astringent lotion. In India the accumulation of tartar is prevented by an application named miscee, which produces indeed a black jet upon the teeth, but leaves the enamel untouched, while it destroys the tartar and hardens the gums. Its ingredients are not known. SPECIES VII. ODONTIA EXCRESCENS. EXCRESCENT GUMS. THE SUBSTANCE OF THE SURROUNDING GUMS EXCRESCENT. GENVn ^°T 0nly by the concrete deposit called tartar are the teeth oc- Spec.VII. casionally incrusted and buried, but sometimes by a prurient growth of the substance of their own gums, which from different circum- stances appears under the two following forms— « Spongiosa. Fungous or spungy gums. Scurvy of the gums. a Extuberans. With distinct exuberances on the Extuberant gum?. surface. gl. i.] DIGESTIVE FUNCTION. [ord. x. 49 The gums sometimes assume a soft, fungous, or spongy appear- Gatt. I. a nee: and this too, as Mr. John Hunter has observed, in persons f aE'J-11' who are in all other respects perfectly well :* and this case, though creacens vulgarly called a scurvy of the gums, is distinctly an idiopathic affec- Iwf'y of tion. It may however be symptomatic of dyspepsy or some other the gum', disorder of the stomach, or some equally remote organ ; or the re- sult of a morbid state of the alveoli, or teeth themselves ; and un- questionably it may appear as a symptom of porphyra, or real scur- vy, affecting the system generally. If the craggy stump of a tooth be the source of irritation, it will be in vain to attempt a cure till the relic of the tooth be removed : and if the socket be in fault, it will be necessary to expose and ex- amine it. But in all cases in which the disease originates in the scariGca^ gums, and depends upon a lax and debilitated state of their texture, .ion,he^ scarification, freely and repeatedly made use of, will be the best, and e8trem T in many instances, the only remedy. It disgorges the overloaded vessels, and constringes and invigorates their fibres ; and leads not more to immediate ease than to a radical cure. I have frequently found it necessary to follow up the scarification into the roof of the mouth which often partakes of the irritation, and is puckered into wrinkles of exquisite tenderness, that cannot endure the slight- est touch. After scarification, the gums and mouth should be washed with some warm and resinous tincture, as that of bark and myrrh ; and be gradually accustomed to the friction of a tooth-brush, and some astringent tooth-powder, in the choice of which the patient may be allowed to please his own fancy; though perhaps the best are those prepared from several of the more astringent funguses, Astringent and especially the cynomorion coccineum of Linne"us, better known a.PP,iCB-- by the name of fungus JVIellitensis. And if this plan be not suffi- ciently stimulant, it will be necessary to wash the mouth and gums with a very dilute solution of nitrate of silver ; or to apply it with a pencil-brush to the gums alone in a much stronger state. Dr. Paris recommends as adentrifice equal parts of powdered catechu and bark, with one fourth the quantity of powdered myrrh.t Where this variety is neglected, it will often spread deeply and Severe and widely, and be productive of severe and even fatal mischief: afntal case' striking example of which is given by Mr. Hill, in the Edinburgh Medical and Surgical Journal.f It succeeded to the extraction of a tooth in an athletic man, aged 52, who had some degree of unea- siness in the socket and adjoining parts for several weeks after the operation, but which gradually disappeared, At the distance of about two months, a puffiness was discovered in the cavity formed by the loss of the tooth, preceded by a sense of soreness in the roof of the mouth. The excrescence soon assumed the character of a bleeding fungus, spread very extensively towards the roof, and so much affected the patient's speech that it was difficult to understand him ; at the same time the sublingual glands began to sympathize in the morbid action, to inflame and tumefy. At this period, " the * Diseases of the Teetb, ch. iii. t Pharmacol. Vol. ii. p. 131. Edit. v. 1823 + Edin. Med. and Surg. Journ. No. lxi. 80 cl. i.J C04LIACA. [0K1>. I) Gek. r. mouth presented a spongy, bleeding fungous swelling, protruding f a e^U" the upper lip, and extending backwards to the centre of the ossa crescens palati. The teeth on each side the tumour were loose and divergent, i?urfy°of appearing as though stuck in a thick jelly. The slightest handling the gums. 0f these parts produced a discharge of venous blood. I removed the loosened teeth, each of which brought away with it a large piece of fungus, with the scalpel. I also removed the whole of this sub- stance as clear as I could." This, however, was not sufficient. Though the bones did not at this time, on examination, appear dis- eased, both the maxilla and os palati became so soon afterwards, and portions of them were separated by Mr. Hey's circular saw. Still the disease held its ground: it was scorched, but not killed. Fresh and more extensive excrescences were protruded, and bid equal defiance to the knife and to various caustics. It does not ap- pear, however, that the actual cautery was tried. "Feeling at length too feeble to labour, he suddenly adopted the resolution of retiring to his native place, as he said, to die." And truly enough he said. He retired into the country, and about three months afterwards, being less than a twelve-month from the attack, fell a sacrifice to pain, debility, and distress : at which time the tumour extended from the angle of the jaw to the top of the shoulder, surrounded by various others, one on each side of the nose, all moveable and elastic; the fungus on the gum filling the cavity of the mouth, rendering the speech inarticulate, and the poor sufferer's swallowing extremely difficult. 0 Excre- The extuberant excrescence which forms our second variety, is scens extu- sometimes firm and unyielding, rising into distinct and hardened knobs Firm extu- instead of assuming the appearance of soft and spongy germinations. uTe'gums.°f I" tfiese cases the general texture and consistence is that of the gums themselves : and the only radical cure consists in extirpating them by the knife, a ligature, or a caustic. Even after extirpation, they are very liable to grow again, and with great obstinacy and perse- verance. Mr. J. Hunter mentions a case in which they were repro- duced six times in succession ; and here he suspected a cancerous disposition. They are also, in general, very largely supplied with blood vessels of considerable magnitude, which often produce a troublesome hemorrhage after the operation. And on both these accounts a ligature or a caustic has usually been found a more con- venient mode of excision than that of the scalpel. <*.*.-] DIGESTIVE FUNCTION. [orb. i. 81 GENUS II PTYALISMU8. PTYALISM. INVOLUNTARY FLOW OF SALIVA FROM THE MOUTH. The saliva issues from three distinct sets of glands distributed over G ex. II. different parts of the mouth, as the pai»tid, the submaxillary, and saK»£U ° the sublingual; and is a spumous and highly resolvent fluid, consist- ing of a large portion of water united with some albumen, and holding in solution, as we have already seen in the last species, a small quan- tity of phosphate of lime, the source of the tartar of the teeth, and occasionally of calculi found in the glands that secrete it. Its quantity has been very differently calculated. Nuck estimates it a pound in twelve hours ; Mr. Cruickshank, with more appearance of truth, at a pound in twenty-four hours. Its office is two-fold : that of moist- ening the mouth in combination with a small portion of mucus secreted by the labial and buccal glands, and, as observed already, that of contributing to the digestion of the food in the stomach and duodenum. Under the influence of the irritating passions, and especially of vio- H°w ex lent rage, it assumes a frothy appearance, and in many animals be- comes poisonous. It is said, indeed, to become so sometimes in man himself ;* as we shall have occasion to observe farther when treating on lyssa canina, or canine madness. When the saliva is secreted in a healthy proportion, and the vari- ous muscles of the mouth perform their proper office, it is never discharged from the mouth, unless voluntarily ; but passes readily from the fauces into the esophagus. But it may be secreted im- J^"jodfe". moderately, and this both in an active and passive state; or the creted in muscles of deglutition may not properly perform their functions : and ™"°"s in either case the saliva will flow from the mouth involuntarily, ac- companied with a specific difference of symptoms. And hence ptyalism, as a genus, offers the three following species of disease ; 1. PTVALISMUS ACUTUS, SALIVATION. 2.---------CHRONTCUS, CHRONIC PTYALISM. o.----------INERS, DRIVELLING. * Hoffman, Diss, de Saliva ejusque Morbis, p. -'.. Vol. I.—11 82 cl. i.] CCELIACA. [om>. x. SPECIES I. PTYALISMUS ACUTUS. SALIVATION. Gen. II. Spec. I. Sometimes symptoma- tic. Produced by siala- gogues; by mecha- nical pres- sure; by remote mechanical irritation. INCREASED SECRETION OF SALIVA FROM AN INCREASED ACTION OF 111F, SALIVARY GLANDS. As increased action of the salivary glands, productive of salivation, occurs not unfrequently as a symptom of some other disorder ; and a symptom that in many cases proves highly salutary and even critical; as, in fevers of various kinds, exanthems, of which Dr. Perceval of Dublin, writes me word he has had instances in'miliaria with transparent vesicles, iff jaundice, and dropsy ; and instances of which are given in the author's Nosology. It often takes place also in suppressed discharges of various kinds, as those of menstruation, perspiration, and urine, and is occasionally found a useful substitute. But as in all these cases it is a mere concomitant or dependent affec- tion, we must defer our consideration of it in these relations till we come to the diseases themselves of which it is a symptom or sequel. The salivary glands are directly excited to an increased action by stimulants, or sialagogues as they are called, of various kinds. There are numerous plants endowed with this power, which in their roots, bark, or leaves, contain a warm, acrid juice : as, tobacco; mezereon ; pyrethrum, or pellitory of Spain ; pimpinella saxifraga, or smaller burnet saxifrage ; imperatoria, or masterwort. Simple mechanical pressurer produced by the manducation of any hard substance, as when we eat a dry biscuit, is also a stimulant of the same kind : far less active indeed, but highly useful in its effect, as tending to resolve the substance to which the pressure is applied. Dentition is a common cause whatever time the teeth be produced. Even the mechanical irritation of another organ with which the salivary glands are closely connected by continuity or sympathv, will often lead to a like effect. Mr. Powell has given an interesting instance of this in the Medical Transactions of the College. A piece of wool, accustomed to be worn in the ear, had imperceptibly slid into the meatus auditorius, and for upwards of two years stimu- lated the organ without being suspected ; during the whole of which period the patient discharged from a pint to a pint and a half of saliva daily. The ear itself at this time became painful, and was examined ; the piece of wool was detected, and extracted in a very offensive state ; and the salivation in a short time entirely subsided.* In like manner it is a frequent accompaniment of pregnancy • as it is occasionally of some other irritation of the stomach or intestinal canal; m which last case it frequently betrays its source bv a saccharine taste. V51. ii. p. 34, Letter to Sir Georsre Baker. cl. i.] DIGESTIVE FUNCTION. [ord. i. S3 Generally speaking however, though not always, an increased Gen. 11. flow of saliva from any of these causes is of such short duration, pfyXmua and so easily removed when troublesome, that it is rarely the subject acutU3. of medical attention ; and the only varieties to which it gives rise SahvaUon' that are particularly worthy of notice are the following : « Hydrargyratus. Produced by the use of mercury or its pre- Mercurial salivation. parations. p Sensitivus. Produced by the sight, smell, or thought of Mouth-watering. agreeable food. y Mellitus. Accompanied with a sweet or mucilaginous Sweet-spittle. taste. Quicksilver, in whatever mode introduced into the system, whether « P- acutui by the skin, the stomach, or the lungs, uniformly stimulates the tus.rargyra" salivary glands, and produces an increased flow of saliva : and is M^u^ial almost, if not altogether, the only substance we know of, which, in- Salivation troduced internally, universally acts in this manner. Nitric acid has by°raercury been suspected to produce a like operation ; but we have no proofs however upon the subject, and there is little ground for any such belief. jnto°thee Antimony has also been thought by a few practitioners to have BJstem- some such influence upon the salivary glands. " Dr. James lately informed me," says Sir George Baker,* " that for sixteen years past his fever-powder has contained no mercury ; and yet that within that space of time he has known at least six instances of a salivation The .only raised by his medicine. He added, that the patients who were thus that thus salivated had neither their teeth loosened nor their breath made act? offensive, as happens in a mercurial ptyalism." Fusch tells us, that he has occasionally observed a like effect ;t as does Willich, when tartarized antimony has been employed. J No other writer or prac- titioner that I am acquainted with has noticed any thing of the kind : and it is hence probable that the antimonial, in such cases, meets with some contingent auxiliary in the idiosyncracy of the patient, or im the preparation of the medicine made use of in the anomalous cases. From the general tendency of mercury to produce this specific Effects «f effect, those who are engaged in working quicksilver mines, as those miners. of Idria or New Spain, are almost continually in a state of saliva- tion ; and when, which is often the case, condemned as criminals to such labour for life, drag on a miserable existence in extreme debility and emaciation, with stiff incurvated limbs, total loss of teeth, and equal loss of appetite, till death in a few years, with a friendly stroke, puts a period to their sufferings. From the facility with which'quicksilver evaporates, and combines, Effe^son not only with other metals, but with almost all other substances, "urer".8*1" and especially with many of the elastic gases, a considerable degree of injury is often sustained by workmen in manufactories in which quicksilver is occasionally employed, without their being for a long * Medical Transactions of the College, Vol. \. p. 37&\ t Dissert, de Antochiria, Jan. 1681. t Baldinger N. Magazia, Sand. Tin, p. 252. S4 CL. I.j CCEL1ACA. [ORD. I. Gen. II. Spec. I. • P. acutus- hydrargy- ratug. Mercurial salivation. Singular effect on board the Triumph- Different effects on different constitu- tions. Local symptoms of saliva- tion. Hydrargy- ease Difficulty of account ing for it- time aware of the cause. An instance of a similar kind occurred not long ago on board the Triumph man-of-war, which had received on board thirty-tons of quicksilver contained in leathern bags of 50 pounds each, that had been picked up on the shore at Cadiz from the wreck of two Spanish line-of-battle ships, that had been lost during a storm in March 1810. The bags were stowed in the hold, and other low parts of the ship, but being saturated with sea water they soon decayed, and bursted. The quicksilver thus let loose was collected as well as it could be, and committed to proper casks : but much of it escaped into the recesses of the ship ; and not a little was secreted by the sailors, who amused themselves with it in various ways. The quicksilver that had escaped unnoticed sank into the bilge-water, became partially decomposed* and ascending soon after, amidst an intolerable stench, with the vapour of the water, coated every metallic substance in the ship with a black hue ; and at the same time a general affection of the mouth took place among the men and officers to such an extent that no less than two hun- dred became severely salivated, and did not recover till the ship, being carried into Gibraltar, was docked and cleaned to its lowest planks. Mercury, however, produces very different degrees of effect upon different constitutions or states of the body. In a few rare instances it has exerted no sensible influence whatever upon the excretories of the fauces : in others, a very small quantity of almost any of its pre- parations has stimulated them at once to a copious discharge. In persons of a highly nervous or irritable temperament, I have known salivation produced by a single dose of calomel; and Hildanus asserts it to have followed from merely sprinkling a wound with a little red precipitate. In scorbutic, scrophulous, and other debilitated habits, it will sometimes act in the same manner ; and hence a con- siderable degree of caution is requisite in all cases of this kind. Even the wearing of a leathern girdle, or the occasional application of mer- curial ointment to the head to destroy vermin, has, at times, been followed with a like effect. When mercurial salivation is produced, it is accompanied with a high degree of irritation, not only of the mouth and fauces, but of the system generally. The common course of symptoms is as follows, the mouth feels unusually hot, and is sensible of a coppery or metallic taste : the lingual and sublingual glands swell; aphthous vesicles ap- pear, and terminate in minute and offensive exulcerations : the tongue tumefies ; the throat becomes sore ; pyrexy and sleeplessness super- vene, and are, indeed, often present from an early period of the dis- ease : while in idiosyncrasies, or habits of great irritability, we fre- quently find the surface of the body wholly > or in particular parts reddened with a peculiar erythematic inflammation,-continuous or in patches, to which the name of hydrargyria has been given by some writers, and that of erythema mercurialeby others. It is difficult to determine by what means mercury produces this singular effect on the salivary glands. It was at one time supposed to act by the gravity of its particles, which were conceived to force themselves between, and divide those of the blood, and thus reduce cl. i.] DIGESTIVE FUNCTION. [ord. i. 85 it to a more attenuate state. But this will by no means account for Gem. II. its peculiar or specific irritation of the excretories of the fauces. Nor 0 p."'^^ is it by any means true that the blood is dissolved in this mechanical Mrargy- manner, however it may be dissolved by the chemical qualities of the Mercurial mercury. Dr. Cullen, indeed, denies that the blood is ever attenu- ^'n's"' ated in any way by the use of mercury, and regards all the appearances «piana- that have been adverted to in support of such an opinion as fallacious. lon' And he denies, with still greater pertinacity, that it acts as a specific antidote in lues: a subject which we shall have occasion to examine hereafter. He regards it as nothing more than a general irritant, operating equally upon all the sensible and moving fibres of the body, and hence powerfully operating upon all the excretories of the sys- tem, without having a special affinity to one set more than to another. k' It proves often," says he, " diuretic ; and I have particular proofs of its reaching and acting upon the organs of perspiration."* The whole of Dr. Cullen's views upon this subject are among the weak and weakest of his speculations. But he has laid down a general princi- "on*.*13 aC" pie upon the doctrine of the incidentia, and attenuantia, and the present views were necessary for its support. It is impossible, how- ever, to deny that mercury, whether it possess a specific affinity or not for the excretories of the saliva, acts, from some cause or other, more readily and powerfully upon them, than upon any other excre- tories whatever : and hence this ingenious physiologist endeavoured to account for this notorious fact in the following manner :—He first supposes that mercury has a particular disposition to unite with ammoniacal salts ; and that it is by its union with the ammoniacal salt contained in the serum of the blood that it becomes so much dis- posed, and more universally than any other substance we know of, to pass off by the excretories generally. And he next supposes that the ammoniacal salts are thrown off by the salivary glands more copiously than by any other excretion. " And hence," says he, 'l we shall find a reason why mercury, associated with such ammoniacal salt, will readily pass to the salivary glands; and being thus applied to their excretories will produce the salivation that so readily hap- pens."! From what experiments Dr. Cullen deduced this highly ammoniacal quality of the saliva he has not informed us. It is a de- duction at variance with all the chemical analyses of the present day : but his hypothesis required such a result. In attempting a cure of salivation from mercury, our attention is *fedt£*J to be directed to the local state of the fauces and the general state of the system. If the throat be not much inflamed, acidulous gargles and acerb J^1*1^,, fruits, as the sloe, may be employed with great advantage and should tives. be used freely ; but if there be considerable irritation, we must at first content ourselves with emollient gargles of barley-water or quince-seeds: and in either case employ, at the same time, purga- tives of Epsom or other neutral salts. When the system is much 2jjj™fnd affected, sulphur and opium have been strongly recommended, and seem in many cases to have been successful. The former is trusted * Mat. Med. Vol. n. p. 443. + Loc. citat. p. 446. 86 cl. i.] C03LIACA. [ow>. i. Gen. II. to, chiefly, from its being well known to diminish the activity of oSp.E»cijtu« mercury out of the body ;—a doubtful reason, however, for our em- Uydrargy- ploying it internally. The latter is certainly of considerable use in Mercurial allaying the general restlessness and irritation of the system. Pure PuriTair0n' a*r an(^ a mu^ met are highly serviceable ; but, perhaps, there is no and mild disease in which such warm and tonic diluents as the Lisbon diet- oiiuents. drink, or compound decoction of sarsaparilla, may be used with better effect. Taken in the quantity of a quart a-day, they equally attenuate and carry off the poison, and support and strengthen the system. Mercury -Like most other poisons, mercury, when properly directed, and ^medicine! under proper subjugation, may be rendered a most valuable medi- cine ; and is at this moment, in its multifarious forms, one of the most common, as well as one of the most efficacious in the Materia Medica. In this place, however, we can only contemplate it as a source of disease. 0p.aoutus A certain degree of active ptyalism or salivation is also well Mouth-1" known to be produced by any high degree of mental or sensorial watering, excitement: in which case the discharge most commonly assumes a frothy appearance. This is particularly the case with violent rage, which stimulates the salivary glands almost as much as grief does the lachrymal. And as the same muscles of the mouth and throat are strongly roused in epilepsy and lyssa, we have here also a like increase of saliva, worked into the same sort of foam, and ac- companied with a similar biting of the lips and gnashing of the teeth. But the most striking proof of this effect is produced by an eager longing for agreeable food of any land, whether seen, smelt, or only thought of: and which is vulgarly denominated mouth-watering. Among mankind this increase of secretion is seldom so considera- » ble as to occasion any involuntary flow from the mouth; but among dogs it flows freely and continuously; for here the salivary glands are peculiarly irritable, so that the animal is almost continually sla- , yering; the discharge appearing to answer the purpose of insensible perspiration in other quadrupeds, and which dogs do not seem to possess : a fact whieh may serve to explain some of the most singu- lar complaints to which this animal is subject, though it has not hitherto been laid hold of by pathologists for this purpose. meHitMUtu' We meet also occasionally with an increased secretion of saliva Sweet- from a cause less obvious, distinguished by a sweet or mawkish spittle. taste .* t0 wnich some writers have given the name of sweet-spit- tle. | It is the dulcedo sputorum of Professor Frank.J It may pos- sibly exist, at times, as an idiopathic complaint, but is more usually connected with a morbid state of the stomach, and accompanied with a sense of nausea : the saccharine matter being formed, per- haps, by a like assimilating power as that possessed by the kidneys in diabetes. It is relieved by magnesia, and other absorbents ; but is most effectually cured by an emetic, followed by warm stomach- .trAct- £at- c*r- voL IV- 0bs. 59- 89. vol. v. Obs. 71. Dejraye, Diss, de Natura et Usu Salivas. Monspel, 1783. B ' ' e mlur" t Pauliini, Cent. i. Obs. 81. 1 De Cur. Horn. Morb. Epit, Tom. v. p. 59,85. Mannh. 8yo. 1792. cl. i.] DIGESTIVE FUNCTION. [ozv. i. 87 ics. A lady of delicate habit, now under my care, has been sub- Gen. il ject to this variety for some years. It returns irregularly, for the y p acc'utu"g most part once in about a month or six weeks, and generally yields meintus. to a course of rhubarb, taken sometimes in conjunction with two or spittle. three grains of calomel. Bloch mentions a case in which it returned at periods still more regular.* This variety of ptyalism is.also occa- sionally the result of a scorbutic diathesis, but more frequently of phthisis; and especially in the last stage, when, as Frank observes, it is often "insignis et ad nauseam usque molesta."t Acute ptyalism frequently occurs during dentition ; and is by no ^sume J>g~ means an uncommon sequel or crisis of other diseases. companies In all these, as I have already hinted at, it proves salutary, and deatitlon; terminates the disorder that excites it. Fevers afford, perhaps, the and fevers. most numerous examples of this ; and the following case is worth relating :—A lady, aged twenty-four, of a delicate constitution, was attacked with a typhus, in the spring of 1788, which ran on for three weeks. She appeared to be in great danger ; but on the twentieth day a sudden and copious salivation took place that unaccountably afforded her great relief. It continued for upwards of a week, the daily flow from the mouth being never less than a pint and a quarter. In the mean while she increased in strength, recovered her appetite and got well. We have numerous instances in which this discharge has proved Ajninof equally serviceable about the acme of small-pox ;j though in one or and dropsy. two cases death has#succeeded.§ The fluid of dropsies is said to have been carried off at times by the same channel. In the Medical Observations and Inquiries,ii there is a singular Chronic case of an obstinate vomiting of five months standing being relieved hereby re- upon a return of salivation, which for this period had ceased. But heved- perhaps one of the most extraordinary instances to be met with is related by Dr. Huxham, in the Philosophical Transactions.IT The patient was a man aged forty, of a spare, bilious habit, who had an attack of jaundice, followed by a paroxysm of cholic, this last being produced by drinking too freely of cider. Among other medicines was given a bolus, containing a scruple of jalap, eight grains of ca- lomel, and a grain of opium. Copious dejections followed ; and a few hours afterwards the patient complained of pain and swelling in the fauces, spat up a little thick, brown saliva, which was soon con- siderably increased in quantity, of a deep colour, resembling green- ish bile, though somewhat thinner. This flux of green and bilious saliva continued for about forty hours ; during which time the quan- tity discharged amounted to two sextarii, or four pints. The colour of the saliva then changed to yellow, like a solution of gamboge, with an increase rather than a diminution of the quantity. It con- tinued of this colour for the space of forty hours more, after which it gradually became pellucid, and the salivation ceased as suddenly * Beinerknngen, p. 203. f Ut supra, p. 59. X Act. Nat. Cur. vol. vii. Obs. 109. Fich, Diss, de Salivatione spontanea, prscipue Variolarum. Jen. 1713. § Riedlin, Lin. Med. 1695, p. 384. Weber, Obs. Med. Facie. I. !| Vol. in. p. 241. If Vol. xxxni. 1724. 88 cl. i.] CCEL1ACA. [oRi>-1. Gen. II. ag ^ Came on. During the flow of the saliva, the teeth and fauces >Sp.Eacutus were as green as if they had been stained with verdigris, and the meiiitus. teeth retained the same colour for a fortnight after the ptyalism had BpTttTef ceased. The patient had a few years before been suddenly attacked by a spontaneous salivation, so excessive as to endanger his life. In the present instance, therefore, it is probable that the dose of calomel co-operated with the peculiarity of the constitution, in exciting the discharge. But whatever was its cause, it proved critical both of the jaundice and the cholic ; for, from the moment it took place, the pain of the bowels ceased, and the greenish colour of the skin began to subside, the urine being at the same time secreted more abundantly, and of a blackish hue. SPECIES II. PTYALISMUS CHRON1CUS. CHRONIC PTYALISM. INCREASED SECRETION OP SALIVA FROM DEBILITATED HABIT, ANI> RELAXATION OF THE SALIVARY GLANDS. Gen. II. There is another species of ptyalism which is worthy of our at- Spec.II. tention, and consists in an increased secretion of saliva, but not, strictly speaking, produced by increased action of the salivary glands, but an habitual relaxation and debility. To this species I have, therefore, given the name of chronic ptyalism. The stimulus, in this case, depends upon morbid habit alone ;* and is an example of what Mr. John Hunter intends by the phrase stimulus of relaxa- Howpro- tion. It is often very distinctly produced by a long and continued duced use of tobaccot whether chewed or smoked ; and is said by Quarin How reme- to follow equally upon an habitual use of squills.| Warm astrin- gent tonics, as cinchona and port wine, will frequently be found serviceable, as local applications, or in the form of gargles: or a few drops of some pleasant essential oil, particularly that of the cajeput tree (melaleuca Leucodendron,) may be taken four or five times a day on a lump of sugar. * Souquet, Journ. de Med. torn. xxii. p. 40. t Harder, Apiarium, Obs. 43. J Animadversiones, &c cl. r.J DIGESTIVE FUNCTION. [or». j. 89 SPECIES III. PTYALISMUS INERS. DRIVELLING OR SLAVERING. INVOLUNTARY FLOW OF SALIVA FROM A SLUGGISHNESS OF DEGLUTI- TION WITHOUT INCREASED SECRETION. There is a third species which belongs to this genus, in the pre- Gen. U. sent system, distinguished by the name of inert ptyalism, or ptyalism SpEC*In> of inertion ; and which depends upon a want of command or power over the muscles of deglutition, rather than on any increased action of the salivary excretories. In vulgar language it is denominated drivelling or slavering. It occurs under the three following modifications:— et Infantilis. Of infancy. /3 Senilis. Of old age. y Moriae. Of dotards or idiots. It is found therefore, in three states of life : among infants, before cause«. the will has acquired a power over the muscles of deglutition, and is altogether distinct from the salivary flux of dentition ; in advanced life, in which the will has lost its power: and in idiots, who pos- sess the power, but seldom or never exercise it. In the first case, time is the best physician ; in the two last, no physician can be of any avail. GENUS III. DYSPHAGIA. DYSPHAGY. PAIN, OR OBSTRUCTION IN SWALLOWING ; WITHOUT INFLAMMATION ; AND, MOSTLY, WITHOUT IMPEDED RESPIRATION. It is necessary to limit the character of this genus, as in the Gen. III. above definition, since inflammatory affections, in whatever part ofLiraltatM>n- the system they occur, constitute one natural order ; and dyspnetic affections, or those essentially impeding the respiration, another order ; and should, therefore, be arranged and considered in their re- spective associations : the former under the diseases of the san- guineous function, and the latter under those of the respiratory, \"ol. I—12 90 a. i.] CCELIACA. [OBP. I* Gen. III. , The organs chiefly concerned in the act of swallowing, are the Organs affected. tongue, the parts composing the fauces, and the esophagus : all ot which, when diseased, may produce impeded deglutition; and con- sequently lay a foundation for various species under this genus. In Sauvages, and most of the Nosologists, these species are extremely numerous. It is possible to reduce them to the five following :— 1. DYSPHAGIA CONSTRICTA, 2. 3. 4. 5. ATONICA, GLOBOSA, UVULOSA, LINGUOSA, CONSTRICTIVE DYSPHAGY. ATONIC DYSPHAGY. NERVOUS QUINSY. UVULAR DYSPHAGY. LINOUAL DYSPHAGY- SPECIES I. DYSPHAGIA CONSTRICTA. CONSTRICTIVE DYSPHAGY. Difficulty of- swallowing from a permanent contraction op THE ESOPHAGUS. Gen. HI. Spec. I. Diagnos- tic*. Examples common. Sometimes the diameter of the canal is diminished in particular parts by fleshy excrescences, or schirrhous tumours; sometimes a fechirrhous thickening of its coats extends through its entire length ; and sometimes it becomes contracted by ossification: independently of the casual and symptomatic obstructions which do not fall under our present survey, produced by hysteria, and other spasmodic afc fections ; enthesis, or the lodgment of foreign bodies in the in- terior of the canal; or external tumours, as in bronchocele, or aneurism of the aorta, pressing against its sides. The different repositories of medical cases are full of examples of all these : the schirrhous contraction of the coats of the eso- phagus is, perhaps, the most frequent: which, in some instances, is limited to a quarter of an inch in length, and in others extends through the greater part, or even the whole of the tube. In one case, in which the stricture was confined to the upper part of the passage, the author knew a lady supported for twenty years by food passed through a silver canula, somewhat larger than a fe- male catheter, into the stomach. But this is an example of rare She disease, occurrence : for the canal usually grows more and more contracted, till at length, if the life be preserved so long by the occasional aid of nutritive clysters, the passage will only admit a common probe. At times the constriction is accompanied with internal ulceration, KTeJT1 and ? PerPetual formation of matter. Mr. Warner's Cases contain a striking example of this painful and distressing complication of symptoms in a young woman of twenty-five; and another has lately occurred in the author's own practice. The patient was here alet> Usual course of ul. i.] DIGESTIVE FUNCTION. [ord. i. 91 a female, of a delicate habit, about thirty-five years of age. Rapid Gen. III. was the progress, and she was carried off in about twelve months IJt constric- from the first sensation of a difficulty of swallowing. For the last j* . _ six months the passage would only admit a bougie of the largest tivedys" size employed in obstructions of the urethra. The bougie would at PhasJ- times pass with ease ; but at other times gave great pain from the extent of the ulceration, and the lodgment of mucus, scabby crusts, and bloody matter, which were occasionally thrown forth in abun- dance. During this painful state the lady went through a period of pregnancy, and lived to bring forth a feeble and emaciated child that died a few months after birth, and a few weeks after the mother. From the urgent desire of swallowing, and the food being per- mitted to descend as low as it can, the latter often accumulates upon the mouth of the stricture, and the esophagus is in this part con- siderably widened in consequence of the pressure which takes place. Dr. Odier relates a fortunate case of a young nobleman at Ge- Singular i'ii i-i i i • cnse t9rnu_ neva, in which the esophagus, which seems to have assumed a scir- nating fa- rhous character, had become dilated in this manner into two large voorably- bags, one on each side of the neck, and appeared strikingly promi- nent. The food he took commonly remained in these sacks for an hour or two, and was then thrown up, but whether in any degree digested we are not informed. After having tried the skill of almost every physician and surgeon in the city without success, the patient was at length recommended to swallow hemlock pills, and com- press the protuberance by a bandage round the throat. As soon as the pills were rejected, which, like the food, they were sure to be in an hour or two, their place was supplied by others, so as to have the hemlock constantly acting on the seat of the disease. The pa- tient soon became relieved, and was gradually cured ; the pouches disappeared, the aliments descended into the stomach, and the eso- phagus recovered its former calibre.* Where osthexia or an ossific diathesis is present, the stricture sometimes assumes a bony hardness ; and Metzger gives a pitiable case of this kind, in which the passage was so narrow that the un- happy patient perished altogether of. hunger.! At times indeed JJjSjJ^ the esophagus has become entirely imperforate either from the in- indurated creasing contraction, or the enlargement of internal or surrounding an ony' tubercles : of the former, Rhodius relates a singular case.J Ex- amples of the latter have occasionally followed upon small-pox,§ or strumous indurations.il In a few instances half the length of the esophagus has been completely gorged by a single fleshy or glandiform excrescence ; an instance of which is given in the Edinburgh Medical Essays; the patient died of marasmus in the seventh month from the commence- ment of the disease, and in the prime of his life. The tumour reached from the middle of the canal to the cardia, and so tho- * Edin. Med. Com. m. p. 193, Letter from Dr. Odier to Dr. Duncan. t Advera. Med. Vol. i. p. 175. $ Cent. 11. Obs. 46. 5 Act. Hafn. Vol. I. Obi. 109. Eph. Nat. Cur. Dec. ii. Ann. IX. Obs. 45. fj Mauchart, Diss, do Stroma (Esophagi, hnjusgue Coalitu, &c. Tubing, 1742. 92 cl. i.] CCELIACA- [dR1)- T< Gen. HI, Spec. I. D.con- strict a. Constric- tive dys- phagy. Ulcerations below the stricture. Remote causes. Mode or treatment. Cured by mercury. roughly blocked it up that a probe was with difficulty passed into the stomach on examining the part after death.* It is a singular fact that, where ulcerations occur, they are more commonly found at a short distance above or below the contraction than in its immediate range ; a remark for which 1 am indebted to Dr. Baillie, who has illustrated it in his Morbid Anatomy by two distinct plates.t Of this distressing disease it is often difficult to trace the remote cause. And hence it commences without being sufficiently at- tended to, and makes an alarming progress before professional ad- vice is sought for. Sometimes it has been evidently superinduced by a neglected catarrh ; occasionally by small-pox or syphilis ; and at other times by a highly nervous or spasmodic diathesis. It is said to have been brought on by the smoke of tobacco ;| by the use of the datura Stramonium ;§ by mercurial preparations improperly in- troduced into the system ; by a habit of drinking too largely of coffee, or any other fluid immoderately hot or cold.ll A temporary con- traction of the esophagus has also been produced by worms in the stomach and intestines; and, in one or two instances, apparently by worms lodged in the hepatic and common duct. IF Its cure is of difficult accomplishment. In an early period of the disease some benefit has been derived from hemlock and ammoniated copper. And sometimes mercury, carried to the point of saliva- tion,** has been found highly serviceable. Where the disorder depends upon spasmodic action, cold freezing water as a beverage, and applied externally, has diminished and even taken off the morbid effect ;tt and the action of emetics, as recom- mended by M. Ferrein,|J may prove a valuable auxiliary, not only in spasmodic, but in various other cases, by relaxing and expanding the affected tube. But unless either of these medicines be had recourse to in an in- cipient state of the disease, little benefit is to be expected from their use. Dr. Munkley, however, relates one case of great severity and some years standing, in which mercury carried to the effect of ptyalism, proved perfectly successful. The patient was a female of about forty years old, and, at the time of admission into Guy's Hos- pital, was incapable of swallowing any thing but the thinnest liquids, and even these in only a very small quantity. She was greatly ema- ciated ; her voice was hoarse ; and her breathing very considerably disturbed. She was salivated as soon as possible, and continued under the influence of this process for nearly six weeks; and as the time advanced all her symptoms gradually disappeared; and at the end of this period she went out of"the hospital perfectly cured.§6 * Vol. n. Art. xxiv. | Fascic. HI. PI. m. iv. J Eph. Nat. Cur. Dec. in. Ann. i. Obs. 79. § Eph. Nat. Cur. Dec. m. Ann. ii. Obs. 68. )| Blenland, De sana et morbosa (Esophagi Strnc.tura. If Eschenbach, Vermiscbter Bemerkungen, i. Ob^Sns a»TlntuSi"s,0VKerVati0nS- BriSbane' "^ ^ D°bS°n' MediCal |t Montat. Memoires de Paris. Tode, Diss. Adversaria Med. Pract. Hafn 17°9 U Memones de Pans. §§ Med. Transact, of the College, Vol. iT Art It ll. i.j DIGESTIVE FUNCTION. [ord. i. 93 Neither hemlock nor mercury, however, will answer in the greater <|EN* MI. number of confirmed cases. And even from the first, while these d. con- are employed as auxiliaries, the chief dependence has hitherto been, "r0'^ar"ic. as in strictures of most other dilatable and highly sensible canals, tive dys- upon the bougie ; which, from an early state of the disease, should uSe8of the be introduced twice a day, of as large a volume as the patient can bougie. bear without much uneasiness, and increased in its diameter as often as an increase can be borne. I cannot, however, avoid recommending instead of this the inge- Read'* nious stomach syringe, invented by Mr. Read, for diluting and wash- syringe ing away various poisons introduced into the stomach, whether by "",*„£„. design or accident. I do not know that this instrument has thus far ously ever been applied to, or thought of for this purpose, but it appears '"P10^- to be admirably adapted to the joint object of enlarging the diameter of the esophagus by a gradual pressure, and of conveying any quan- tity of liquid food that may be desirable. The instrument, as brought Description. into notice by Mr. Jukes, consists of an elastic gum tube, a quarter of an inch in diameter, and two feet and a half in length, terminating in the lower extremity, or that introduced into the stomach, in a minute globe of ivory with various perforations, which for the pre- sent purpose must be omitted, and fitted at the upper end either by a screw or a plug to an elastic bottle of sufficient size to contain at least a quart of liquid, with a stop-cock fitted to it, as in the hydro- cele bottle. Instead of the bottle a pewter syringe may be adapt- ed, of equal capacity, and used in the same manner. The bottle or syringe being filled with warm water and fitted to the tube already introduced into the stomach by the mouth or a nos- tril, on turning the stop-cock the water or other liquid may easily be forced into the stomach, and withdrawn by a reverse action : and hence laudanum, or any other poison apable of dilution, may be pumped up in a diluted state till the s mach is entirely unloaded ; and liquid food may be introduced t • any extent at option. Mr. Jukes has tried the instrument on himself, as well as on various pa- tients, with complete success, in one or two cases after ten drachms of laudanum had been swallowed for the purpose.* * Letter to the Editors of the Lond. Med. and Pbys. Journ. No. xlviii. p. 334. 94 cl. i.) C03LIACA, [orb. r. SPECIES II. DYSPHAGIA ATONICA. ATONIC DYSPHAGY. DIFFICULTY OF SWALLOWING FROM DEBILITY OF THE MUSCLES OF DEGLUTITION. Gen. HI. The external tunic of the esophagus is muscular, and the muscular Economy' fibres are both transverse and longitudinal. The protrusion of the ofdegiuti- food from the fauces into the stomach commences in the action of the circular fibres of the pharynx, which contract in succession, and in a downward direction ; and as this direction is continued to the muscular fibres of the esophagus, the swallowed morsel is carried forward into the stomach by a progressive or peristaltic propulsion. Causes of Now in all cases of debility in the muscles of deglutition, the con- phagy. y tractile action of their fibres, and consequently their propulsive power, is lost or enfeebled, and a difficulty of swallowing must be the necessary consequence. Persons of a nervous or irritable tem- perament are most subject to this species. Like the last, it is often brought on by long continued and neglected catarrhs; and occa- sionally by a habit of drinking very hot fluids, as tea or coffee. Medical The cure may be attempted by repeated blisters to the throat and oreatmeit. chesti which stimulate from without; and by tonic and astringent gargles, as of alum, catechu, rhatany, port-wine, and decoction of cinchona, which stimulate from within. For the same reason the warm and stimulating sialagogues may be employed with advantage, as the root of the pyrethrum, the leaves of the imperatoria, or master-wort, and the bark of the mezereon : or, where a slighter irritation is required, the root of the arum Ma- culatum or wake-robin. In paralytic affections of the tongue and fauces, Boerhaave recommends the use of gum mastick (the resinous exudation of the pistachia Lentiscus, Linn.), but of itself it is too inert, though it makes a good dentifrice, and is still very largely em- ployed for this purpose. In the hands of Boerhaave, indeed, it was commonly united with ginger, or some other warm aromatic. A few drops of some of the more grateful essential oils, as juniper, carraway, lavender, and particularly cajeput, as already recom- mended in chronic ptyalism, will often be found a simple and pleasant remedy, if taken on a lump of sugar three or four times a-day. A draught of cold water drunk frequently during the day-time, and especially at night and morning, has also as a tonic been fre- quently found useful. And if the habit be relaxed or irritable, the same tonic plan should be rendered general as well as local: and be especially combined with exercise, sea-air, and sea-bathing; hard study must be relinquished, and if possible, anxiety of mind. «,. i.] DIGESTIVE FUNCTION. [ord. i. 95 SPECIES III. DYSPHAGIA GLOBOSA. NERVOUS QUINSY. DIFFICULTY OF SWALLOWING FROM WIND IN THE STOMACH, SPAS- MODICALLY COMPRESSED INTO THE FEELING OF A BALL ASCENDING INTO THE ESOPHAGUS, AND PRODUCING A SENSE OF STRANGULATION. From this feeling of a hard ball in the throat, the species is in the Gen. III. present system distinguished by the specific name of globosa. It is |PEC> UI« peculiarly common to persons of a nervous or spasmodic tempera- ment : and is hence called by Dr. Darwin and many other writers globus hystericus, and by Dr. Heberden nervous quinsy. It is the chute de la luette of the French. Most frequently it occurs as a mere symptom of the hysteric or Causes. hypochondriacal affection ; and on this account is regarded as such alone by many Nosologists. It is, however, often to be traced in sudden gusts of passion, as fear, grief, and anger, especially in young subjects whose passions have never been disciplined ; and at times exhibits so much violence as to threaten suffocation. In nervous habits I have frequently met with it as a pure idiopathic affection ; and, in a few instances, in persons who were not thus constitutionally predisposed to it. Two clergymen of this metropolis, who bear an equally high cha- singular racter for pulpit eloquence, and have a very sufficient self-possession, "b^00"' have been occasionally under my care for some years in consequence of this complaint. One of them has most commonly been attacked during dinner; the regular action of the muscles, in swallowing, being converted, from debility of the organ, into the irregular action of spasm. The other received the first paroxysm while reading the service in his own parish-church, and was incapable of proceeding with it. In this case the regular action of the muscles of the glottis in speaking, excited irregular action in those of the esophagus from contiguous sympathy. And the effect was so considerable, that when the clergyman came to the same passage of the Liturgy on the en- suing Sunday, he was obliged to stop again, for he found he could not get through it. But he preached with as much fluency as ever; and this too with nothing more than a syllabus of his discourse be- fore him. It was many weeks before he could summon courage to make another attempt in the desk: and his first effort was even then made in another church and before another congregation. In this he was fortunate enough to succeed : and he has now entirely over- come the morbid habit. In both these cases I have found the most effectual remedy at the Remedy at moment to be a tumbler of cold water swallowed gradually, and the mlX° application of a handkerchief dipped in cold water to the throat- 96 cl. I.] CCELIACA. [oR». i- quinsy. Gooeral treatment. Gen. III. The spasm thus counteracted soon ceases ; and, in the cases before aoiobSa us> has returned not only less frequently, but with far less violence. Nervous ' Yet, during the intervals, general tonics, a light diet at regular hours, and as much as possible horse exercise, have been had recourse to, and contributed their respective services. The usual antispasmodics, as volatile akali, ether, camphor, assa- fcetida, and even laudanum, had formerly been tried, but I was told, with little success. When ether is had recourse to, whether in this or any other affec- tion, the best means of dissolving it is a preparation little known in our own country, but which is introduced into the current French Pharmacopoeia* under the name of Oleum de vitellis ovi, obtained by evaporating the mixed yolks of eggs to about half; the oil is produced from this by pressure : but it must afterwards be filtered through paper to become refined. Oil of the white of egg*. SPECIES IV. DYSPHAGIA UVULOSA. UVULAR DYSPHAGY. SWALLOWING OBSTRUCTED OR TKOTTRT.ESOME FROM RELAXATION AND ENLARGEMENT, OR FROM DESTITUTION OF THE UVULA. from mflamma tion. Medical treatment. Gen. III. The uvula is sometimes enlarged from inflammation ; but in such h*11^"1^' case tne disease, for reasons already stated, belongs to another class. Anguished In the inflammatory state the uvula is hot, acutely painful, of a red or livid colour, and deviates, as it enlarges, from its proper form. In the species before us, its natural form and colour are scarcely inter- fered with, excepting that, as it grows larger and longer, it also grows paler. It is soft, relaxed, and edematous. The complaint, therefore, in this variety requires to be treated with spirituous and astringent stimulants. Gargles of alum or port- wine form, perhaps, the best local applications: and should be com- bined with cathartics and general tonics. If the disease do not yield to this plan, the elongated and pendulous part must be ex- tirpated. In a few rare instances the uvula and even the tonsils become hard and cartilaginous ;t and in such cases the morbid portion must be removed by the knife instead of by a ligature, as ordinarily re- commended.! The uvula in its natural state appears to assist in swallowing, and * Codex Medicamentarins sive Pharmacopoeia Gallica. Paris, 1818. t Jaegen, Chirurgische Cautelen, Band. H. t Sharp, Critical Enquiry, &c. Ch. vi. Siebold, Chirurgisehes, Tagebach. N. 78 cl. i.j DIGESTIVE FUNCTION. [ord. i. 97 to direct the food to its proper channel. And hence, when from Gen- HI. ulceration or any other cause it becomes lost or deficient, the act of d.PtjvUw deglutition is rendered troublesome and even difficult,* though not so yvular much so as in the enlargement and illapse of this organ. In this c?oLa.sy' case the healing art can administer nothing, and habit becomes the ?heenucveu£f only physician. There are examples, however, in the medical repo- becoming sitories of so total a loss of the uvula from gangrene, or the bar-lost* barous cruelty of cutting out the tongue, that the sad sufferer has been compelled to force the food in every meal into the esophagus with his fore-finger. SPECIES V. DYSPHAGIA LINGUOSA. LINGUAL DYSPHAGY. SW ALLOWING OBSTRUCTED, OR TROUBLESOME FROM PROTRUSION OR MAGNITUDE OF THE TONGUE. This species exhibits itself under the two following forms or Gen. III. varieties : Spec. V. a Exsertoriu. Tongue extended from the mouth, often with Lolling tongue. enlargement of its substance. /3 Ranula. Intumescence of the salivary glands or ducts. Frog-tongue. It is necessary, as in the last species, to distinguish both these af- a D- in- fections from inflammatory enlargements. The variety before us is fenoriaf" often produced by an improper use of mercury or other metallic poi- ^namf. sons, and may be treated as the enlarged uvula. ♦ M. Magendie, in the Bulletin of the Philomathic Society of Paris, singular for September 1817, quotes the case of a Jew, who was able to swallowing double his tongue backwards, and plunge it with the greatest ease the t0"8ue' into the pharynx: and tells us of a child who acquired the same power by imitating the Jew. The first efforts of the child were un- successful : but at length he ruptured the frasnulum, and a haemor- rhage ensued, which nevertheless did not alarm the boy, for he found, from that moment, that he could pursue the imitation more per- fectly ; till, by continued repetition, he too acquired the singular fa- culty of swallowing, in the same manner, his own tongue, without the least inconvenience to his respiration. This variety sometimes occurs as the result of lesion or injury to Effects of the tongue. M. Manoury has a case of this sort, in which the tongue * l9 vane y" suffered so much mischief and was become so enlarged, that not the smallest particle of food could pass by the mouth : and the patient * Act. Erudit. Lips. 1717, p. 408. Salmuth. Observationes Medica;. Cent, in Obs. 6. Vol. 1—13 98 cl. i.j CtELlACA. [obd. r. Gen. m. was entirely supported by means of a flexible tube thrust through the n d^Lhi- nostrils into the oesophagus, by means of which nutritive fluids were guosaex- conveyed into the stomach.* Loiii"!' But the substance of the tongue under this variety is not always Nof always enlarged. M. Fournier knew a handsome young woman, sixteen enlarged years of age, who, although she had a long neck, had a slender and elongated, still longer tongue, insomuch that she could protrude and extend it to her bosom without stooping her head. And he tells us of another female whom he saw at Berlin, with a tongue astonishingly wide, but as thin as a cat's. When this woman laughed, the tongue covered the whole of her mouth, and hung out like folds of drapery. It was always cold, and communicated a most frigorific sensation to the hand of another person.! 0 D. Lin- The Ranula, or frog-tongue as it is commonly called, is said to Ranuia. be an enlargement of Wharton's duct; and often possesses a scro- ton°ue. phulous character.J M. Justamond has removed it by a strong so- lution of alum : but it will sometimes advance, though slowly, to an imperfect suppuration. From the danger of wounding the salival ducts, it is best to leave the abscess to open spontaneously ; but, if it be opened by the lancet, the incision should run in a trans- verse direction, and the tongue be carefully held up during the ope- ration. The irritation and enlargement proceeds occasionally from a mor- bid secretion of calculous or ossific matter. M. Fournier records the case of a stone which was hereby formed under the tongue of a man only thirty-seven years of age, and at length acquired the size of a pigeon's egg. It was accompanied with great pain and profuse salivation : but the disease yielded to a removal of the morbid con- cretion^ Painful In the valuable manuscript commentary upon the author's volume Rami?a. of Nosology by his distinguished friend Dr. Perceval, of Dublin, ad- verted to in the introduction, is the following notice of a severe case of ranula produced by cold upon mercury : " A horrid case of dys- phagia linguosa has lately occurred in a young girl, who took a large drink of cold water whilst her mouth was sore from mercury. The protruded tongue lolled out on the chin, and was half cut through by the pressure of the lower teeth. The ulcer was exceedingly foul, but its appearance soon changed for the better by the use of mel rosre and carbonas ferri." * Journ. de Med. Tom. u^xxvi. t Diet, des Sciences Medicales. Art. Cas. Rares. j Alix, Observationes Chirurg. Fascic. I. § Diet, des Sciences Medicales. Art. Cas Rares. cl. i.j DIGESTIVE FUNCTION. [ord. i, 99 GENUS IV. DIPSOSIS. MORBID THIRST. THE DESIRE FOR DRINKING EXCESSIVE OR IMPAIRED. Between the present and the ensuing genus, entitled limosis, or Gen. IV. morbid appetite, there is a close natural connection, though their position is in different and even distinct organs. The sense of hunger is well known to be seated in the stomach ; causes of and that of thirst in the throat or fauces. Yet though we can trace ence^be" the organs in which these faculties reside, we are to this moment Jween totally unacquainted with the causes of their difference. And and thirst though we give them the name of sensations, they have none of the unknown" characteristics which the term sensation imports as applied to any other part of the system, or as derived from any particular set of nerves with which we are acquainted. In the local senses, as those of sight, smell, taste, and hearing, we can trace the respective nerves from which these respective feelings proceed. In the seats of hun- ger and thirst, ©n the contrary, we can trace no other nerves than those which are common to the sensation of touch ; and we know of no modification of these nerves that is capable of producing a new sensorial power : for hunger and thirst are not touch, any more than they are sight, or smell, or taste, or hearing. Within a certain degree of intensity they are both pleasurable sensations: but, like all other pleasurable sensations, they become acutely painful when raised to an extreme. In this obscurity of the subject, it is not to be wondered at that various hypotheses should have been devised to account for these sensations: thus, the feeling of hunger has been ascribed by Dr. Sensation Willis to acid vapours generated in the stomach ; by Dr. Cullen, to howUac-r an uneasy contraction of this viscus when no longer distended ; and, counted t°r- by others, to the stimulus of the gastric juice. In like manner thirst Sensation has been attributed to a diminished or exhausted power of secretion howac- in the salivary or buccal glands ; to the stimulus of salt, or other counted for. acrid matters taken by the mouth, and lodged in the follicles or ducts of the same glands; and to acrimonious materials in the sto- mach sympathetically affecting the fauces. In all these conjectures ah such there is ingenuity, but no satisfactory elucidation. Many of them vague and are evidently erroneous; and none of them entitled to adoption. "0nry*tisfac* In thirst, there is, perhaps, always a sense of dryness in the fauces ; and yet dryness of this organ does not appear to be the cause of thirst; at least the intensity of the feeling does not appear to depend on the intensity of the dryness: for there is sometimes but little 100 cl. i.J . C03LIACA. [ord. r. Gen. IV. These sen- sations how quenched. Pressure employed to deaden hunger by savage beasts. The same by barba- rous tribes. Overcome by emotions of the mind. Thirst in- creased by some passions. Morbid thirst rarely treated of. thirst, where the tongue, to its very roots, is covered with a thick and dry crust, as in the acme of continued fevers; while it is often vehement under the influence of violent passions, and intolerable on a surcharged stomach, when the tongue and fauces have no dry- ness whatever. The common modes of quenching these agonising sensations are well known to be eating and drinking: yet when these cannot be indulged in, there are other modes that may answer as a substitute. Thus violent pressure against the coats of the stomach, whether ex- ternally or internally, is well known to take off the gnawing sensa- tion of hunger; and stimulating the fauces, to take off the burning faintness of thirst. It is on this last account that chewing a mouth- ful of hay, alone, or merely moistened wjth wajer, proves so refresh- ing to a tired horse, and is found so serviceable when we dare not allow him, in the midst of a long stage, to slake his thirst in the na- tural way. Savages and savage beasts are equally sensible of the benefit of pressure in the case of hunger, and resort to it upon all occasions where they have no opportunity of taking off the pain in the usual way. The manis or pangolin, that swallows its food whole, will swallow stones, or coals, or any other substance, if it cannot obtain nutriment; not that its instinct deceives it, but for the purpose of acquiring such a pressure as may blunt the sense of hunger which it finds intolerable. Almost all carnivorous beasts pursue the same method; and a mixed mass of pieces of coal, stone, slate, and earth, or other hard materials, is often met with in the stomach of ostriches, cassowaries, and even toads. The Kam- scadale obtains the same end by swallowing saw-dust; and some of the northern Asiatic tribes, by a board placed on the region of the stomach, and rudely laced behind with cords, drawn tighter and tighter according to the urgency of the uneasiness. In our own country we often have recourse to a similar expedient, and only ex- change the tightened stomach-board for a tightened handkerchief. It is possible, therefore, temporarily to overcome these natural sensations without the natural means: and the passions of the mind have as strong an influence on both as any of the substitutes just ad- verted to. Thus both are completely lost beneath the sudden com- munication of news that overwhelms us with grief or disappoint- ment. So, Van Helmont tells us, that, happening to dislocate his ankle while walking with a good appetite to dine with a friend, his appetite immediately forsook him ; but returned as soon as the joint was replaced, though the pain continued for some time with little alteration. There are some passions, however,* as those of rage and eager desire, which, while they repel the sense of hunger, in- crease that of thirst. But they prove equally the close connection of both feelings with the state of the nervous'system generally ; and the strong and extensive influence which is sympathetically exercised over them. Morbid thirst, as a genus, is new to the science of Nosology • and hence the two species which belong to it have hitherto, in almost every instance, been separated from each other and thrown loosely into remote parts of the classification. Dr. Young, however offers i;l. i.] DIGESTIVE FUNCTION. [ord. i. 101 an exception to this remark : for, with his accustomed accuracy, he Gen. IV. has united them under a common head. The genus being new, it has hence been necessary to create a new name for it: and that of Dipsosis, from hipcta>, " to thirst," has appeared-.ot only most perti- nent, but most consonant with the nomenclaiure in common use, which has naturalized various terms derived from the same root; as adipsia, polydipsia, phobodipsia ; this last being a synonym for hy- drophobia. The two species of the genus are the following :— 1. DIPSOSIS AVENS, IMMODERATE THIRST. 2. ------- EXPERS. THIRSTLESSNESS. SPECIES I. DIPSOSIS AVENS. IMMODERATE THIRST. CONSTANT DESIRE OF DRINKING ; WITH A SENSE OF DRYNESS IN THE MOUTH AND THROAT. Simple thirst is a natural;—immoderate, or inextinguishable Gen. IV. thirst, a morbid feeling. Yet even the latter is less frequently an SpEC- L idiopathic disease than an individual symptom of some other com- plaint, or some peculiar state of body, the removal of which will alone effect its cure. Occasionally, ho,, ever, we meet with it un- der the first of these two forms ; and it - hence necessary to assign it a distinct place in a System of Nosology. I have at this time under my care a young lady of about thirteen striking ^ years of age, in other respects in good health, who is tormented with idiopathic a thirst so perpetual that no kind or quality of beverage seems to diPSOBi»- quench it for more than a few minutes. Emetics and purgatives have been tried in vain. Squills and other nauseating expectorants seem to promise more success. It has now lasted for several weeks. The most grateful palliatives are the vegetable acids, and especially acescent fruits, and a decoction of sorrel-leaves (rumex acetosa Lin.) slightly inspissated with gum Arabic or some other mucilage, and sweetened to meet the palate. Liquorice, which among the Greeks had so high a reputation for quenching thirst as to be honoured with the name of uh^ov " the thirst extinguisher," has little or no effect. And itismost probably true, as suggested by Dr. Cullen, that it only acts in this manner when the root is -.veil chewed,by which means the salivary excretories become stimulated to an increased secre- tion of fluid. In a foreign medical miscellany we have reported to us a case ot the same kind, brought on by drinking a cold beverage during the 102 cl. i.j cq:liaca. [ORD. I. Gen. IV. Spec. I. Dipsosis Avens. Immode- rate thirst Quantity drunk sometimes enormous. Symptom- atic thirst. paroxysm of a fever that continued for more than a twelvemonth.* And in another foreign journal we have an account of this disease as epidemic among children.! The quantity actually drunk is sometimes enormous. Four hun- dred pints of wine and water have, in some cases, been swallowed daily. As a symptom, excessive thirst is chiefly found in the hot fit of fevers, in dropsy, dysentery, diabetes, diarrhoea, and other dis- charges. It is also frequently excited in wet-nurses as soon as the child takes hold of the nipple ; but perhaps is felt most intolerably under the torture inflicted to compel a confession of guilt; in which case it is said to form the worst part of the suffering.! SPECIES II. DIPSOSIS EXPERS. THIRSTLESSNESS. CONSTANT WANT OF THIRST. Gen. IV. Spec II. Some ani- mals never drink. Thirstless- ness in «ther ani- mals a disease. Examples. Considering that thirst is a natural feeling, and contemplating the vehemence of this feeling when extreme, it is not a little extra- ordinary that instances of its total absence should ever occur. Yet there are many animals, and warm-blooded animals too, that never require drink, and consequently never thirst : as mice, quails, par- rots. Here, however, the want of thirst or desire to drink, is a na- tural condition in the economy of these animals. In man, and animals constituted like man, with a constitutional proneness to thirst, and an instinctive urgency to quench it by drinking, this want of desire can never take place without disease. Nor are the cases in which it occurs by any means frequent. Sauvages, however, mentions two instances that occurred to himself. In the one, the patient, a learned and excellent member of the Academy of Tou- louse, never thirsted, and passed months at a time without drinking even in the hottest part of the summer : in the other the patient, who was a female of a warm and irascible temperament, abstained frOm drinking for forty days, not having the smallest degree of thirst through the whole of this period.§ Neergaard, as quoted by Blumenbach, has furnished us with other examples :|! and M. Four- nier informs us, that one of his most intimate friends reached, not long since, the age of forty-eight, without ever having drank of any fluid, or been thirsty; but he was accustomed to eat voraciously. It is singular that he should have died of dropsy of the chest, ap- parently the result of a second bleeding for some accidental ma- lad y.ll * Henermann, Bemerkungen, i. p. 28. t Gazette de Sant€, 1777 p. 9S. X Pecklin, lib. lit. Obs. S9. § Nosol. Method, vol. i. p. 770, 4to edit 1 5!ume?b- .Ph7si°'- s,ect- 3Bd- 322.—J. W. Neergaard Vergleichende Anatomie und Physiologic des Verdenungswerkzenge, &c. T Diet, des Sciences Medicales, Art, Cas. Rares. A cl. i.] DIGESTIVE FUNCTION. [ord. i. 103 GENUS V. LIMOSIS. MORBID APPETITE. the appetite for food impaired, excessive, or depraved. The sensation of hunger, as observed already, is seated in the Gen. V. stomach ; and, like that of thirst, is a natural or instinctive desire. It may, however, become disease^ and lose its natural character; and this in various ways, and" accompanied with various sets of symptoms ; each of which lays a foundation for a distinct species. Like the species of the last genus, however., they have hitherto in most Nosologies been omitted, or loosely scattered over different parts of the classification, though they evidently belong to a common family, and should be contemplated in a concentrated view. It is for this purpose they are now united under the banners of a single genus, to which I have ventured to give the name of limosis from Ai|ttos, " hunger," being the root of various terms current in the me- dical vocabulary; as, bulimia, alimia, alimon, ahmonia, alimentum ; though the three last have been commonly mis-derived by the lex- icographers from alo, "to nourish :" unless alo itself be from the same source. The species that properly appertain to it are the following :— 1. LIMOSIS AVENS, VORACITY. 2. _____ expers, long fasting. 3^ _____ pic a, depraved appetite. 4# _____ cardialgia, heart-burn, water-brash. 5. -----flatus, flatulency. 6. ------ EMESIS, SICKNESS, VOMITING. 7. ______ DYSPEPSIA, INDIGESTION. SPECIES I. LIMOSIS AVENS. VORACITY. 1XSATIABLE CRAVING FOR FOOD. This aflection may be produced by a sense of faintness and in- ^-\ anition, without any known cause of exhaustion ; probably in con- sequence of some organic error in the stomach ; by gluttony, or an 104 cl. i.J CCELIACA. [oRn. i. Gen. V. Spec. I. habitual indulgence in large and frequent meals ; or by exhaustion from hard exercise, long fasting, fevers, or excessive discharges : thus offering the three following varieties of this species :— a, Organica. Canine appetite. (3 Helluonum. Gluttony. y Exhaustorum. Hunger of exhaustion. a L. Avens organica. Canine ap- petite. Supposed causes. Gastric juice, how far a cause Quantity of food de voured sometimes enormeus. From a feeling of faintness and inanition. From an habitual indulgence in large and frequent meals. From exhaustion as the conse- quence of hard exercise, fe- vers, or excessive discharges. There are many persons who from birth, or a particular period of life, without any habit of indulgence, are capable of taking into the stomach an enormous quantity of food, and cannot be satisfied without it from a constant sense of faintness and inanition; and who by no means increase in bulk in proportion to the quantity swallowed ; being often, on the contrary, slender and emaciated. It is difficult to account for this effect in every case ; but there is great reason to believe that in general it depends upon some error in the structure or position of the stomach, by which means the food passes out of this organ as soon as it is introduced into it. Thus, Ruysch gives a case, in which the diameter of the pylorus was considerably enlarged from relaxation : and there are others in which it has been changed from its natural to a lower or dependent position, in consequence of the left side of the stomach being ele- vated by a dropsy of the ovarium, or an enlargement of the hver. The existence of a double stomach, or of an immediate insertion of the ductus communis choledochus into the stomach, though noticed as causes by Blasius and Bonet, are more doubtful. In the hunger of general exhaustion, forming our third variety, we know it to be produced by the secretion of an extraordinary quantity of gastric juice, by which the food is digested almost as soon as it reaches the •digestive organ. And it may sometimes, as supposed by Galen, be produced by some acrimony in the stomach, exciting that mimic feeling which is commonly known by the name of false appetite. Upon the theory of Dr. Wilson Philip, its real cause should be an excessive secretion of gastric juice itself, for it is the flow of this material over the interior tunic of the stomach that, according to him, excites the sense of hunger.* It should, however, be recol- lected that if this sensation be not indulged within a few hours, and in weak stomachs within a much shorter period of time, after its commencement, it suddenly dies away, and is succeeded by ano- rexy ; although it is reasonable to suppose that there is then in the empty stomach a much larger quantity of the secretion. Whatever be the cause, the quantity of food devoured by persons labouring under this affection is enormous, and in some instances almost incredible. Dr. Mortimer! relates the case of a boy of only twelve years old, who from a feeling of inanition had so strong a * Treatise on Indigestion, &c. p. 73, 1824. t Phil. Trans, vol. xun. p. 336 cl. i.] DIGESTIVE FUNCTION. [ord. i. 105 craving that he would gnaw his own flesh when not supplied with Gem. V. food ; when awake he was constantly eating : the food given him a L.EAvens consisted of bread, meat, beer, milk, water, butter, cheese, sugar, organica. treacle, puddings, pies, fruits, broths, potatoes ; and of these he petite.e "p" swallowed, in six successive days, three hundred and eighty-four pounds eight ounces avoirdupois ; being sixty-four pounds a-day on the average. The disease continued for a year : and in this case Sometime* we have a clear proof that the feeling of hunger did not depended. 'S°s upon any extraordinary secretion of gastric juice producing a rapid digestion: for the food was usually rejected soon after it was swal- lowed, but whether without passing, or after having passed into the duodenum, it is impossible to say. And there are other cases re- lated by Lommius of a similar kind. In various instances, however, the food thus voraciously swallowed In oll,ei does appear to be digested, and that almost as soon as taken. The digested. case of the notorious Tarrare, as related to the National Institute, by M. Percy, a surgeon in chief to the French army, is a striking illustration of this. Before his enlistment, he was in the habit of devouring enormous quantities of the coarsest flesh, fruits, and roots : and, subsequently, he was found, after swallowing his own rations, to feed on the refuse of his comrades' messes, or offensive meat thrown on the dunghills; and to devour cats, dogs, and serpents. M. Fournier tells us that at seventeen vears of age, when he weigh- singular ii iii 11 iii • i f example of ed only one hundred pounds, he could devour in the space ot twenty- canine four hours a quarter of beef as heavy as his body : and that on one aPl,et,,e' occasion, when in the army, he devoured in a few minutes a dinner prepared for fifteen German labourers, and composed of various substantial dishes. There is a singular story that the French com- mander attempted to turn this wonderful voracity and extent of sto- mach to a good account, by employing it as a safe deposite for a letter of secrecy which he wished to send to a French officer at that time in the hands of the enemy. He sent for the man, showed him a wooden case containing the letter, and, having put him into good humour by treating him with thirty pounds of liver and lights. prevailed upon him to swallow it, and to depart with all speed to the enemy's quarters. Tarrare, however, was taken prisoner in the attempt; and while in prison passed the box by stool before he could meet with the officer, but immediately swallowed it again to prevent it from falling into the enemy's hands. He was strongly- suspected of cannibalism ; and was often restrained with difficulty from the ward appropriated to the dead. He at length fled from the army before a rumour of having devoured a child of sixteen months old, which had suddenly disappeared. The alvine evacua- tions of this man were not immoderate ; but after gorging his sto- mach, he slept and sweated in torrents of perspiration, a symptom common to the disease. He fell at length into a hectic, and died of marasmus.* Voracity is often a symptom of some other affection : it will some- jg"P£j!ffl times occur, in the most capricious manner, during pregnancy, often * Diet, des Sciences Medicales, Art, Cas, Pares. Vol. I.—14 106 cl. i.] CCELIACA. L°*»- *• Gen. V. in tne middle of the night, or at some other unexpected period ; a L.EAven3 when the patient, with a sudden sense of faintness and inanition, organica. WJH perhaps devour an inordinate quantity of almost any food that Uunine ep- i , ■ i , , i • ,1 petite. can be obtained at the moment; though in many cases there is a fanciful longing for a particular kind, as for herrings, of which Tul- pius gives an instance of a lady, who in this state devoured four hundred at a meal.* In these instances it is probable that the urgent desire becomes a stimulus to the secernents of the stomach, and that a greater quantity of gastric juice is in consequence poured forth. In like manner voracity and the sense of hunger occur also as a symptom in many cases of helminthia, or worms in the stomach or duodenum. But from the emaciation which usually accompanies such persons, it is most probable that the inanition or emptiness of the stomach is here produced, not by a rapid or elaborate digestion, but by an irritable state of the muscles of the stomach, which con- tract too readily, and force the food into the intestines before chymi- faction has taken place. Dr. Burroughs relates the case of a pa- tient in the Philosophical Transactions, who, from this cause alone, was rendered capable of devouring an ordinary leg of mutton at a meal for several days together, and fed greedily at the same time on sow-thistles and other coarse vegetables. woiTknown Among the Greeks, idiopathic voracity appears to have been a to the frequent disease : they paid much attention to it, and distinguished Greeks. jt ^y a variety of names, but do not seem to have been very success- ful in determining the nature of its cause, or the best means of treating it. The last, indeed, must be as variable as the efficients Treatment, ^hat produce it. When we have reason to ascribe it to a morbid state of the stomach in respect to tone or secretion, purgatives, and especially those that are warm and bitter, as aloes, may be found suc- cessful. Stimulating stomachics have been found equally so; whence Galen very judiciously recommends frequent and small doses of brandy, and Riverius, of ambergris. If these do not succeed, the stomach should be kept for some days in a state of constant nausea: and with this view as well as with that of destroying the morbid irritation on which the voracity depends, opium will often be found a highly salutary medicine. If the disease be produced by worms, or any other remote irritation, it is obvious that it can only be conquered by conquering the primary affection. And if it depend on a preternatural enlargement of the right orifice of the stomach, so that the food slips away as soon as it is introduced into this organ, a perfect cure is beyond the reach of art; though some benefit may be derived from a strong external pressure so as to de- tain the food in its proper place. heUuoVum The second variety resulting from a gluttonous habit is far more Gluttony"' common, and very readily produced; insomuch, that there is not perhaps a corporate town in the kingdom that does not offer abun- dant examples of it. It is in fact one of the numerous evils to which idleness is perpetually giving birth : for let a man have nothing * Lib. u <-l. i.] DIGESTIVE FUNCTION. [ord. i. 107 to do, and he will be almost sure, whenever he has an opportunity, Gen. V. to fill up his time by filling up his stomach: and hence the lazy ^Ayl'm train of servants that vegetate from day to day, almost without lo- heiiuonum.' comotion, in the vestibule, hall, and other avenues of a great man's ulu,tornjr' house, eat three or four times as many meals as their masters, who may possibly be employed, from morning till evening, in the courts of law, the committee-rooms of parliament, or in a fatiguing maze of commercial transactions. In tracing the cause of this voluntary disease, we have no diffi- Caupe ob" culty whatever. When the stomach becomes accustomed to disten- ™ tion it is never easy without it; and at length requires to be con- stantly full to be free from disquiet. It is also well known that every sense grows more acute the more it is employed; and hence the taste and longing of the glutton becomes more alive to what is relishing and savoury : he enjoys such indulgences more than other men, and turns with disgust from foods that are plain and simple. On this account the difference between the craving of a pampered appetite and that of real hunger is extreme : the former, whatever be its longing, can only satiate itself on delicious and high seasoned dishes; the latter is content with a fare of any kind, and enjoys the plainest more than the richest. There can be no doubt, moreover, as indeed we have already Enlarge- seen, that by constant distention the capacity of the stomach becomes stomach enlarged, and will not only hold, but require for satiety, a far more £y p"^-6'8" copious quantity of food than in its natural state, and hence one duced. cause of that enormous bulk of the organ which ha3 often been mistaken for dropsy. Bonet gives a case, in which, owing to a mistake of this kind the patient was actually tapped and the contents of the stomach hereby discharged, though the patient died soon afterwards. Magendie relates an instance that occurred to himself, in which the patient, then seventy-two years of age, vomited in a few minutes, from a stomach enormously distended, as much as filled two large pails. It is not often that we are asked to attempt a cure of this com- Mean* ofn plaint: it generally proceeds till the tone of the stomach is exhausted from so ° by its hard labour, and the cure is effected by the introduction of oJfahabit. dropsy, or some other disorder worse than itself, which utterly extin- guishes all appetite whatever. The man, nevertheless, who would honestly undertake to reclaim himself from this mischievous habit, and to acquire a better, should proceed in his career gradually; for organs that have long been under the influence of perpetual excite- ment, would lapse into atony upon the sudden adoption of a severe counterplan. The food should gradually be plainer, less in quantity, and repeated at a greater distance of time ; while the intervals should be filled up with some pleasant and active pursuit that may wholly engross the attention; for the surest way for such a man to produce faintness, flatulency, and uneasiness in his stomach, is to think about it. The bowels will at first perhaps be costive ; but this may easily be remedied by occasional doses of the warmer and bitter purga- tives, as aloes, colocynth, and rhubarb ; which will operate as use- fully by their tonic, as by their aperient qualities. 108 tx. i.J CCELIACA. [OED. I. Gen. V. The voracitv produced by an exhausted state of the system is vSLEAvI™ rarely of difficult-removal; for, in general, it requires good plain exha'usto- food, and abundance of it. It is most usually consequent upon HuVof rapid growth of the body in the period of youth, fevers, excessive exhaustion, discharges, especially from the bowels or blood-vessels, long tasting, caulesry severe and uninterrupted exercise ; and particularly the union of the last two, as often occurs in shipwreck, or the retreat of an enemy. It happens not unfrequently that in such cases the stomach occasion- ally overloads itself, and throws back some part of what has been swallowed. But this is of little importance, and often proves ser- viceable, by more effectually inculcating moderation than can be ac- complished by medical precepts. SPECIES II. LIMOSIS EXPERS. LONG FASTING. LOSS OR WANT OF APPETITE WITHOUT ANY OTHER APPARENT AFFEC- TION OF THE STOMACH. Gen. v. The causes that lay a foundation for this species are numerous, Spec". IL ana some of them are accompanied with a slight diversity of symp- toms. The following are the chief varieties it offers to us :— * Defessorum. From too great fatigue or pro- Want of appetite from ex- tracted fasting. haustion. 3 Pathematica. From violent passion or other Want of appetite from mental absorption of the mind. emotion. y Protracta. From habit or other cause ena- Chronic fasting. bling the system to sustain al- most total abstinence for a long and indefinite time with- out faintness; L. Ex- :rs di sort! m Muscular exertion and long fasting, in a vigorous constitution, Porumefes* Prove often, as I have just observed, the most powerful incentives to Want'of hunger. But, if even in the robustest frame, these are carried be- from'w- yond a certain limit, the appetite palls, and is recovered with great haustion. difficulty: while in the feeble and delicate, a very little exercise, and a slight protraction of a meal beyond the accustomed hour, and especially where the attention is directed to it, and hangs upon the Best pallia- delay, is productive of the same effect. In all these cases, the stomach is best re-excited to its proper feeling by half a wine glass .:l. i.] DIGESTIVE FUNCTION. [ord. i. 109 of sherry or madeira, with a crust of bread or piece of biscuit; or, Gen. v- if there be very great languor, by a few drops of laudanum in a tea- a Lepers spoonful or two of aromatic spirit of ammonia ; while the interval defessorum. should be filled up by what is most likely to attract the attention ; appetite for one of the surest revellents in uneasinesses of the stomach is a exhaustion. strong excitement of the mind. I have just said, that a strong excitement of the mind is one of 0 l Expets the surest remedies for general uneasiness of the stomach : and Jlcl6™* every day shows us how powerfully this acts in repressing or taking ^anttilgf away the painful sensation of hunger. No man, perhaps, ever had from an appetite for food under a full influence of the depressing passiona, "notion. as fear or grief: he may eat from persuasion, or a sense of duty ; but he eats without desire, or any craving sense of hunger. Hence causes of those who are suddenly deprived of their senses by an overwhelming and unexpected evil, pass days and nights without food of any kind, exclaiming perhaps in the language of King Lear— —When the mind's free The body's delicate: the tempest in ray mind Doth from my senses take all feeling else Save what beats there. Even where the mind is simply but entirely abstracted, and lost in itself while pursuing an abstruse problem or proposition, or adjust- ing a long train of intricate accounts in a banking house, the indi- vidual has no sensation of hunger ; and, if left alone, may perhaps persevere without knowing how the time proceeds, till warned by the darkness of the evening. And hence, La Bruyere, if I mistake Examples not, in one of his pictures of an absent man, describes him, without Sruyere* any deviation from nature, as totally mistaken upon the subject of his dinner. Being summoned by his servant to the dinner table, he answers that he will come immediately, but still continues in the same place, and indulges in the same revery for an hour ; when, being summoned a second time, he shows himself angry at the in- terruption, and still more so at the servant's stoutly insisting upon it that he had not dined, and that the dishes were still upon the table untouched, while the master contended, on the contrary, that he had actually made his dinner, and that too in the dining-room. In simple cases of this kind, medicine is not wanted; and in General the severer, it is of no use ; for it is not in the healing art, under ™™lse' such circumstances, to " minister to a mind diseased " This must be left to time, the palliatives of friendship, and a change of scene. The modifications, however, thus far contemplated, may be re- j-L.Expera garded as mere paroxysms, or acute cases of fasting. The most ^£1*' singular variety of the species consists in what may be called the chrome fast chronic form of affection, exhibited in those who are able to endure ing' an unbroken abstinence from food for a long and indefinite period of time without faintness or inconvenience of any kind. The medical journals and ephemerides of different nations, and the transactions of learned societies, abound with examples of this last and most extraordinary modification : many of them extending to a term of time so apparently extravagant as almost to repulse be 1 10 CL. I.] CCELIACA [ORD. I. GfcN. V. lief, notwithstanding the respectability of the authorities appealed y l. Expers to. It is necessary therefore, before any such histories are noticed, protracta. that I should lay down a few general principles, too well established chrome to allow of controversy, which by their conjoint force may lead us fasting. more readily to an admission of such as are founded upon trust- worthy evidence. accountin *• ^s tne stomacfi is capable of acquiring a habit of gluttony, or for long of craving too much ; so, it may acquire a habit of fasting, or of aMbDg' craving too little : or, in other words, we are as capable of tri- umphing over the appetite of hunger, as we are over any other ap- petite whatever. The desire for food, or the sense of hunger, is very painful for the first two or three days, after which it ceases, and does not return un- less stimulated by fresh food. The Chipey wans, or native savages of Canada, according to Mr. Long, give striking proofs of the power of the stomach in both extremes—that of hard eating, and that of hard fasting—and as nearly as may be at the same time : for when one of these is on the point of commencing a journey, he devours as much as he would otherwise take in a whole week. The daily al- lowance of animal food alone being, on such occasions, as Captain Franklin tells us, eight pounds ;* and having gorged the stomach, he starts upon his expedition, and commences a long season of severe abstinence. mro°."yhDy0n 2' Most of the cases of lon2 fastim3- that are credibly recorded, degrees: have been introduced by a habit of this kind. A few, indeed, have den!/ '" been brought on suddenly ; as the result of an accidental shock, in- ducing an instantaneous and unconquerable antipathy to food : but by far the greater number are of the former kind; and have had their origin in severe abstraction of the mind, by intense study, rigid mortification of the natural feelings in a course of religious disci- pline, or some growing obstruction, or other affection in the passage from the mouth to the stomach, or in the stomach itself, producing great uneasiness in deglutition, or digestion. quantity of 3# When a habit of this kind is once established, and a life of food actu- indolence or perfect quiet is associated with it, the quantity of food mended. capable of supporting the animal frame may be reduced to a trifle, and may perhaps consist of water alone for weeks, or even months. ^eTrSof ^e see examples °f tms m other animals than man. It forms a for some well-established fact in the history of fishes of various kinds. Even ammais. t^e p^^ tne most voraci0us, perhaps, of all fishes, when he has no longer an opportunity of indulging his gluttonous propensity, will em fo^lbr botn live and thrive uPon water alone in a marble basin. The mere many aui- air of the atmosphere appears to afford nourishment enough for many fectSquieter forms of animal life. Snails and chameleons have been often known *m- to live upon nothing else for years. Garman asserts it to be a suf- ficient food for the greedy spider ; and tells us, that though the spider will ravenously devour flies and other prey, whenever he can seize it he will not starve upon the spare regimen of air alone. Latreille confirms this assertion by an experiment of his own. He stuck a * Journey to the shores of the Polar Sea in the years 1819-22. p. 250. Lond. 4to. ci. i.] DIGESTIVE FUNCTION. [ord. i. Ill spider to a piece of cork, and cut him off from all food whatever for gev. V. four months; at the end of which period he appeared to be as lively y iffixpers as at first. Mr. Baker in like manner confined a beetle under a protracta. glass, for not less than three years ; allowing him nothing but air for chronic his diet; at the expiration of this period he was not only alive but lastinSi fortunate enough to effect his escape, and go in pursuit of a more substantial repast. And we are hence prepared to receive with less hesitation than we should otherwise do, the wonderful tales of frogs, toads, lizards, and other reptiles, found imbedded in trunks of trees, or blocks of marble, so deeply seated, that, though exhibiting life and activity on exposure to the atmosphere, they must have been Power of blocked up in their respective cavities for fifty, and, in some instances, ing in coid- for a hundred years ; cut off from every kind of food except the g^^g.' moisture by which perhaps they have been surrounded, and from all direct communication with the atmosphere itself: though, from ex- periments lately made by Dr. Edwards of Paris, it is absolutely necessary that there be an indirect communication of air through the pores or some other opening of the surrounding substance.* Fishes, when rendered torpid by being suddenly frozen, are wellIn fishes- known to five in this manner through the winter in the Polar seas, and to be re-quickened into activity by the returning warmth of the summer. " The fish," says Captain Franklin, describing the winter he passed at Fort Chipeywan, on the skirts of the Polar sea, " froze as they were taken out of their nets, and in a short time became a solid mass of ice; and by a blow or two of the hatchet were easily split open, when the intestines might be removed in one lump. If, in this completely frozen state, they were thawed before the fire, they recovered their animation. This was particularly the case with the carp. We have seen a carp recover so far as to leap about with much vigour, after it had been frozen for thirty-six hours."! 4. It may possibly be observed that these examples are drawn, Alike for the most part, from cold-blooded, or exsanguineous animals, and "" that in such cases there is no waste of living matter by the skin, the ^^j^ great vehicle of discharge in animals of a higher rank.v But they are drawn from animals, that, in their common customs and habits, have the same instinctive craving for food, and the same faculty of converting it into their own substance, by the process of digestion, as animals of any superior class. While a like power of enduring long periods of fasting in a state of inactivity, without any injury to the general health, is quite as conspicuous and incontrovertible in many kinds of warm-blooded animals, and especially those that sleep through the winter season. In the hedge-hog, indeed, and the Alpine marmot, we trace a slight loss of substance on their reviving in the spring; as they are then found somewhat thinner and less weighty than when, three or four months before, they first became torpid ; but in dormice and squirrels, as in by far the greater num- ber of hybernating plants, we perceive no waste or diminution what- ever. In the Transactions of the Linnean Society, there is an * Memoires sur l'Aspbyxie, consideree dans les Batraciens. Paris, 1817. t Journey to the Shores of the Polar Sea, in the vears 1819-22. p. SMS. 4to. Lond. 1823. power in warm as in 112 cl. i.] CCELIACA. [ord. i. Gen. V. account of a pig that lived without food for a hundred and sixty Slex "r* davs ; whicn if- is difficult to resolve into any other principle than protracta. that which thus operates in winter-sleeping quadrupeds.* ctaSi? 5. We have reason, therefore, as well from analogy as from re- nting, corded facts, to believe it possible for man himself, under certain analogical- circumstances, not indeed to pass life altogether without food, but iy toman; lQ ,oge a,, reiigJl for it^ and to habituate himself to fastings of very considerable length, and only interrupted by slender portions of the SupportPd sparest and dilutest aliment. The cases are innumerable in which toni fasting has been endured, ten, twelve, or fifteen days; and, where fasting. tkere },as Deen access to water, twenty or thirty days ;t Raulin men- tions one of fifty-two days, water alone being drunk during the time:J and Dr. Willan attended a patient who had fasted sixty-one days, with the exception of drinking from half a pint to a pint of water daily, mixed with a very small quantity of orange-juice, two oranges lasting him for a week, without any employment of the pulp.§ But there are other cases related at full length, and upon authority altogether unimpeachable, of fasting continued for twenty- five months :i three," ten, fifteen, and eighteen years ; and, with a very spare and only occasional taste of solid food, through the entire life. In the running commentary to the volume on Nosology, 1 have given several of these histories at some length, and the reader may amuse himself with them at his leisure.** Fluids seem Jn most cases, and probably in all if they had been critically in- necessaryf8 vestigated, water, tea, or some other fluid seems to have been indis- Fasting pensably necessary : and such was found to be the fact in the noted Telbury?f instance of Ann Moore of Tetbury that has occurred within our own day. That she was an impostor, in pretending to be able to live without any food whatever, is unquestionable. But so very spare was the quantity she had accustomed herself to, from the very great difficulty and pain in deglutition, that there is reason for believing that, for many years before she submitted to the test proposed, she had swallowed very little food of any kind except tea and spring water. And such is, in truth, the recorded opinion of the active and very intelligent committee who undertook the trouble of watch- ing her night and day for a whole month, in rotation. Absolutely cut off from all fluids as well as solids, this woman was on the point of expiring when she reached the tenth day, and had scarcely strength enough left to confess the fraud she had been induced to practise. Yet the committee thus close their report of her history:—" On the whole, though this woman is a base impostor with respect to her pretence of total abstinence from all food whatever, liquid or solid; yet she can, perhaps, endure the privation of solid food longer than any other person. It is thought by those best acquainted with her, that she existed on a mere trifle, and that from hence came the * Vol. xi. Extracts from the Minute Book. Communicated by T. Marshall, Esq. t Phil. Trans. Vol. xiv. p. 577. Memoires de Toulouse, ann. 1788. I Observations de Medicine, p. 270. § Medical Communications, Vol. ii. || Bresl. Samml. Band. II. passim. 11 Phil. Trans. 1742. 1777. ** See also Mem. de l'Acad. des Sciences, l'ann. 1769. Stulpart Van der Wiel Observ. Bar. Mem. of the Lit. and Phil. Soc. of Manchester, Vol. n. p. 467. cl.i.J DIGESTIVE FUNCTION. [ord. i. 113 temptation to say that she did not take any thing. If, therefore, any Gen. v. of her friends could have conveyed a bottle of water to her, unseen y i^Expe^ by the watch, and she could have occasionally drunk out of it, little protracta. doubt is entertained that she would have gone through the month's chronic1 trial with credit. The daughter says, that her mother's principal fasline- food is tea, and there is reason to believe this to be true."* Where persons from famine, superstition, severe grief, or any Great judg- other cause, have persevered in a course of rigid fasting for many "*"' "nectehs; days, and the frame is become frightfully emaciated and weakened, allowance the greatest care is necessary in the administration of food; which recovery.0' at first should be light, liquid, and small in quantity; for not only the stomach but the organs of assimilation, lose all power by degrees ; and if once re-quickened, are very apt to be unduly excited, and in- duce delirium and fever. It was in this way Dr. Willan lost his patient on the fifteenth day after his return to food, though the regi- men adopted was peculiarly'promising and judicious. SPECIES III. LIMOSIS PICA. DEPRAVED APPETITE. APPETITE FOR IMPROPER AND INDIGESTIBLE SUBSTANCES. In this species there is no want of appetite, often indeed an inor- Gen. V. dinate craving; but, instead of its directing the patient, as in the fy3c'IH" first species, to palatable and substantial food, whenever such can as com- be obtained, it urges him in preference to the most whimsical and [hTpreced- innutritive materials. This character forms the specific definition. «»g species. The specific name here given is pica. Not that the term has any particular or very obvious merit, for its origin and primary mean- ing are doubtful; but that out of many terms with which nosology has been encumbered to express this disease, pica appears to be the most general, and there is no sufficient reason for changing it. Now an appetite for improper and indigestible substances may be of two descriptions. It may proceed from a want of taste or dis- crimination, as in infants or idiots : or from a corrupt taste, or cor- rupt indulgence, often founded on empyrical or other dangerous advice, as the eating of chalk or acids to produce a fair skin; and we have hence the two following varieties : ec Insulsa. From want of correct taste or dis- Unwitting pica. crimination. /3 Perversa. From a corrupt taste or indulgence. Perverse pica. The depraved appetite which is sometimes manifest in infants can ?ns^is^ca only proceed from want of proper management and direction : for unwitting * Full exposure of Ann Moore, the pretended fasting woman of Tetbury. Vol. I.—15 \14 cl. i.J CXELIACA. |o*D« *• Geh. V. nothing is more tractable than the organ of taste in early life. And f> L*p'icii hence, indeed, it is that the different nations of the world are brought injuisa. by habit, and habit almost coeval with their birth, to prefer such Pica?""12 kinds of food as their respective climates produce in the greatest Produced abundance, or as they obtain by an easy barter of indigenous sub- habi£ stances. Thus, the Hindoos live entirely on fruits and grain ; the Tonguses, on berries, the refuse lichen found undigested in the sto- mach of the rein-deer, dried fishes, and beasts of prey ; the Cali- fornians, on snakes, rats, lizards, rabbits, intermixed with the wild herbs of the soil. But perhaps there is no stronger proof of the force of habit in forming an acquired taste to be met with in any part of the world than in our own country ;—in our exchanging the natural and instinctive desire of a bland and sweet fluid, as milk, for the bitter beverage of tea for breakfast, and beer for dinner. On this account it is not to be wondered at, that children without a guidance, or with an improper one, should often acquire depraved or vicious tastes, and be longing for substances that are innutritive or even hurtful to the general health. Where this propensity has obtained a footing, it may be successfully opposed by discipline, and overpowered by a counter-habit. Among idiots it is incorrigible. ? l. Pica A longing for improper and indigestible substances, however, is Peiverse often produced by other means, and occurs in persons who are pos- £ca- sessed of a sound judgment. It is frequently to be traced as a symp- Sometimos torn of some other disease, as pregnancy, chlorosis, and perhaps by°anCimer- somc species of mental emotion : in all which cases it is only to be nai morbid cured by curing the primary disorder. But it sometimes exists as a oft'en'by11 primary malady ; and is then most commonly brought on by a vain vanity. desire of iniproving the beauty of the person, of giving a graceful slenderness to the form, or a languishing fairness to the skin, through the medium of chalk, acids, or other empyrical materials. In con- sequence of which, the Greek physicians, in whose day the practice seems to have been more common than even in our own, and this too, among young men as well as young women, gave to this variety of the disease the name of fu»w<«, softness or effeminacy. Substances Whatever the cause, when this morbid propensity has once ob- tdheVmoraetd °f tained a triumph over the natural taste, the substances for which it dufiit"ns excites a desirei are often, not only of the most indigestible, but dis- a'y' gusting quality. We have had examples of an inclination for de- vouring dirt, cinders, ordure, fire, spiders, lice, toads, serpents, leeches, bits of wood, squills, hair, candles, and more literature, in the form of paper, and printed books, than is devoured by the first scholars in Christendom. Borelli gives us numerous examples of most of these ; and some of them of a very extravagant kind ;* and those who are desirous of gratifying themselves still further, may have full indulgence by Kwest consulti"g the Ephemerides of Natural Curiosities. Mr. John indies. Hunter describes a longing for dirt, in the form of clay or loam, to have been an endemic disease among the blacks in Jamaica.! But * Cent. i. Obs. 24, 52. 11. 37. iv. 95. t Observations on the diseases of the Army in Jamaii «l. i.] DIGESTIVE FUNCTION. Lord. i. 115 he is surpassed by Dr. Darwin, who tells us, that he once saw a «en. V. young lady, about ten years of age, that had filled her stomach with fS"1, earth out of a flower-pot, and then vomited it up-with small stones, perversa. bits of wood, and wings of insects among it.* pica.0'"0 There are other persons who have had a taste for harder sub- J'9ns™s- * ji iii i Singular stances, and nave glutted themselves with stones,! glass,} and even case related leaden bullets § Others, again, have feasted on pieces of money, s!„gui™in' which have sometimes formed a very expensive repast; for Borelli examples gives us an instance of a pantophagist who swallowed a hundred and'other . louis-d'ors at a meal.H Yet perhaps, after all, the most marvellous, J,'*™^,,. though certainly one of the most common exhibitions of depraved vowed. taste, is an appetite for knives. There is not a country in Europe but has furnished examples of this in both sexes : and hence the medical journals and miscellanies are numerous in their descriptions of London knife-eaters ;1T Prussian knife-eaters ;** Bohemian knife- K"if*- eaters ;!! and even out of Europe, Brazilian knife-eaters.}} The e' wretched patients have sometimes perished shortly after the extraor-. dinary feat; and sometimes dragged on a miserable existence for a few years before they fell victims to their madness or malady. In a few instances they have recovered. In an extraordinary instance of this kind that not long since oc- enmmings, curred in our own country, the knife-fancier, Cummings by name swaiiower. and by craft a sailor, lived ten years after his first experiment, and occasionally persevered in the same trick during the whole of this time. The rash act is sometimes overcome, and the materials dis- charged piece-meal: and it might have been so in this man, but for the fool-hardiness that made him insensible to the earlier warnings given him, and urged him to a repetition of the offence.§§ Even the American American States seem of late to have furnished us with a similar tower!** example, in a young man who had long, we arc told, been in the habit of swallowing various indigestible substances, as buttons, musket-bullets, and billiard-balls ; and being thus initiated in the art, On June 22, 1822, swallowed not less than fourteen knives within the course of the day. Repentance came too late, though it began soon afterwards. He sunk gradually beneath his exploit, and died on the ensuing 25th of August. Two of the knives had been dis- charged from the body, one was found in the esophagus, and the rest in the stomach. The same individual is said, on one occasion, to have swallowed a gold watch, with its chain and seal, ami to have evacuated them on the ninth day, darkened in colour, but not other- wise injured. || |( If this variety should happen to be united, as it sometimes is, with Wonderful pica avens, or voracity, there may be no bounds to the deglutition, when" either in quantify or quality.' M. Fournier, in his Cases Rares, has unitcd with • #. i • i • i i- i •/••!! mea avens. given us an instance of this kind, so extraordinary, that if it had not piea avens. * Zoonom. CI. III. i. 2. 19. t Act. Hafn. vol. r. 1 Camerarius, Memorab. Cent. v. I Bonct. Medic. Septentrion. lib. i. p. 610. Binninger, Obs. Cent. n. f| Cent. iv. Obs. 95. IT Act. Hafn. v. 107. ** Doheus, Encyel. Chir. p. 679. tt Crollius, Basilic. Chym. praef. p. 110. JJ Binninger, Cent. v. Obs. 7. Marcet, Transactions of the Med. and Chir. Society, vol. xn. p. 52. New-York Medical Repository, Oct. 1812. II, 116 cl. i.J CCRLIACA. [orb. r, Gen. y. been most unexceptionably attested, it would not have been credible. j8 if Pica ' A galley-slave, he tells us, of this description, and who was disordered perversa m his intellects, fell at length a sacrifice to a colic accompanied with pica. a cough ; and on opening him, the stomach was found to occupy Longmg. jjjg ieft hypochondrium, the lumbar and iliac regions of the same side, and to stretch down into the pelvis. It was of a long, square form, and contained the following substances : a piece of stave, nineteen inches long, and half an inch in diameter; a piece of a broom-stick, six inches long and half an inch in diameter ; another piece of the same, eight inches long ; ditto, six inches long ; twenty- two other pieces of wood, of three, four, and five inches in length, a wooden spoor., five inches long ; the pipe of an iron funnel, three inches long and one in diameter ; another piece of funnel, two inches and a half long ; a pewter spoon entire, seven inches long ; another, three inches long ; another, two inches and a half long; a square piece of iron, weighing nearly two ounces ; various other articles, among which were nails, buckles, horns, knives, &c. ; the whole weighing about twenty-four ounces avoirdupois.* So that the stomach of this unhappy being became gradually enlarged into a warehouse for all sorts of marine stores, as the term is applied in the present day. Medical This morbid action is best opposed by giving a counter-action to the organ in which it exists. And hence emetics and purgatives are highly useful. Rhubarb is perhaps the best medicine for the latter purpose ; and in moderate doses it should be continued daily; and in combination with it, bark, steel, and other tonics. An acid has often been suspected as the cause of the disease, and the absorbent earths, as chalk, magnesia, and Armenian bole, have been tried in large quantities ; but the relief they afford in seldom more than tem- porary. In the mal d'estomac, or cachexia Africana, as it has been called, which is the disease of dirt-eating among the wretched negroes referred to by Mr. John Hunter, an acrimony of some kind or other, perhaps an acidity may exist: and may instinctively call for the drier earths, as absorbents. But the longing for such materials is, in this disease, a mere symptom ; and rarely shows itself till the frame is completely exhausted by atrophy, dropsy, and hectic fever, brought on by a longing of a far more serious kind—a longing to return home ; a pining for the relations, the scenes, the kindnesses, the domestic joys of which the miserable sufferers have been robbed by barbarians less humanized than themselves ; and which they have been forced or trepanned to resign for the less desirable banquet of cattle-whips and threats, and iron harness, and hunger. Diet, dea Sciences Medicales, Art. Cas. Rares. ci.. i.] » I)I(.'ESTIVi: FUNCTION. |okd. i. 117 SPECIES IV. LIMOSIS CARDIALGIA. CARDIALGY. IMPAIRED APPETITE, WITH A GNAWING OR BURNING PAIN IN THE STOMACH OK EPIGASTRIUM, AND A TENDENCY TO FAINT. The symptoms laid down in this definition are sufficiently marked Gen. V. to separate cardialgy from dyspepsy, in which it is merged by Dr. Hov^dis- ' Cullen and various other writers: for in the last there is not neces- tinguished sarily a gnawing or burning pain ; and the appetite is rather fasti- dyspepsy. dious than essentially or at all times impaired. Cardialgia is cer- tainly sometimes found as a symptom in dyspepsia, as it is also in a multitude of other complaints ; as flatulency, scirrhus, or inflamma- tion of the stomach, worms, retrocedent gout, suppressed menstrua- tion, and various diseases of the heart, liver, pancreas, kidneys, and intestines ; in hypochondrias, and in sudden and violent emotions of the mind : but it is likewise found in many instances, as an idiopathic aflection ; and should therefore' be described as such. Cardialgia admits of the three following varieties : « Mordens. Gnawing or burning uneasiness, Heart-burn. felt chiefly at the cardia, the tendency to faint being slight. (3 Syncoptica. The pain or uneasiness extending Sinking hoirt-burn. to the pit of the stomach; with anxiety, nausea, coldness of the extremities, failure of strength, and great tendency to faint. y Sputatoria. Burning pain extending over the Black-water. epigastrium ; and accompa- Water-brash. nied with an eructation of wa- tery fluid, usually insipid, some- times acrid. The first variety is perhaps the most common form of the disease. °,^cardi- And as the gnawing or burning pain is in this case felt chiefly at the dens. cardia or upper orifice of the stomach, the specific name of cardial- Hea»-burn' gia is derived from this symptom. The cardia is indeed generally supposed to be the immediate seat of affection : but this is an erro- neous view. It is from the greater sensibility of the upper orifice of the stomach than any other part of it, that we are most sensible of uneasiness in that region : but irritability of the whole, or of any other part of the organ, and perhaps of the adjoining organs, as the pancreas, spleen, and liver, will often produce the same local 118 CL. I.j co;liaca. [ORD. I. Gen. V. Spec.IV. a L. Cardi- algia moi- dena. Heart-burn. PL. Card. tlgiasyn- coptiea. Sinking heart-burn. y L. Cardi' algia sputa- toria. Black- water. Water- brash. Excellent description l>v Cullen. pain ; and in some instances it has been ascertained after death to have been occasioned by a scirrhous, or some other, obstruction of the pylorus. In the second variety, we find the pain or uneasiness somewhat less intense, but far more general; reaching, indeed, over the whole range of the stomach and epigastrium, accompanied with nausea and anxiety ; and, by sympathetically affecting the general system, attended with coldness of the extremities, failure of strength, short- ness of breath, and great tendency to faint, which continues till the system re-acquires warmth and perspiration. From the wider circumference of the affection, Hippocrates de- nominated it periodynia stomachi. It is distinguished in popular language by the name of sinking heart-burn. The third variety is distinguished by a morbid increase in the quantity of the fluids secerned; and hence the peculiar symptom of an eructation, frequently in considerable abundance, of a thin watery liquor ; chiefly in the morning after food has been abstained from for many hours, and the stomach has nothing in its cavity but its own fluids. Dr. Cullen has admirably described the disease; though he has singularly sepa-ated it to a great distance from dyspeptic affections, transferred it to another order, and erected it, apparently contrary to his own mode of reasoning, into a distinct genus. " It appears most commonly," says he, " in persons under middle age, but seldom in any persons before the age of puberty. When it has once taken place, it is ready to recur occasionally for a long time after ; but it seldom appears in persons considerably advanced in life. It affects both sexes, but more frequently the female.—The fits of this disease usually come on in the morning and forenoon when the stomach is empty. The first symptom is a pain at the pit of the stomach, with a sense of constriction, as if the stomach were drawn towards the back : the pain is increased by raising the body into an erect posture, and therefore the body is bended forward. This pain is often severe ; and after continuing for some tune, brings on an eructation of a thin watery fluid in considerable quantity. This fluid has sometimes an acid taste, but is very often absolutely insipid. The eructation is for some time frequently repeated; and does not immediately give relief to the pain w Inch preceded it, but does so at length, and puts an end to the fit."* To this description it may be added that, when the watery discharge is altogether insipid, there i? merely an increased secretion of the fluids poured into the stomach, apparently in a thinner or more dilute condition; and that, when this discharge is of an acrid taste, the gastric, or other juices, which exist simply and without food or other intermixture in the stomach at the time, possess an acidity in themselves; a fact which closely connects pyrosis with cardialgia as a species, and readily reduces it to the rank of a variety under its banner. In the colloquial tongue of England it is called black-water, in that of Scotland water-brash and water-qtialm. It is the pyrosis of Sauvages and many other writers. * First Lines, vol. iv. p. 13. cl. i.] DIGESTIVE FUNCTION. [oki>. i. 119 Most of these varieties have sometimes returned periodically,* Gen . V. especially in the spring :| and as their general causes and mode of Limosis. treatment do not essentially differ, it is more convenient to consider cardialgia. them jointly than under detached heads. Dr. Perceval, of Dublin, General".'; in the manuscript comment with which he has obliged me on the of'the'Tari- Nosology, ingeniously inquires, " Does it ever arise from an affec- eties. tion of the pancreas ?" I think it likely that it does, from contem- plating the structure and office of this organ ; and we have various cases, in which, after death, the pancreas has been found considera- bly enlarged. The remote causes then of the present species, under whatever General variety it shows itself, which is chiefly regulated by the habit or causes idiosyncrasy of the individual, are indigestible food or other ingesta ; and habitual and copious use of very cold or very hot beverages, but especially the latter; indulgence in spirituous potations ; worms, hydatids, and insects or their larves; drastic purges ; obstructed perspiration ; repelled cutaneous eruptions ; and bile depraved, or excessive in its secretion. Of the indigestible foods, the most com- mon are animal fat, oil, butter, or cheese eaten in excess; which last has produced a cardialgia that continued for three years.J The stones or kernels of fruits have often laid a foundation for the complaint, especially where they have remained, as they have occa- sionally been found to do, and particularly cherry-stones, for two, or even for three years, with little or no change whatever.§ It occurs also, as already observed, not unfrequently as a sequel, or symptom of some other affections. All these causes have a direct tendency to produce imbecility of Genera! the stomach, especially a loss of tone, or weaker action in its mus- e cular fibres ; and consequently a morbid condition of the fluids, secreted by, or poured into the stomach ; which hence become changed in their quantity or their quality, and are given forth too freely Or too scantily, with an acrid or other acrimonious character, or tendency ; or with several of these in conjunction, according to the idiosyncrasy or peculiarity of the constitution. And hence, through the whole of this species, we meet with a peculiar proximate cause, as well as a remote one. The existence of an acrimony from acidity seems to be common Acrimony to all its varieties ; and this to such a degree that, as Dr. Darwin dity'com- observes, the contents of the stomach when regurgitated on a mar- t™°Dv!1°ia.!i ble hearth, have often been seen to produce an effervescence on it. ties. The acid, according to the experiments of M. Perperes, is chiefly the acetous, and he has found that not less than two ounces and six drachms of it have been produced by eight ounces of roasted ches- nuts, an aliment that ferments in the stomach for an hour and a half; and is even then digested with great difficulty. In some cases the formation of acetous acid seems to be favoured by the nature of the * Bartholin. Hist. Anat. Cent. in. Hist. 50. Zacchius, Consil. N. 54. 98. f Bpb. Nat. Cur. passim. | Paulini, De Nuce Moschata, sect. iii. p. 3. Eph. Nat Cur. Dec. n. Ann. V, app. 71. § Bresl. Saraml. 1725. i. p. 77. Gronen. Commerc. Liter. Nov. 1733, p. 189. 120 cl. i.J COXIACA. (obi*, i. Gen. V. Spec. IV. Limosis Cardialgia Cardialgy. Therapeu- tic means twofold. First inten- tion how carried into effect. Occasional evil of cal- careous earths as remedies. Whether an acid ever eaters into the circu- lating fluiJ> gastric fluid itself, which appears to be secreted in too dilute or weakly a condition for the purposes of digestion ; on which account, the food, instead of being converted into chyme, runs readily into a state of fermentation, so that some persons cannot take either honey or sugar without producing this effect: while, in others, the gastric juice is possibly itself acid at the time of secretion ; since we occa- sionally find that the disease is not increased by vegetable foods, or even acescent fruits; and that water alone, or small wine-and-water suit the stomach better than undiluted wines or spirits. It is not improbable that the third variety, cardialgia sputatoria, may, in some instances., be produced by a peculiar paresis or inac- tivity of the proper absorbents of the stomach. The experiments of M. Magendie show that, in a state of health, all fluids disappear from the stomach with great rapidity, in consequence of the urgency of their absorption, insomuch that a ligature on the pylorus does not in the least retard their vanishing. And hence the quantity of fluid that is often regurgitated may result from a want of this action. This, however, is a cause that pathologists have not. attended to, so far as I know. In applying to this disease the resources of the art of healing, it is obvious that our intention should be two-fold: to palliate the present distress, and to prevent a recurrence of the paroxysms. The first may be obtained by small doses of opium, and sometimes by other antispasmodics, as the ethers and volatile alkali; and where acidity is unquestionable, by calcareous and saponaceous earths. Limewater, or acidulous alkaline waters, or the different alkalies of the alkalescent earths, magnesia and lime, have been almost the only ones that have hitherto been employed, or at least the others have not been submitted to a sufficient trial and under a sufficient variety of modifications to enable us to speak of them with accuracy. It is a common belief that chalk, with an acid in the stomach, pro- duces an astringent, and magnesia a laxative neutral This idea is doubted by Dr. Cullen : but it seems to have a foundation, and should regulate our practice. Chalk, however, when used in large quanti- ties, and long persevered in, has an indisputable evil, which does not equally belong to magnesia ; and that is, its aptitude to form balls or calculi in some- part of the intestinal canal; and thus pro- duce a very troublesome obstruction, and occasionally colic. I have known various instances of this ; and, in some cases, attended with alarming symptoms before the balls were dejected ; many of which I have also known to be evacuated in masses of more than an ounce weight each. There is no evidence that an acid is found below the duodenum, and hence it is chiefly in the upper part of the alimentary canal that these calculous concretions are impacted and agglutinated. Dr. Parr and some others assert, that an acid formed in the stomach certainly never enters the circulating fluid. It is indeed, true, that we have no sensible trace of it in the course of the circulation : but the benefit which has lately been discovered and which we shall have occasion to advert to more fully hereafter, of introducing magnesia into the stomach, in habits possessing a ten- dency to form calculi in the kidneys and bladder from a superahun- c, . i.] DIGESTIVE FUNCTION. [ord. i. 121 dant secretion of lithic acid, seems to show that an acid principle, Gen. v. or base, still passes from the stomach into the circulation in certain Lf*0cB;sIV" cases, though too minutely divided to be detected by chemical tests ; cardialgia. and that the introduction of magnesia into the stomach destroys or ar iagy' neutralizes it at the fountain head. (See Enteroliths and Li- thli.) M. Perperes, in taking off acidity from the stomach, unites the calcareous earths with a warm bitter ; and recommends, as the medicine he has found most successful, columbo root with magne- sia, in doses often grains of the former to twelve of the latter.* Oleaginous preparations have also been had recourse to, and in oleaginous some habits apparently with success. In such cases it is most pro-remedies- bable that they act in a double way ; first by converting a part of the acid into soap : and next by proving aperient, and thus accelera- ting the passage of the acid material into the intestinal canal. They may also, perhaps, in other acrimonies than acidity, obtund their irritating power : for in many cases of heart-burn, speedy and effect- ual relief is obtained by the simple and pleasant remedy of eating six or eight almonds. Yet where we have full proof of acidity as the exciting cause, there Operation are few medicines we can more fully depend upon than soap : pro- ° soap" bably because in its decomposition it lets loose the oleaginous prin- ciple, which may in some degree obtund the pain, and at the same time unites its alkali with the acid of the stomach ; thus neutralizing its acrimony, and forming a valuable aperient : " it is often," says Dr. Cullen, " a more convenient remedy than common absorbents or simple alkalies."! If the pain be very severe, we shall much improve the beneficial operation of the soap, by combining it with opium. This I have already mentioned as a very valuable medicine in all the varieties of the disease ; but it is peculiarly so in water- brash, or the third variety. The distinguished writer I have just quoted asserts, indeed, that he has found nothing but opium that will give it real relief: but this, he afterwards adds, relieves only the present fit, and contributes nothing to the prevention of future attacks. It is hence necessary, in every case, to direct our view to the Second cu- second intention I have pointed out; I mean, that of preventing a ten'tioi,,.n" recurrence of the paroxysm. Now this can only be done effectually by restoring the stomach to its proper tone : and hence the entire process we shall have to notice under Dyspepsia, forming the seventh species of the present genus, will here be found equally advantageous. The warmer bit- ters, the metallic oxyds, and' especially the oxyds of zinc and bis- muth, first mentioned by Odier, bid fairest for success. Of the bit- ters, one of the most elegant as well as most effectual, is the extract of chamomile. Yet the matricaria chamomilla, or dog's chamomile, seems to rival its powers ; and has often been found a very active and useful stomachic in most debilities of the stomach. The nux Nk vomica, long since extolled by Linneus, remains yet to be fairly v0 experimented with in this country. It has the peculiar property of * Opera citata, Vol. n. t Mat. Med. Vol. n. p. 400. Vol,. I.—1« 122 cl. i.] C04LIACA. [ORD. I. Gen.V. diminishing the sensibility, while it increases the irritability of the KSS.17, animal frame—a property of which I shall speak more at large when cardialgia. discussing the subject of Paralysis. It is said to have been given Cardiaigy. m dogeg of ten graing three times a_day. But this I very much question, where the drug has been sound and genuine. In palsy, 1 have never been able to raise it above seven grains without making the head stupid and vertiginous. Terebin- Among the aromatics, many of the terebinthinate balsams will be £*£.. found highly useful. The balsam of Gilead, and that of Mecca, amyris Gileadensis, and a. Opobalsamum, were once highly extol- led, and perhaps deservedly ; but are too dear for common use. The Turks take eight or ten drops as a dose ; but the quantity may be considerably increased. In some of the pharmacopoeias, cubebs, as much cheaper, have been ordered instead of the balsams. It is almost superfluous to add, that the diet should consist of articles least disposed to ferment; as animal food generally, shell- fishes, biscuits; and for drink, small brandy-and-water, toast-ami- water, lime-water, or most of the mineral waters. SPECIES V. LIMOSIS FLATUS. FLATULENCY. IMPAIRED APPETITE, WITH AN ACCUMULATION OF WIND IN TUB STOMACH OR INTESTINAL CANAL ; AND FREQUENT REGURGITA- TION. Geh. V. It is supposed by Mr. John Hunter, and there is reason for the Spec. V. supposition, that air is occasionally secreted from the mouths of the air whence secernents into certain cavities in which it is found: but, in the obtained. present instance, there can be little or no doubt that it is merely separated from the materials introduced into the stomach in the form of food, and tending towards fermentation. When the fluids which are poured naturally into the stomach are secreted in a state of health, they concur, and perhaps equally so, in checking fermenta- its effects, tion. But when from imbecility of this organ, or its consociate viscera, they are secreted in a dilute or other imperfect state, they lose their corrective power, fermentation rapidly commences, and the stomach is overloaded, distended, and sometimes ready to bur9t with the air, for the most part carbonic acid gas, that is hereby let loose ; relief being only obtained by frequent eructation or rejection upwards, crepitation or rejection downwards, which the Greeks de- nominated QofdZos as the Latins did crepitus; or its combining loosely with such fluids as may exist in the large intestines, where it often rolls about in an ascending or descending direction, according to the action of the diaphragm and abdominal muscles; sometimes with a rumbling sound where the intestinal fluid is but small in cl. i.] DIGESTIVE FUNCTION. (qrd. i. 123 quantity, and sometimes, where it is considerable, with a gurgling Gek. V. noise like air rushing into a bottle as the water contained in it is Line's ' poured out: and hence by the Greeks denominated borborygmus. *l.alu?- We have, in consequence, the three following varieties, under which this species presents itself to us : et Borborygmus. With frequent rumbling of the Rumbling of the bowels. bowels. £ Eructatio. With frequent rejection upwards. Eructation. y Crepitus. With frequent rejection down- Dejection of wind. wards. The quantity of air separated in the manner just described, is Quantity of sometimes prodigious, and may amount to an eructation of many sometimes hogsheads in an hour. Nor need we be surprised at this ; for, by enoImous■ the experiments of Dr. Hales, it appears that a single apple, during fermentation, will give up above six hundred times its bulk of air : while many of the vegetable materials introduced into the stomach possess far more ventosity than apples. Flatulency, undsr one or other of the forms now enumerated, j^™^0" is often found as a symptom of other diseases; especially in dyspepsy, cholera, colic, hysteria, and hypochondrias. But there is no doubt that it occasionally exists by itself, and is strictly idiopathic, occurring idiopathic. after the deglutition, and even enjoyment, of a full meal without any other symptom of indigestion, and ceasing as soon as the process of digestion is completed. A very common and a very active cause is drinking a large quan- From cold tity of some cold fluid while the system is labouring under, great heated heat. Van Swieten mentions a singular instance of this kind offiame- inflation from indulging in a draught of cold whey,* and Riedlin, another from a like indulgence in cold beer,| during an extreme heat of the body. Infants are peculiarly subject to this affection from the natural J^^ delicacy of the stomach, and particularly when brought up without'" their natural sustenance, and upon food which requires more labour of the stomach to digest. In many cases it must necessarily be combined with acidity; for this, as already observed, is a general effect of impaired action in the chylific viscera : and when both these causes concur, the infant will also be tormented with severe gripings, and great irregularity in the bowels; a distressing and wa- tery diarrhoea; or an obstinate costiveness; and sometimes with both in succession. Essential oils, absorbent powders, and aperients may Jjj^^ palliate the symptoms, but the best cure will always be found m a healthy breast of milk. Hypochondriacs, and others of weak digestive power, are very *™«£ apt to acquire a morbid habit of eructing; and are perpetually striving acquire to throw up wind from the stomach in an expectation of reliev- ^J^. ing themselves from the elastic vapour with which they seem to be bursting. The habit is vain and mischievous : for the vacuity hereby * Crinstit. Epid. L. B. p. 83. 1 Cent. M. Ob?. 43. 124 <«" at the same time that it inverts the stomach, acts powerfully on the olfactory nerves, and becomes a pungent emetic. It is hence by far the best emetic we can select in affections of the eyes, and several species of cephalea. Hot water operates only as a simple Hot water. stimulant to the stomach, and hence, unless there be other irritants in its cavity, rarely takes effect until the stomach becomes distended, and the nervous fibres of the pylorus are inordinately excited by the quantity swallowed. If, however, we infuse in the hot water, a cer- Power in- tain portion of horse-radish, mustard-seed, the root of mezereon, or addingdby a. handful of chamomile flowers, we increase its stimulant power, simP,e sti~ and a much smaller quantity is sufficient. And it is probable that as horsed all these substances act in like manner, as simple stimulants alone ; rad,sh> kr~ for in small doses they tend rather to take off than to excite sick- ness. There is little doubt that air acts in the same way : for some Air. persons, as Mr. Goss, of Geneva, by swallowing and distending their stomach with air, are at any time able to discharge its contents. The sulphates of zinc and copper, and the more powerful prepara- ^mJ**i1(!jine tions of antimony, as the vitrum and crocus metallorum, are proba- bly simple simulants also, but of a high degree of activity. They act on the stomach almost as soon as they are introduced; and hence are peculiarly eligible for a rapid expulsion of poisons that have been taken inadvertently. If taken, however, in too large a dose, they become quite as mischievous as any poison they are in- tended to remove ; for they prove violently corrosive to the coats of the stomach, and excite haematemesis, or vomiting of blood. There Al^alifl« are some of the alkaline salts that act in the same manner when BBl taken in excess, and throw not only the stomach, but other parts of the system into violent spasmodic motions. Two ounces of nitre Nitrate of were taken, by mistake, for one ounce of Epsom salts. An almostpotash' incessant vomiting for two days was the result, accompanied with a copious discharge of grumous blood from the excoriated mucous membrane of the stomach; notwithstanding that very large nuanii • 132 CL. I.] CCELIACA. [OKD. 1- Gen. V. Spec. VI. Limosis Emesis. Sickness of the sto- mach. Prussia acid. Mode of action.. Symptoms excited- Remedial process. ties of warm water were repeatedly drunk, and alternated with equal quantities of gruel and mucilage of gum arabic, to defend the sur- face of the stomach by an artificial mucilage. Mr. Buller, who relates this case, informs us that the patient recovered, but was long afterwards subject to chronic spasms, resembling chorea.* > Many of the concentrated acids act in the same manner as the alkaline salts : and some far more generally and extensively, espe- cially the Prussic acid, which exhausts the whole nervous system, almost like a stroke of lightning, at the same time that the stomach is burnt up. The following is a good condensed view of its effects, with which every reader in the present day ought to be well ac- quainted. 1. When introduced into the stomach in large doses and highly concentrated, it irritates or corrodes it, by dissolving the gelatin of its coats, and death takes place by a sympathetic injury of the ner- vous system. 2. When diluted, it acts neither by irritation nor sympathy, but by absorption, operating on distant organs : and, caeteris paribus, it acts much more rapidly when diluted than when concentrated. 3. It. is very difficult of detection when absorbed in any of the fluids, being probably decomposed in passing through the lungs, and its elements combining with the blood. 4. It is a direct sedative. The organs it act.« upon through ab- sorption are the spine and brain primarily, and the lungs and heart secondarily : and the immediate cause of death is sometimes para- lysis of the heart, sometimes slow asphyxy, and sometimes a com- bination of both. The first symptom it produces in the stomach is an instant burn- ing pain, often also existing in the throat : violent vomiting generally follows : the matter discharged is commonly dark, chocolate-hued, and sanguinolent. The bowels are little affected : the pulse is very feeble, almost imperceptible, with cold clammy sweats, and lividity of the nails and fingers. The stomach, on examination, generally contains a quantity of the material vomited, being extravasated blood, altered by the poison as in the case,of other acids. In attacking this poison, a rapid and natural vomiting is advan- tageous by removing a part of the material: but diluting it assists in promoting its absorption, and rendering it more mischievous. The oxalates of the proper alkalies, ammonia and potash, are as dangerous nearly as the acid itself, and hence alkalies must not be used ; but the alkaline earths, chalk and magnesia, make insoluble compounds, and afford immediate relief: they should be used with the most powerful stimulants.! It is now very well known that the ipecacuans, and indeed most of the preceding emetics, excite vomiting as effectually by being introduced into the blood vessels, and consequently exciting the ab- dominal muscles through the medium of the brain, as by being con- veyed into the stomach. But there are some articles of the Materia * Edin. Med. and Surg. Journ. No. liii. p. 34. t Experimental Inquiry on Poisoning by Oxalic Acid. By Robert Christian, M.D., and Charles W. CoindeJ, M.D. Edin. Med. and Snrg. Jourii. Apr. 1823 rL.i.j DIGESTIVE FUNCTION. [okd.i. 133 Medica, that will produce this effect on being applied to the surface Gen. V. of the epigastric region, or the hypochondria alone; as the oil of Lim^sls ' croton, tobacco, and what, we should far less expect to possess such.^"in- activity, the leaves of groundsel beat up into a cataplasm. Mr. Sted- of the man, of Kincross, who, 1 believe, first published an account of this Tobacco power in both plants, availed himself of it as a remedy for agues, applied to and parabysmic tumours of the liver.* mach.° As the stomach is the common centre of sympathy, it is not to j^"""^*1 be wondered at, that nausea or sickness should be a symptom com- thesto- mon to a variety of diseases seated in the organs more or less remote gickness from itself. And hence we find it occurring in colic, cholera, f">m sym- stone, the accessions of fevers, repelled gout, and various affections of the head. The last is, indeed, a very frequent, perhaps the most frequent, of fromaffec- all the sympathetic causes whatever ; for nothing can disturb the head.° regularity of the sensorial function without disturbing the stomach ; and hence sickness is sure to follow upon oppression of the brain, whether produced internally, by hanging, drowning, or apoplexy: or externally, by a fracture of the cranium, accompanied with de- pression. A severe jar of the brain, as in the case of concussion, even without extravasation, is cert .in of exciting the same effect. Nay, any slighter motion to whicli the head has not been accustomed, as that of moving it. rapidly from shoulder to shoulder in a half-rota- tory direction, accomplishes the same purpose. And hence we see the reason of the vomiting induced by running, or riding a horse round a small circle : by the action of swinging, of riding backward Hence from in a coach ; and all the languor and deep regurgitation of sea-sick- ^ng"1^ ness. The living frame, however, has a most wonderful instinctive Sea-sick- power of accommodating itself to circumstances : and hence, by ceadesby habit, we are enabled to undergo the new motion without any use- inconvenience to the sensorium, and consequently without any sick- ness of the stomach. And this power of accommodation is so con- Singular siderable that we have numerous instances of extensive depressions, ™ ^ccom- and even of bullets and other foreign substances lodged in the brain, nidation, which though at first productive not only of incessant sickness, but of the most dangerous symptoms of compression, have by habit been borne without any evil to this organ ; and hence also without any disquiet to the stomach : while in a few rare instances, the very act of vomiting is said to have raised the depressed bone and re- stored it to its proper level.t In all these cases, however, the brain must still retain a certain T°kP™du£e degree of excitability : for if this be entirely or very nearly lost, neither brainm^t6 the muscles surrounding the stomach, nor even the stomach itself, p™seesdse. possess energy enough to produce an inversion of this organ. Hence gree of ex- in an extreme state of apoplexy, or asphyxy, there is no vomiting Cltab,llty- whatever, nor is it possible to excite it in the profuse and sudden ex- haustion of the nervous power which follows upon swallowing large doses of the atropa belladonna, and various other narcotics ; in com- * Edin. Med. Essay, Vol. H. Art. v. 295. t Pelargus, Medicinishe Jahrgange, in. p. £58. 134 cl. i.\ COZLIACA. [0K0. J. Gen. V. bating the effects of which fourteen grains of tartarized antimony Limosis ' have been administered to no purpose ; " now if in such a case,"' Emesie. savs jjr# Paris, " a copious draught of some vegetable acid be given, the sto- the emetic will be more likely to succeed." And agreeably with mach' the principles just laid down, "here then," says he, " we perceive that the brain, being paralysed by a narcotic poison, is unable to lend its aid to the muscles requisite for the operation of vomiting until its energies are restored by the anti-narcotic powers of a vegetable acid."* Troatment jn an affection resulting from such an infinite variety of causes, no to vary ac- , , » , H .-i cordiug to one remedy or even plan of treatment can apply generally, bympa- the cause. th.efjc sickness can only be radically removed by removing the idio- pathic disease upon which it is dependent, though it may often be mitigated when very distressing, and the primary disorder is likely to be of longstanding. The best palliatives in most cases of this kind will be found in carbonic acid air ; the saline draught, as it is called, in a state of effervescence, whether made with lemon juice, or, as first proposed by Riverius, with sulphuric acid ; the more grateful carminatives ; and small doses of opium. When the stomach is overloaded, or irritated by bile or any other material that sits uneasily, the offending matter must be first discharged, and then the stomach restored to its proper tone and action by some aromatic cordial, or if necessary by narcotics. Food should at first be given in the small- est quantity and of the lightest kind. A little toast and water alone, taken in small sippings, or a small spoonful of brandy and water with a single morsel of sopped biscuit, will often sit easy when nothing else will remain ; and gradually solicit the stomach to a healthful re- action. Stimulant cataplasms applied to the epigastrium are also frequently serviceable. When the sickness proceeds from a chronic debility of this organ, the lighter and warmer bitters, as the infusion of orange-peel, casca- rilla, or columbo ; or, where a more active stimulant is necessary, that of leopard's bane (arnica montana) may be found useful. The cinchona rarely agrees with the stomach, and is of doubtful efficacy where it is not rejected. The metallic oxydes are less precarious, and especially those of zinc and bismuth. Sea-sickness is only to be cured by habit: yet it has often been relieved and rendered less dis- tressing by small quantities of brandy, the aromatic spirit of ammo- nia, or laudanum. * Pharmacologia, p. 152. Edit. v. 1822. cl. i.} DIGESTIVE FUNCTION. [ord. i. 135 SPECIES VII. LIMOSIS DYSPEPSIA. INDIGESTION. THE APPETITE FASTIDIOUS ; THE FOOD DIGESTED WITH DIFFICULTY ; HABITUAL COSTIVENESS. This is by far the most complicated of all the disorders belonging Gen. V. to the present genus. The three preceding species may often be SpEC"VII> traced by themselves, or in a state of separate existence. Dyspepsia may be regarded as consisting in a combination of their respective symptoms irregularly intermixed; sometimes one set of symptoms taking the lead, and sometimes another ; with a peculiar tendency to costive bowels, and especially that species of costiveness which we shall hereafter have occasion to denominate coprostasis obstipata, dependent on a weakly temperament or a sedentary habit, and in which the discharged feces, instead of being congestive and volumi- nous, are hard, slender, and often scybalous. Dyspepsy, therefore, in the language of Dr. Cullen, may be de- ^m,p,toxms scribed as" a want of appetite, a squeamishness, sometimes a vomit- and often ing, sudden and transient distensions of the stomach, eructations of 8hlfiins- various kinds, heart-bum, pains in the region of the stomach, and a bound belly." Yet none of these are uniformly present, and all of them seldom. So that, as already observed, the symptoms of car- dialgia, "flatus, and emesis, with a few others, enter in irregular modi- fications into dyspepsia, as those of dyspepsia enter into hypochon- drias. All these species lead to it, as they have a natural tendency to lead to one another; dyspepsy is, in many instances, a direct sequel of the whole, a chronic concentration of their respective symptoms. There is also another complaint which frequently enters into the Gravel of multiform combination of maladies of which dyspepsy is the general loT^or"1^ expression, and which has rarely been noticed by writers, although «equei. it is often a very troublesome symptom, and that is gravel. In treating of gravel or lithia, as an idiopathic affection, we shall have to notice that one of its chief and most common causes is an excess of acidity in the primae via?; and, as such excess is almost constantly to be found in dyspepsy, gravel must frequently attend or follow, and is even a necessary effect where there exists what has been called a calculous diathesis. And for a like reason, where there is a poda- Sometimes gric diathesis, gout in some form or other is a frequent concomitant. gout,/ The grand proximate cause of the three preceding species, is de- Common bility of the stomach, whence, among other evils, a morbid secretion ?BUg™aU of gastric fluid. In the present instance, the debility is not often con- fined to the stomach, but extends to the intestinal canal, and the coiiatitious viscera, as the mesentery, the spleen and the pancreas, especially the liver, in which it most frequently commences; though 136 cl. i.] CCELIACA. [oru. i, Gen. V. Spec VII. Limosis Dispepsia. Indigestion. Proof of debility in the intesti- nal canal- Proof of imbecile action in the liver; in the me- sentery ; in the pan- creas and spleen. Second state of the disease. Catenation of the lungs with the digestive organs. this fact has not been often, if at all, noticed by pathologists ; and hence another cause of the greater complexity of this disease than of those we have just examined. The debility, and indeed torpitude, of the intestinal canal is evi- dent from the habitual costiveue.ss which so peculiarly characterizes this affection. Whether this be direct or indirect, intrinsic or sym- pathetic, as harmonizing with the weakness of the stomach, it is not easy to determine ; but nothing can be a stronger proof of the great inactivity of the intestinal tube, from whatever cause produced, than the feebleness of its peristaltic motion, notwithstanding the pungency of the acid and other acrimonious matters that are so frequently formed in the stomach, and hence so frequently diffusing their aspe- rity over its inner surface. The imbecility of the liver is equally obvious in most cases, from the small quantity of bile that seems to be secreted, or its altered and morbid hue, as evinced by the colour of the feces ; which, in some instances, are of an unduly dark, and in others of an unduly light tint; and possibly from the inactivity of the intestines themselves, whose peristaltic motion is conceived by Dr. Saunders and other pa- thologists to be, in a great measure, kept up by its stimulus. When the mesentery is affected, the chyme is generally obstructed in its passage to the thoracic duct, and the general frame, deprived of its needful nutrition, becomes flaccid and emaciated ; and, from a collapse of the minute vessels on the surface, assumes a wan or sallow complexion. It is highly probable that the pancreas and spleen are both also affected in many cases of dyspepsia. Of the actual part taken by either in the process of digestion, we have already had occasion to observe that we krjow but little : but we do know that the pancreas pours forth a considerable portion of the fluid which holds the solid part of our aliment in solution: while in most of the cases of dys- pepsy, brought on by a habit of drinking spirituous liquors, the spleen is evidently affected as well as the liver. Sir Everard Home has endeavoured to show that the spleen is a direct organ of commu- nication between the stomach and the iiver : and though he has not betm able to detect any set of vessels that immediately connect the stomach with the spleen, he seems to have sufficiently established it that, fluids pass by some channel or other into the latter from the cardiac portion of the former.* But this is a subject we shall soon have an opportunity of examining more at h.rge. It is in this state of the disease that we frequently meet with that tenderness or other uneasiness in the epigastric region, and that peculiar hardness of the pulse, often accompanied by febrile symp- toms, which Dr. Wilson Philip has pointed out as pathognomic of what he calls a second stage of the disease.! It has also been well observed by Dr. Philip, that the lungs are, in many instances, apt to associate in the morbid action of the digest- ive organs, when it has become chronic, and to produce, as a result, * Phil. Trans, 1808. p. 45. 133. 135. 144. t Treatise on Indigestion, &c. p. 41. 8vo. London, 182 J cl. i.J DIGESTIVE FUNCTION. Lord. i. 137 a peculiar variety (with him, species) of consumption, to which he Gen* v* has given the name of dyspeptic phthisis.* The dyspeptic character LfmoCsis of the disease, however, and especially the hepatic symptoms, to- Oyspepsia,. gether with those of lowness of spirits, flatulency, and other hypo- " lges lon chondriacal affections, rarely fail to accompany it when complicated with phthisis, and point out its real source ; and the cure must be chiefly directed to the primary malady, how much soever the induced symptoms may also demand our attention : for it will be in vain to subdue the latter while the former is still suffered to bear sway. It must nevertheless be admitted, that in some instances the se- Primary condary disease seems to afford relief to the primary, and that the sometimes organ first affected recovers its health in proportion as that subse- ggC'0*dary.y quently affected yields to the attack ; in the same manner as in ery- sipelas and the migratory forms of herpes, the eruption travels for- ward, the part relinquished heals, and fresh parts are affected in suc- cession. In all such cases the secondary complaint becomes a new This affec- malady, and must often be followed up under another principle, and c°meT* another mode of treatment. And not unfrequently we can very "^ma- advantageously take a lesson from this peculiar march of nature ; and by exciting an artificial irritation in some neighbouring and less vital part, can draw off the morbid action into such quarter. It is by this means that blisters, setons, and other counter irritants are so fre- quently found productive of the best advantage. And as a disease of the alimentary canal is thus, sometimes, communicated or trans- ferred to the lungs, so a morbid state of the lungs is sometimes ex- tended to the stomach, of which Dr. Gardiner has lately furnished us with a striking example.! In chronic inflammation of the stomach we also frequently meet with several, and sometimes all the symptoms of dyspepsy ; but as dyspepsy occurs here merely as a secondary or induced affection, it will be more regular to examine the nature and effects of this cause hereafter.J Under whatever form, and from whatever cause the disease occurs, °*nerar' nd there is a considerable degree of general languor and debility. Exer- debility. cise or exertion of any kind soon fatigues ; the pulse is weak ; the sleep disturbed ; the extremities are cold, or rendered so on slight occasions ; and the tongue for the most part is furred or covered with a creamy mucus in the morning. Yet this last symptom is not al- ways to be depended upon ; for it is sometimes wanting in the dis- ease, and sometimes common to those who have no such disease whatever, and are in the enjoyment of habitual health. That dyspepsy should be connected with a morbid condition of any Coiiatitious of the adjoining organs, is by no means difficult to conceive, when we earned in reflect that they are all concerned, directly or indirectly, in com- ^veeptg0e!" pleting the great object of the digestive process, which is that of fur- cess. nishing a constant supply of nutrition for the system at large. Di- gestion is commonly supposed to take place in the stomach alone ; but this is an erroneous view, though the stomach may be regarded as * Treatise on Indigestion, &c. p. 323. 8vo. London, 1824. t Transact, of the Medico-Cbir. Soc. of Edinburgh, Vol. i. 8vo. 1121 I Vol. ii. CI. in. Ord. ii. Gen. vii. Spec. xi. Vol. I—18 138 cl. i.j CCELIACA. [ord. t. Gen. V. Spec. VII, Limosis Dyspepsia- Indigestion Part per- formed by the sto- mnch. Chyme. Chyle. Chyle yet to be ope- rated upon by ventila- tion. Hence close con- nexion be- tween the' stomach and the lungs. the chief link in the great associate chain. In the stomach, as we have already seen in the proem to the present class, the food is only broken down into the pultaceous mass called chyme, and thus con- verted into the mixed principles of oil, gelatine, and sugar, and little else ; for though we'have some traces of animalization, they are ru- diments and nothing more. Yet this, which is the first, is the most important stage of digestion; and its perfection depends upon the quantity, perhaps the elaboration, of the vital power which is furnished from the sensory, and pervades the system generally. Where this power is small or enfeebled, the process of chymifaction is necessarily impaired or interrupted : the wonderful machinery of the stomach, which finds no parallel, not only without the body, but in any other part of it, is disturbed or impeded in its operation ; and its fluids are poured forth too sparingly or too inconditely. The next stage of the digestive process takes place in the duode- num, which easily admits of distention, and receives the food in the form of chyme from the stomach. Here the bile, the most highly animalized of all the secretions, and abundance of the pancreatic juice, meet it, and a new play of affinities commences; the bile, as supposed by Fourcroy, being separated into two parts, its saline prin- ciples and its resin. The latter is discharged with, and gives a co- louring matter tothe excrements ; the former become decomposed, attenuate the chyme, communicate their azote, and thus complete its animalization ; while the juice of the pancreas dilutes and holds the material in solution, and probably contributes to some other effect, but which has not yet been detected. In this liquid state it is called chyle. The recrementory part, which descends into the larger intes- tines, is attacked, as it proceeds, by the mouth of a considerable num- ber of lacteals that drink up whatever^ small quantity of the chyle may be accidentally intermixed with it; while the great body of this fluid is absorbed in the duodenum itself, by an innumerable host of the same vessels which concentrate their mouths on its inner surface. We thus see how larjffely the digestive process ranges, and from what a wide spread of organs, closely sympathizing with each other, the disease of dyspepsy may proceed. But the finishing touch still remains to be added : the absorbed chyle, before it becomes com- pletely assimilated, has to be exposed to the action of the atmos- phere, and for this purpose has to travel to the lungs. What change it sustains in consequence of this exposure will be the subject of a subsequent inquiry. At present it is sufficient to show the con- nexion ftvhich subsists between the stomach and the lungs in the common function of providing for the sustenance of the animal ma- chine ; and to indicate the means by which a morbid action of the former may be communicated to, or lay a foundation for impaired action in the latter ; since, to say nothing of the sympathy of ap- proximation, or of that sympathetic influence which is always found to take place between the extreme links of a chain that runs thrtough any part of the animal machine, it must be obvious that if the chyle, which originates in the stomach, and when in a state of health, communicates a peculiar stimulus to the lungs, as it enters their sub- stance in combination with the recurrent and exhausted blood. «jl. i.J DIGESTIVE FUNCTION. [o«». i. 139 should be conveyed to them in an unhealthy condition, this peculiar Gen. V. stimulus may be changed in its mode or degree of action, and the ^molis lungs in consequence become a sufferer ; more especially where Dyspepsia. they are predisposed to any kind of morbid action. And hence whence0"' another origin of dyspeptic phthisis, which, like every other modifi- d^h^tic cation of the disease, may depend, therefore, upon imbecility of one or more of the digestive organs. The common causes of this imbecility, whether confined to the Causes of stomach, or co-extensive with the associate viscera, may be contem- \ocl\m$ plated under two heads, local and general: under both which they s™e™\. are still further resolvable into the two opposite extremes of deficient and excessive stimulation; and consequently into a divergency of any kind from that medium of excitement and activity upon which health is made to depend. The local remote causes are, a too large indulgence in sedative Loeal re- and diluting substances ; as tea, coffee, and warm water, or similar J^.8 liquids taken as a beverage ; or an equal indulgence in stimulant and acrid materials, as ardent spirits, spices, acids, tobacco whether smoked or chewed, snuffs, a daily habit of distending the stomach by hard eating or drinking ; or a rigid abstemiousness, and very pro- tracted periods of fasting. The general remote causes are, an indolent or sedentary life, in General which no exercise is afforded to the muscular fibres or mental facul- cause? ties. Or, on the other hand, habitual exhaustion from intense study, not properly alternated with cheerful conversation ; becoming a prey to the violent passions, and especially those of the depressing kind, as fear, grief, deep anxiety, immoderate libidinous indulgence ; and a life of too great muscular exertion. Perhaps the most com- mon of this latter class of causes, are late hours and the use of spi- rituous liquors. Dyspepsia is hence presented to us under several varieties, of which the two following are the chief: a, Organica. Originating in the digestive or- Organic indigestion. gans and principally confined to them. & Enervis. Originating in a relaxed state of Enervate indigestion. the constitution from causes acting generally. For both these, the general principles that should govern us in attempting a cure are the same, though the means of carrying such principles into effect will admit of diversity. Under what shape soever the disease may present itself, the first Medical thing to be enjoined is a relinquishment of whatever cause has laid a foundation for it: we must next palliate the symptoms that aggra- vate and continue the disease; and, lastly, we must restore the de- bilitated organs to their proper tone ; or, in other words, we must correct or remove what is called, though not very precisely, the proximate cause of the maladv. 140 cl. i.] CtELIACA. [OKD. 1. Gen. V. "phe patient must, in the first place, be convinced of the necessity frj^s'J11' of putting himself under a new rule of conduct, and be deeply impress- py.spepsia. ed with the idea, that though he may have continued his late plan FirstYnten- of life for a considerable period of time without having sensibly suffer- aba'nd'o'n- ecl ^or **'vet now tnat he is suffermgi nothing but his conforming to ment of another plan will remove his present complaint. ma^have Severe and long continued study, protracted, as I have often been the known it, through ten hours a-day for many months, without any re- cause, laxation or interchange of pursuit, must give way to the exercise of Excercise walking or riding, and this not occasionally, but daily ; and to the fui convcr- still better cordial of cheerful conversation. The last is of very great sation. importance ; and without it even exercise itself will be of little avail: for the mind, accustomed to a certain track of intellectual labour, will otherwise relapse, even while riding or walking, into the same habitual course, be dead to the most fascinating prospects around it, and become exhausted by its own abstraction. And it is to characters of this kind, perhaps more than to any other, that the amusements of a watering-place promise ample success ; where the general bustle and hilarity, and the voluntary forgetfulness of care, the novelty of new scenes, and new faces, and new family anecdotes, and the perpetual routine of engagements that fill up the time with what would otherwise be trifles and frivolities, reverse the mischievous order and monotony of the past, break the sturdy chain of habit and association, and give leisure to the worn-out sensory to refresh itself. Where the same effecthas proceeded from a town life of fashionable follies and dissipation, nothing is more common than to recommend a like change of residence. But in this case, though it may be a change of residence, it is not a change of life ; and hence it is too For the dis- often made without any benefit whatever. A total retreat from the retreat from world, the unbroken seclusion of a remote hamlet, the sober society fashionable 0f a few intimate friends, simple meals and early hours ; instead of close and heated rooms, crowded and motley routs, costly feasts, and midnight madrigals, are what are specially called for in this instance, but are not always to be met with in the resort of a watering-place. In such as are still distinguished for their quiet and unfrequented shores, where all is rude and simple, and spruce squares and long- drawn parades have not yet put to flight the scattered and irregular cottages of former times, these advantages may still be obtained. But it is rarely that patients who are suffering from a life of dissipa- tion will consent to relinquish the higher attractions of our gayer and more public retreats, for what they are apt to esteem the dulness of an unfrequented coast, till it is of little importance whether they go any where, or remain at their own homes. Hv«?pUune .In like manner the habitual use of hard eating and drinking must fare 'and give way to a wholesome plainness of diet; though I am afraid that early hours. not ^ littles mischief has often ensued by rigidly compelling the man who is suffering from a long habit of the former, to abandon this habit But sudden at onc.e\ and run to an extreme of abstemiousness. Nothing can be and ex- more injurious. Even in full health the animal frame, though it mav changes be brought to any extreme by degrees, very ill brooks abrupt changes"; mischiev- and 1 have often seen where such changes have been attempted in an it. r.j DIGESTIVE FUNCTION. [ord. i. 141 enfeebled constitution, that they have introduced worse complaints Gen. V. than they have been intended to remove. The use of tobacco is not, i *n0cs;V in our own day, employed very often to such excess, whether in Dyspepsia. smoking or chewing, as to become a very alarming cause of dyspepsy : l§es but I have known instances where the former has been suspected, though perhaps unjustly, of having been the cause of this complaint, and where an abrupt prohibition of its entire use has introduced a dangerous atrophy. It is certain, however, that a free use of tobacco under either or any How far the form has produced very severe dyspeptic affections, and consequently, {Jacco is° a in such cases, it ought to be relinquished by degrees. Nor is it cause- difficult to conceive by what means tobacco thus acts : for, like opium, it is a stimulant readily producing a narcotic effect, or in other words, rapidly exhausting the sensorial power. In chewing, a considerable . portion of tobacco is conveyed to the stomach along with the saliva: in smoking a somewhat smaller quantity is conveyed in the same manner; and in both, the salivary glands are excited to a great waste of secretion ; which cannot take place without impairing the chy- mifactive process indirectly, as the introduction of the tobacco into the stomach impairs it more immediately. The areca, or Malabar nut, Areca, or though a good bitter, when chewed for a long time, is well known to nul.a " impair it in the same manner. Even in the form of snuff, tobacco has not unfrequently been found to produce the same result; partly perhaps from the paresis of the olfactory nerves in which the stomach participates by sympathy, and partly from the portion of tobacco that is constantly passing into it from the nostrils. " I have found,'" says Dr. Cullen, " all the symptoms of dyspepsia produced by snuffing, and Snuffing. particularly pains of the stomach occurring every day. The depen- dence of these upon the use of snuff became very evident from hence, that upon an accidental interruption of snuffing for some days these pains did not occur; but upon a return to snuffing the pains also re- curred ; and this alternation of pains of the stomach and of snuffing having occurred again, the snuff was entirely laid aside, and the pains did not occur for many months afterwards, nor, so far as I know, for the rest of life."* Dr. Cullen tells us in another place, in proof of the same fact, but in proof also that the habit is sometimes variable in its influence, that he knew a lady, who had been for more than twenty years ac- customed to take snuff, and that at every time of day; but who Case in came at length to observe that snuffing a good deal before dinner t^okotrthe took away her appetite ; and that even a single pinch taken at any appetite; time in the morning, destroyed almost entirely her relish for that meal. When however she abstained entirely from snuff before din- ner, her appetite continued as usual; and after dinner for the rest of the day, she took snuff pretty freely without any incon- venience.! This singularity may partly have depended, as Dr. Cullen sup- accounte poses, on the inequality of the power of habit in exerting its effects : or" but it most probably depended also upon some peculiar change * Mat. Med. Vol. n.p. 275. t Op. citat. p. 274. 142 cl. i.] CtELIACA. [ORD. I. Gen. V. Spec.VII Limosis Dyspepsia. Indigestion. Remote cause not always as- certainable Stomach often ca- pricious, but what- ever disa- grees with it to be avoided. Tea narco. tic to some; agrypnic to "others. Second in- tention, to palliate the symptoms. in the stomach at the time ; apparently on an increased irritability which made it more susceptible, in an empty state, to the nauseating quality which tobacco possesses in common with many other nar- cotics. We are perpetually witnessing a like change in other cases. At the time of writing, J have a patient who has just consulted me on an obstinate dyspeptic affection ; but who is otherwise in very good general health, and was a few years ago able very readily to digest all the articles of food that enter into our ordinary meals, as butter, cheese, sugar, tea, malt-beverage, and wine. Such however is the state of his stomach at this moment, and has been for some years past, that he cannot take the smallest quantity of any of these ar- ticles without serious inconvenience. He becomes oppressed, flatu- lent, and distressed with acidity and sickness. I am unable to learn what was the cause of this morbid change ; for he has ever been a man of the greatest temperance and most regular habits. It is a change however that seems entirely confined to the stomach ; for though other organs suffer slightly and occasionally, it is clear that in these the evil is only secondary and dependent. Thus he is sub- ject to a severe costiveness, and never has a motion without some aperient. His motions however are well tinged with bile, though constantly loose from the means made use of. His appetite is good, and his sleep undisturbed ; but his vascular system is languid, his extremities often cold, and, without a free use of horse-exercise, his appetite and sleep fail equally. I do not state the plan I have put him upon, as he has only just commenced it, and it must be long before its real effect can be discerned. There can be no doubt, however, that in the present condition of this gentleman's stomach, he has done wisely to change his former diet for a new one. And the remark is applicable to every one who is labouring under the present disease; for not in manner of life alone, but in manner of food, should we rigidly proscribe whatever we find to be a cause of indigestion. And hence dyspeptic patients should pay a particular attention to themselves, so as to discriminate between the viands that sit easy on the stomach and those that ren- der them uncomfortable : for nothing in a morbid state is more ca- pricious than this organ, and twenty different cases may perhaps de- mand- as many varieties of regimen. Thus tea of all kinds, and especially green tea, is generally accounted a narcotic. Dr. Smith and Dr. Lettsom endeavoured to trace up its narcotic principle by experiments; and it is to this principle that Dr. Cullen ascribes the deleterious effects it produces upon some stomachs. Yet while it acts as a narcotic upon many persons, upon others, and myself among the rest, it proves powerfully agrypnic ; and if taken on going to bed, keeps up wakefulness through a great part of the night. We must first then prohibit, in our endeavours to effect a cure, whatever we know to be a local or general cause of the disease. Our next intention should be to palliate the symptoms that aggravate and continue it. ah. i-J DIGESTIVE FUNCTION. [ord. i. 143 As the stomach is often overloaded with crudities and acidity, Dr. Gen. V. Cullen recommends an emetic at the outset. I have rarely found l^J11, this of use ; it often adds to the debility of the stomach; and at Dyspepsia. most is only of service for a few hours. For so long as the cause EmS'""' continues by which an accumulation of undue materials is produced, „°^" this effect will be perpetually taking place, and an emetic might be necessary every day. The most rational mode of prevention is, to limit the stomach to such food as it will most easily digest; to allow it in small quantities; to quicken its removal by gentle aperients that may increase the peristaltic action, and warm tonics that may invigorate the digestive organs. A spare diet, however, though often J^"^1'" recommended, is rarely found of service, and very generally adds to the disease: for as the stomach and bowels have been accus- £ spare tomed to the stimulus of food, and a certain degree of impletion, if injurious" this be not maintained, the atony will be increased, the natural func- tion still further impaired, and all the symptoms of uneasiness be aggravated. A moderate proportion of excitement and impletion is hence imperiously called for ; and our discretion is principally to be exerted in determining the nature of the viands and the degree of impletion which will best agree with the stomach, and which it may most easily master. For the correction of flatulency, most of the carminatives noticed Flatulency under the fifth species of this genus may be conveniently had recourse rected,°arnd to ; and for that of acidity, lime-water, the acidulous alkaline wa- Oddity a ters, the alkaline salts, and absorbent earths. Magnesia is a remedy oause of of peculiar value for this last intention. In some cases of great ob- Magnesia!" stinacy, but evidently dependent upon a chronic tendency to an ace-its u*e- tous fermentation, magnesia, given in the proportion of an ounce a-day, has effected an entire cure :* and in all cases it resists the costiveness as well as the acidity, and is far less disposed to coacer- vate in the alimentary canal than the calcareous earths. It is also, as I have already observed, a powerful antidote against that class of calculous concretions in the kidneys and bladder that depend upon an acid principle. The eructations that occur in dyspepsy, however, are not always acid. They are often of a compound and very offensive taste, and give to the breath the smell of carburetted hydrogen gas, or rotten eggs : as though the gastric juice were incapable of performing its proper office, and the food were retarded in the stomach till the pro- cess of putrefaction had commenced. In this case, instead of avoid- Acids|wheu ing acids, we should recommend a free use of them, from whatever quarter they may be obtained ; as they not only tend to correct the fetor, but to strengthen the stomach. The mineral are the most MUwr-ai powerful; and of these the sulphuric is by far the pleasantest; but, in common with the rest, it labours under this disadvantage, that only a small quantity of it can be taken at a time because of its cor- rosive quality.t It may advantageously be employed as a medicine ; but for acidulated diet-drinks, it must yield to the vegetable acids. Vegetable These are of three kinds, native, distilled, and such as are obtained * See Dr. Watson's Communication, Medic. Observ. Vol. iii. t Horst. Opp. in. p. 62. 144 cl. i.] C03L1ACA. [OKP. I. Gen. V. Spec.VH. Limosis Dyspepsia. Indigestion. Compara- tive value of the dif- ferent kind?. Acid of tar water, combines with a tere- binthinate principle. .Powder of charcoal. Some de- gree of acidity in the sto- mach ne- cessary. by fermentation. The first are commonly the most grateful, and especially when they exist in the form of fruits: but as in most of these they are combined with a fermenting leaven, they are apt in weak stomachs to set free a very large quantity of air, and conse- quently to produce a very troublesome flatulency, and even promote the ascescent disposition of the organ. The citric and the oxalic may be exceptions ; and there may be also a few others, but they are not numerous; and where these cannot be procured, we must have recourse to the acids elaborated by distillation, or a fermenting prGcess. The last are called vinegars, whether obtained from malt, weak wines, or sugar; and being of themselves, when properly re- fined, very pure and dilute, they are capable, with a little care, of being rendered highly grateful. The distilled acids of vegetables have not yet been sufficiently tried to determine whether any of them possess any specific virtue. They were at one time very generally made use of under the guise of tar-water ; the whole of whose benefits Dr. Cullen ascribes to the acid of the fir with which the tar was impregnated; but I cannot avoid conceiving, that some, and not a small part, of its good effects resulted from the camphorate or terebinthinate principle which was communicated at the same time. Glauber and Boerhaave seem to have been of the same sentiment; and as the Norway tar is richer in this principle than the American, we are at no loss to determine why Dr. Berkeley preferred the former to the latter. This medicine has experienced the fate of every human discovery whose praise is carried to extravagance: and from being esteemed good for every thing, it is now esteemed by many practitioners good for nothing, and has sunk into total disuse. But this is to sink it very consider- ably below its level. There are many complaints for which it has very fair pretensions ; but I must limit myself on the present occa- sion to a recommendation of it for the purpose before us. Where the taste is not disliked, it will often be found a useful remedy in in- digestions attended with offensive and putrid eructations. I will just mention another remedy which deserves a much more extensive trial than it has hitherto received for the symptom before us: and that is, powder of charcoal. From the experiments of Lowitz and others, this is now well known to be the most powerful corrector, next perhaps to the gastric juice, of putrid substances out of the stomach ; and we can hence account for the success with which it has been occasionally employed as an internal medicine on the continent: the dose may be from half a scruple to a scruple, re- peated three or four times a-day. Before I quite drop the subject of crudities in the stomach, I must observe that our object should not be to destroy all ascescency what- ever ; for a certain proportion is natural to the organ from the early period of lactation, and appears necessary to the digestive process ; and hence we are only called upon to moderate this qua- lity when in excess : upon which ground absorbent powders, and even magnesia itself, when not actually necessary, may add to the mischief instead of removing it. ' l. i.J DIGESTIVE FUNCTION. [orb. ,. 145 Costiveness is a symptom of dyspepsy still more common than Gen. v. acidity, and one that requires a very vigilant attention. In our at- ?f",^IL tempts to remove it, we should always bear in mind that it is a Dy^pria. chronic and not a temporary concomitant; and, consequently, thato0Ke°« violent purgatives are of all things to be avoided ; and that such ape-t0 be,cor"fl nents should be preferred which act gently, and rather by soliciting \TthJ the peristaltic motion of the bowels to the regularity of health, than extent by irritating them to a laborious excitement. Rhubarb is, for this purpose, one of the best articles in the Mate- Rhubarb; ria Medica ; for while by its aperient power it relieves the present distress, we cannot have a much better tonic than its bitter. Where the bowels are merely sluggish, it will prove sufficient without any other cathartic ; though it is better to combine it with soap and such combined aromatics as agree with the patient. It is often however incoinpe- ^Lll' tent of itself; and in such cases derives, in*the form of an extract, a and other valuable assistance from half the quantity of the extract of aloes, mediciaee' or the compound extract of colocynth. Since tha publication of M. Daubenton's little tract in an English Small doses dress, very small doses of ipecacuan, not exceeding a grain or a £jWJ*'r grain and a half, have been extensively tried upon the recommenda- us<*uK tion of this celebrated physiologist. The intention appears to be that of exciting a change of action in the secernents of the stomach : but notwithstanding the advantage which is said to have been de- rived from this medicine by the writer himself, it does not seem to have succeeded in this country; and indeed the dose is so small that little effect of any kind seems capable of being produced by its use. By some writers it is supposed, that in such minute proportions, it will slip over the pylorus, and prove aperient by acting on the intes- tines. 1 have rarely, however, found it to do this alone, though it is a useful auxiliary with aperients of a more decided character. And where there has been great irritability of the stomach, I have known it even in the dose of a single grain excite so much nausea as to prohibit its further use. Far more service has occasionally Tartar- been produced by an external application of the tartar-emetic oint- ointment, ment, made in the proportion of four scruples of the tartarized an- timony to an ounce of spermaceti cerate ; the quantity of a hazel nut being rubbed in every night till the eruption consequent upon this application appears. In numerous diseases of the digestive or- gans, and particularly those of the stomach and liver, this kind of counter-irritation has been found highly useful, probably from the influence which is often produced through the whole length of a nervous fibre and its connecting branches or intersections, in conse- quence of exciting its extremity. Professor Autenrieth of Stutt- gardt advises the application of the ointment three times a-day ; yet this is not only unnecessary, but often mischievous, from its pro- ducing an excess of stimulation. It is to Dr. Jenner we are chiefly indebted for the attention which has lately been bestowed upon the nature and effects of this singular remedy,* though it was occa- sionally long in use before his time. * Letter to C. H. Parry, M.D., F.R.S., on the influence of artificial Eruptions in certain Diseases, &c. 4to. 1822. Vol. I.—19 14b' cl. i.J C- the stomach* which a shorter and more moderate employment has established, it is not at present worth while to inquire, as we shall have occasion to return to the subject when treating of the nature and cure of gout. That some of them contain a mischievous and Their sei*- even a sedative power in union with a bitter principle, is unquestion- probably6' able, for we see it distinctly in the hop, the ignatia Amara or nux fromntcbleit vomica, and more especially in opium ; but to ascribe this sedative bitter prin- or narcotic quality to the bitter principle itself, as Dr. Cullen does cip e' in his explanation of the nature of gout, is only to start one hypo- thesis in support of another. And as the good is unquestionable and immediate, and the evil doubtful and remote, and in every view may be easily avoided by a careful attention to time or a careful re- jection of such bitters as may be suspected, it is to tonics of this kind we ought to have recourse without hesitation, and to look up with a confidence of success. Stimulants, astringents and bitters, are, then, the three classes of stimulants medicine with which we are to make inroad against the intrenchment gerWce'in of dyspepsy. They may often be conveniently united, and have unison their forces hereby increased in a more than double proportion. The stimulants, indeed, ought rarely to be employed by themselves, except in spasmodic pains, or some other temporary extremity. Many of these may be found in the list of carminatives already de- scribed under the species Cardialgia. One of the most valuable medicines of the kind now under con- Myrrh use- templation is myrrh. In doses of six or eight grains it will often muiantand * Mat. Med. Vol. it. p. G4. b"t9r■ 148 cl. i.] CCELIACA. [ord. l Gen. V. Spec. VII. Limosis Dyspepsia- Indigestion. Where the more pow- erful stimu lants may be employ- ed. Capsicum, Agallo- clium. Yellow gum of New Hol- land. excite an agreeable warmth in the stomach without increasing the pulse ; and when it does not sit easy in the powder, it should be given in an extract made by water, in which form it is peculiarly mild. Its most stimulating preparation is its tincture, which, Dr. Stahl asserts rightly, will go as far as twice the quantity in substance ; and, as a stimulant of too high power, should be sedulously avoided. Some practitioners have recommended that the myrrh be slowly chewed in the mouth, and only that part of it be swallowed which is intimately dissolved in the saliva. I have not tried it in this way; but I think it liable to the objection I have already advanced against chewing tobacco, that in dyspepsy it will too much excite the sa- livary glands, which in many cases partake of the imbecility of the stomach. There is an old medicine, whose virtues approach to those of myrrh, now no longer in use, which also peculiarly deserves a trial in this disease ; and that is, the cassamuniar or casmunar, a tube- rous Indian root, bearing from its joints or circles some resemblance to galangal. It was first introduced into notice by Dr. Pechy, then approved by Dr. Marloe and Dr. Meade, and hence soon ac- quired a height of reputation so much beyond its real merits as to prove its ruin. By uniting an aromatic pungency with an agreeable bitter it forms an excellent stomachic; and seems to have been of peculiar service when dyspepsy has been combined with nervous affections of the head, as vertigo and hemicrania. It has the smell of ginger with a mixed taste of zedoary and camphor. I have observed that dyspepsy is often grafted upon an hysterical or hypochondriacal diathesis ; and in these cases we may indulge in stimulants of a much warmer character, as camphor itself, assa- fetida, the alliacea, the spicy aromatics, and even capsicum. Of the last, it may be remarked, that, though the hottest of all the pep- pers, it has a less tendency to produce complaints of the head than any of the rest. It is one of the best carminatives possible in the case of flatulency from vegetable food ; and admirably calculated to remove that stony coldness which distresses a weakened stomach when attacked by a transfer of gout. I have never tried the essen- tial oil of the agallochum or lign-aloes, probably the excaecaria Agallochum of Linneus, though there is some uncertainty upon this point; and cannot therefore determine whether it be entitled to all the commendation bestowed upon it by Hoffman, who regarded it, when dissolved in spirit of wine, as one of the best cordials and in- vigorants that pharmacy has ever possessed, and especially in debili- tated stomachs, accompanied with general depression.* As its taste and odour are equally pleasant, it deserves to be further in- vestigated. A few years ago I had a considerable specimen sent to me of the yellow gum of New-Holland, the product of the acoroides Resini- fera, which is there used very largely in dyspeptic and other weak- nesses of the stomach and bowels. It is slightly bitter and astringent with a little pleasant pungency : but I have not found it essentiallv serviceable. * Observ. Physico-chyra. Lib. i. Obs. 4. cl. i.] DIGESTIVE FUNCTION. [ord. i. 149 In selecting from among the simple bitters we need not be par- Gen. V. ticularly nice, for their principle is the same ; the quassia perhaps E.^11' possesses it in the highest degree, though some have doubted of Dyspepsia. this: then the gentians ; and next to these columbo. Of the gen- simpfe*110" tians, the mo.it powerful seems to be the g. purpurea, first imported J^X,, into this country, by Dr. Home, from Norway, and then known by the name of cursuta, from its Norwegian name skarsote. As a simple bitter it is best to unite it with some aromatic. The tincture of gentian of the London College, which is an improvement upon Stoughton's or the stomachic elixir, by exchanging the cochineal for the smaller cardamom seeds, is an excellent form for occasional use ; but as alcohol should be habitually abstained from in the disease before us, it cannot be employed alone in such quantity as to promise any real benefit, though it may be allowed to enter as an ingredient into more compound remedies. The bitter of the columbo is combined with a slight and not dis- Columbo. agreeable pungency, and has an aromatic smell. It is hence pecu- liarly calculated for dyspectic affections in all its forms, and in most cases will sit easy on the stomach, in that of powder in doses of fif- teen or twenty grains ; and will often give a check to sickness, where bile is not present, more than any other medicine we can em- ploy. It is singular that to the present hour we are unacquainted with the plant that furnishes this excellent drug. Commerson be- lieved it to be a species of menispermum ; but it still remains to be ascertained. It is an Indian plant, said to be exported from Ceylon, from the capital of which it derives its name, though Dr. Davy has informed me that he never met with it in that island. It seems to have been first noticed by Redi in 1685.* There are several other plants that possess a bitter principle in a Compound more intense degree than any of these, as the nux vomica, and worm- NuXrs' wood : but they are not simple bitters. The first is a stimulant vomica. narcotic ; it takes off the sensibility, but renders the head confused ; and at the same time excites the irritable fibres to irregularity of ac- tion. It has no pretensions to be employed in the disorder before us. Whether wormwood possess any thing of the same principle Worm- I cannot satisfactorily determine. Linneus conceived it does not; wo° ' but Bergius, Lindenstolpe, and most of the physiologists on the con- tinent, adopt a contrary opinion. It is probable, notwithstanding Dr. Cullen's hypothesis respecting bitters generally, that whatever degree of this quality it possesses, it derives from its essential oil, for the odour or aroma, not only of this but of southern-wood, is apt to produce a like confusion of head in many persons who are shut up in the same room with these plants. It is clear, however, from this very diversity of opinion, that this narcotic power, if it be present at all, exists only in a very small proportion ; and that the plant as a stomachic is greatly improved by the possession of a sti- mulant essential oil. It continues hence to be in high repute on the continent in dyspepsy and indeed in all debilities of the chylopoetic viscera ;t and has very unjustly been banished from the dispensatories * Experimenta circa Res Naturales, p. 142. t Swalive, Querulse Ventriculi, p. 286. 150 cl. i.] CCELIACA. [ORD. I. Gen. V. Spec. VII. Limosis Dyspi-psia Indigestion. Chamomile. Bitters should not be iufused longer than is needful to extract the bitter principle. Cinchona. Cascaiilla. Acids as astringents. of our own country. It is perhaps less grateful than the hop, though at one time, very generally employed in the composition of purl; but so far as I have been able to judge, it has all the medicinal properties of the hop in a much higher degree. As a plant uniting the two principles of an essential oil, warm without being unduly stimulant, and a powerful bitter, the chamomile is, for the purpose before us, one of the best remedies that we can select. It may be taken in a watery infusion, or an extract: but if in the former, the menstruum should be closely covered, that as little as possible of its volatile aroma may fly off. And it should be far- ther observed, that the infusion should not be continued for longer than an hour ; and perhaps a shorter period may suffice. For it may be remarked in respect to bitters in general, that the matter ex- tracted the first hour is not only more charged with the bitter prin- ciple, but far lighter and pleasanter to the taste than what is extracted afterwards. There are some bitters that do not so readily give out this principle as others, and for which a single hour's infusion in boiling water may be scarcely, perhaps, time enough ; but as a ge- neral notice, the remark will hold good ; since the infusion should, in every instance, be poured off as soon as the water becomes impregnated with the bitter principle of the plant in its'first stage of purity. As we have medicines that unite the two qualities of bitterness, and a stimulant or aromatic warmth, so we have those also that unite the two qualities of a bitter and an astringent; of which the cin- chona furnishes us with a striking example : and hence this medi- cine has been long, and deservedly, one of the most popular of any for debilities of all kinds, whether of the digestive organs alone, or of the system generally. The cascarilla bark has pretensions of a like kind, but far inferior in degree, notwithstanding the high enco- miums that have been paid to it by the Stahlian School, which en- deavoured to hold it up as a rival to the cinchona. There are many stomachs, however, which will not bear the latter, even in decoction or infusion, and in such cases the cascarilla may form a convenient substitute. The acids, both mineral and vegetable, are valuable astringents in particular states of the stomach resulting from dyspepsia : for it is obvious that from the tendency of this organ to co-operate in so many cases in the production of a superabundant acetous fermenta- tion, acids cannot at all times be had recourse to. I have occasion- ally, indeed, employed the mineral acids, and particularly the aqua regia of the old dispensatories, or a mixture of the nitric and mu- riatic acids, in the proportion of one part of the former to two of the latter, for the purpose of checking this tendency to acidity, in several instances with success ; but the plan has not answered gene- rally ; and it will hence be better to limit this class of medicines to the intention I have already pointed out, or to delay them till we have by other means overcome the disposition of the stomach to this mor- bid action. In which case they may be had recourse to with very great advantage under the regulations laid down in the preceding pages. • l. i.] DIGESTIVE FUNCTION. [ord. i. 151 The other mineral astringents which have been employed besides Gen. V. acids are not numerous; and may be limited to the preparations of l^^11' iron and zinc. As general tonics, these, under different forms, have Dyspepsia. proved very extensively successful; but they are less adapted to dys- p"epSaera-°B' pepsy proceeding from primary imbecility of the stomach or its ta7z?[(!,,on adjuvant organs ; or I should rather, perhaps, say, that they are apt to disagree with these organs till they have been restored to some in- creased degree of tone beyond what they usually possess when me- dical aid is sought for. The preparations of these metals, and particularly of iron, have been very unnecessarily multiplied in many pharmacopoeias. In order to render metals active on the human body, it is requisite that they be reduced by acids ox some other solvent to a fine impalpable powder. It is very true that the acid, according to the kind or quantity employed, or the nature of its chemical union, may also communi- cate a new quality ; and it is hence that mercury which, in some of its forms, is a mere stimulant, in others becomes a corrosive poison. For the disease before us, however, all we need is the metal itself in it3 simplest and most attenuate state : and hence it is most com- mon to take it, as reduced to this state by sulphuric acid, under the popular name of vitriol. This is the ordinary, and in many cases the only advantageous form in which we can employ either iron or zinc in the disease before us : and under this form both are pecu- liarly astringent, so much so indeed, as to be occasionally used, and especially the zinc, as external applications in the preparation of collyriums or injections. Other acids have occasionally been employed, but they do not seem to have any superior claim. Hoffman was much attached to the formic acid, or that of ants, conceiving that it was one of the best formic solvents of iron for medicinal purposes. It has characters of its aci ' own, but approaches nearer to the acids obtained from vegetables by fermentation than to any others. It held formerly a place in the Materia Medica of many foreign Pharmacopoeias, and was esteemed a principal ingredient in the once famous aqua magnanimitatis. I have observed, that there is always some degree of acid existing in the stomach in a healthy state, and we have seen that one of the most troublesome symptoms of dyspepsia is a morbid increase of this principle. And hence, upon an idea that the acid, if thus formed in the stomach, may of itself be sufficient to answer the pur- pose of the sulphuric, and reduce the particles of the metal to a due degree of tenacity, both the zinc and the iron are also frequently employed in the simple form of filings, rust, oxydes, or calces ; and simple me- often with the happiest success. And that an acid adequate to this rationsrepa* end does in most cases exist in the stomach, is sufficiently proved |hn<'tacidi,o'f where the rust of iron is employed, by the black colour of the stools, the sto- which may be regarded as a test of the proper solution of the iron ; mach' as it may be also of the existence of bde in a state of healthy bit- terness : for it is by a combination of the iron with the bitter prin- ciple of the bile that this blackness, which is a natural ink, and ob- tained by the same means as artificial ink, is produced. There are some animals that have a power of forming this sort of natiual ink 152 cl. i.J COZLIACA. [ono. i. Gen. V. at option, as the sepia or cuttle-fish, but whether by a solution of iron Llmo'siJ11' I cannot undertake to say. This, however, is very probable, if it be Dyspepsia. used, as it is generally understood to be, by the Chinese, as an ingre- indigestion. dient m t^ manufacture Gf Indian ink. The cuttle-fish, when ex- posed to danger from the attack of an enemy, throws it forth very freely, employing it, indeed, as a means of defence; and effecting his escape by thus converting the water around him into a black muddiness that sufficiently conceals him from view. sulphates It is on this principle that the flowers or oxyde of zinc, have by so txyde's. many physicians of great reputation been preferred to the sulphate : and it is certain that in the form of an oxyde we can introduce a much larger quantity either of zinc or iron, than in that of a salt: but it does not follow from this fact that the metal may be more efficacious ; for from the doubtful measure and strength of the acid existing in a free state in the stomach, there may not be enough to dissolve or form a salt, with the whole of the dose, and consequently a consi- derable portion of it may be lost or remain inert. And on this ac- count I think it better to have recourse at once to the sulphate of both these metals, whenever it be judged expedient to employ them, than to trust to the chemical changes that may take place with so much precariousness in the stomach. How the We may avail ourselves of this remark, before we quit the subject, dofeseof to reconcile the conflicting statements of different practitioners re- metaitic . specting the efficacy of these metals, in their oxydized form, and the as^eTom- dose in which they should be given. The flowers of zinc have been different67 a mecucine of considerable reputation in epilepsy, and other spas- writersmay modic affections, ever since the time of Gaubius : but while some .cfied.0011" physicians have found them successful in doses of five grains, re- peated three times a day,* others have carried the dose to three times the quantityt without any success whatever. In like manner, while the ordinary dose of the oxyde or rust of iron is five or six grains, repeated twice or three times in the twenty-four hours, we are told of persons who have been able to swallow six drachms a-day without sickness, or other inconvenience. It is possible, from the preceding observations, to reconcile these discrepancies; for it is obvious that much of the difference must depend upon the different states of the stomach in regard to its power of generating an acid at the time. atfiStIS to In einP1?yinffthe metallic salts, and, indeed, tonics of every kind, increased in disabilities of the stomach, it is a good rule to begin with small gradually. qUantities, and advance to a full dose by degrees ; thus reversing the method that it may often be found advantageous to follow in acute diseases, when the life of a patient may depend upon a bold practice adopted instantaneously, and gradually remitted, as soon as the object has been obtained. The chronic character of dys- pepsy on the contrary allows us time ; and as no two stomachs will perhaps bear the same precise dose of a remedy, with the same pre- cise effect, on account of the caprice of this organ in a deranged state, it is better to feel our way before us, and to reach the proper I u*n'™7 n ZiDC°.J rU£?; ?at> im' Fou1net' Gardane G^tte, P- "■ T Bell. Med. Coram. Edin. Vol. i. ' * cl. i.j DIGESTIVE FUNCTION. [ord. i. 153 point by degrees ; for if we over-dose the patient at first, we add GEN.ry. to the disease instead of opposing it, and require many days, per- l^,711" haps weeks, to bring him back to the actual state in which we found Dyspepsia. n]m> Indigestioa. In conjunction v/ith this internal treatment it is probable, also, Voitaism that an external application of the voltaic power to the stomach may fbeVto-*6 increase its energy. In the hands of Dr. Wilson Philip it appears mach- to have been of decided advantage. But as I shall have occasion to notice this active remedy more at large when discussing the nature and cure of dyspnoea exacerbans, I shall postpone a further account of its effects and the mode of its application till then. While, however, a proper course of medicine is pursuing, a proper General course of diet and regimen must accompany it, or with the utmost professional skill we shall make no progress. And hence to the re- marks already made at the outset, that where the disease has been brought on by a life of indolence, sedentary occupation, or too free indulgence of any kind, the general habit must be changed, and re- gularity of meals, sleep, and exercise be rigidly insisted upon, it is necessary to add a few other observations to the same purport. One substantial meal of solid animal food daily is sufficient for a Diet and man in full health engaged in a life of ordinary labour. Yet there esiroen' are many who, without any labour, are from a long habit obliged to take two or even three. But the habit is bad, and cannot too soon be broken through. It follows, therefore, of necessity, that, where the stomach is weak, the toil of digesting one full meal of animal food is the most that should be put upon it. This should take place as nearly as may be to the hour of noon, certainly not later than one or two o'clock, so as to occupy the middle of the wakeful pe- riod. The animal food should consist of one dish only ; and be confined to such as is lightest of digestion, or as the peculiar state of the stomach may call for : for in both these respects there is a considerable difference. Thus shellfishes do not always agree with weak stomachs, and will sometimes excite great uneasiness, with pyrectic heat, and even throw out a nettle-rash, or some other cuta- neous eruption. Yet where they sit easy and are relished, several of them, as the crab and lobster, are found to neutralize acidity in the stomach more readily and effectually than any other kind of ani- mal food: an effect we should little predict, considering that they give out, on a chemical analysis, a smaller proportion of ammonia than the flesh of quadrupeds, birds, or even amphibials. The food of young animals is less nutritive than that of old, but it is, in gene- ral, digested with less irritation. Many writers have arranged the different animals that furnish food in tables, founded upon their sup- posed degree of nutriment. But they have drawn them up with con- siderable variations; in some instances apparently according to their own fancy. I have not space to enter into a comparison of these, nor is it necessary. Those who have leisure for such a study may what foods turn to Dr. Darwin's, which is perhaps one of the best, and which fe'nd™08 they will find in his Zoonomia. Generally speaking, the tenderest ^ food is that of the gallinaceous birds: then that of the ungulated quadrupeds ; among which the stag, or cervus kind, claims the pre- Yol. 1.- -20 among anr- 154 cl. i.j (J0JL1ACA. [oiii>. *■ Gen. V. Spec.VH. Limosis Dyspepsia. Indigestion. Cookery cannot be too simple. What vege- table foods allowable. Mischie- vous ar- rangement of fashion- able meals. eminence ; and to this succeed the ox, sheep, and hare, in the order in which they are here placed. Yet it should be observed, that the last, though less nutritive than the preceding, is more easily digested than several of them ; as it should also, that the flesh of animals in their wild or native state, though less coveted by a pampered palate, offers a more wholesome and digestible aliment, and is more perfectly animalised, than that of animals cooped up and fattened for the ta- ble.' Below the hare, we may place the webfooted birds that are ordinarily brought to market; and below these, the oyster and lob- ster tribes, and lastly the numerous genera of fishes. The simpler the cookery of all these the better ; for the complicated processes employed to give new forms to the productions of nature, or even to break them down for the use of the stomach, and thus keep the masticatory organs in a state of indolence, injure, instead of promo- ting the health of a dyspeptic patient. We have already observed that the saliva forms an important part in the chemistry of digestion, and it is best applied to the food when first secreted and in the act of mastication ; and hence if this act be prevented or suppressed, the food is without one of its auxiliaries. It is on this account that con- centrated jellies, and all mashed dishes, sit more uneasily on a weak stomach than meat taken in a solid form. The vegetable nutriment should be such as is least disposed to fer- ment in the stomach, and hence all kinds of new bread, sweet pre- serves, confectionary, and pastry must be sedulously avoided ; and the crust of bread, toasted bread, and unleavened biscuits take their place. The farinacea, whether seeds or roots, as rice, wheat, flour, in the form of light and simple pudding, and potatoes, may be al- lowed in moderation. Water too is the best beverage ; but where there is great flatulency, a small portion of brandy may occasionally be added. The only condiments that can be conceded are salt and spices : pickles might be admitted where acids constitute a part of the medical treatment; but they are disposed to provoke a false ap- petite, and hence to weaken the stomach by overloading it. From fixing the principal meal so near the hour of noon, it is clear that we suppose the day to commence at a very different period from the ordinary regulations of fashionable life; in which the bed is rarely quitted before nine or perhaps ten o'clock, after a night of imperfect and feverish sleep, when the languid idler immediately proceeds to a breakfast of tongue, ham, and eggs in addition to the ordinary materials of this meal, as though he had been already la- bouring in the field for two hours ; and by means of their combined stimulus, fills his stomach with a load, which might indeed do good to the husbandman, but to himself proves nothing more than a mis- chievous oppression. Yet to this morning toil of the stomach suc- ceeds, at about two o'clock, the ordinary luncheon in a still more solid shape ; followed in the evening by a dinner of numerous courses, with high seasoned,condiments and a stimulating change of wines ; the real'business of this vain and frivolous life perhaps not commencing till the better-disciplined peasant has beo-un his quiet sleep : when, roused by a flow of factitious spirits, andprimed tor gayety and gallantry, the votarv of pleasure, as it is called. «al- cl. i.] DIGESTIVE FUNCTION'. [ord. i. 155 lies forth to join his comrades at the allotted place of rendezvous, Gen. V. and to pass the midnight in hot and crowded ball-rooms, or in orgies J"^11, of a still more exhausting nature. Of the whole of this career, Dyspepsia. the only rational part of it is the luncheon a little after mid-day; Ind,208t,on- this may be copied by the invalid before us, as his dinner, but from all the rest we must carefully shut him out. He should quit his bed msh}S. «- by six or seven o'clock in the morning in the summer, and by seven foment," or eight in the winter ; and after having risen for an hour he may and rest* partake of a light breakfast of milk, cocoa, sassafras, or any other aromatic or warm-flavoured tea, with toasted bread, the crust of bread, or sea-biscuits, as observed already. The morning may be devoted to such exercises or recreations as may be most agreeable, without producing fatigue. To this will succeed the chief meal of the day, upon the plan already laid down ; and a light refreshment of the same nature as the breakfast should conclude the daily diet, a few hours before retiring to rest, which should never be later than eleven o'clock. Sea-bathing or the shower-bath before breakfast will considerably add to the means of improvement wherever these advantages can be enjoyed, and particularly when the warmth of the season may give them the character of luxuries. Proper temperature and clothing are also subjects of some im- Tempera- portance ; but as we shall have occasion to enlarge upon these, clothing* more particularly when treating of phthisis, I shall only observe at present, that the feet and chest should be kept especially warm, and that all extremes of heat and cold should be sedulously avoided; a general glow on the surface, when produced by exercise, will be advantageous, but it should not be carried to the extent of much sen- sible perspiration, as this might terminate in a debilitating chill. And where the languor is so extreme as to prevent exercise abroad, Exercise that of a swing or rocking-horse may be had recourse to at home ; weakness. or where these cannot be endured, that of general- friction, in any of the multiplied forms now in use, and especially friction of the ^ric'|on of stomach and belly, may be often employed as an advantageous sub- mach. stitute. Every tender mother is well acquainted with the benefit of such an external stimulant to her infant; and when judiciously ap- plied, it may often be rendered so to an adult in cases of great dys- peptic languor and weakness. 156 cl. i.] CCELIACA. [okjj. j. GENUS VI. COLICA. COLIC. BELLY-ACHE. GRIPING PAIN IN THE BOWELS, CHIEFLY ABOUT THE NAVEL, WITH VOMITING AND COSTIVENESS. Gen. VI. There are various diseases to which this definition will apply ; but which, nevertheless, differ from each other in several particulars. M. de Sauvages thought these particulars of so much importance as to justify him in advancing each of these complaints to the rank of a distinct genus, under the names of gastrodynia, colica, rha- chialgia, and ileus. Dr. Cullen, however, judged differently and more correctly. He regarded their distinctions as of subordinate moment, and in their prominent symptoms traced so close a resem- blance as to indicate their being a sort of natural tribe or family: and he has consequently simplified them into one genus under the name here adopted, of colica. In the ramifications of his species, however, he seems a little too diffuse, and he has unnecessarily, and somewhat capriciously, varied a few of the ordinary specific names, as those of ileus and rhachialgia, which, for reasons assigned in the volume of Nosology, are here restored. In other respects the present arrangement does not especially differ from Dr. Cullen's classification. The species that seem fairly entitled to attention are the following: 1. colica ileus. ILEAC PASSION. 2. ------- RHACHIALGIA. COLIC OF POITOU, OR PAINTER'S COLIC. 3. ------- CIBARIA. SURFEIT. 4. ------- FLATULENTA: WIND-COLIC. 5. ------- CONSTIPATA. CONSTIPATED COLIC. 6. ------- CONSTRISTA. eONSTRICTIVE COLIC. Sauvages' arrange- ment. Cullen's arrange- ment. cl. I.] DIGESTIVE FUNCTION. [ord. i. 157 SPECIES I. COLICA ILEUS. ILEAC PASSION. GRIPING PAIN, VOMITING, AND COSTIVENESS ACCOMPANIED WITH RE- TRACTION OF THE NAVEL AND SPASMS OF THE MUSCLES OF THE BELLY. The name of Ileus (, they have been tainted with lead employed in some part of the ma- c^ide wines cmnerY or vessels made use of. Yet suppressed perspiration, or and Aiders8 cold from long exposure to damp, has perhaps been occasionally a whether16' source of both the present and the preceding species. Sauvages suppressed has observed that rhachialgia has also occasionally followed up an perspira- mjury to the spine by a biow or otner accident: and Cullen has l^cafirijury copied from Sauvages, as Sauvages copied from Astruc. I have to the spine, never met with a case of rhachialgia from this cause, but whenever it occurs it must probably be upon the principle which Astruc has perspicuously laid down ; a compression on the spinal marrow pro- ducing a paralysis of the limbs, and putting a stop to the peristaltic action of the intestinal canal, in consequence of the sensorial fluid from some of the vertebral nerves being obstructed in its course.* Subdivision Admitting that all these are distinct causes of the present species, tieV"cti- it is possible that each may produce some slight diversity in its caiiy unne general symptoms; and we should hereby be presented with four cessary. varietieg of rhachialgia. In Dr. Cullen's Tables these varieties are arranged in order; and in deference to this able writer they have been copied, as his, into the Nosological volume of the present sys- tem. Rut as it appears to me that there is no real ground for di- versity in the treatment, and that lead, under some modification or other, is the common cause of the disease, I forbear to carry the distinction any further. Thatieadis For the discovery of this general cause, medical practitioners and causIT'es-11 the world at large are under almost infinite obligations to Sir Ceorge tabiisied Baker, whose indefatigable pains at length succeeded in setting Baker, this subject in its true light; and in exposing the iniquitous fraud which was at one time very extensively had recourse to for sweet- ening acid ciders, as well as weak wines, by mixing with them litharge or sugar of lead, or employing utensils or cisterns more or less formed of this metal. In the present day, in which the study of chemistry has become popular, and every one is aware of the mis- chief of such a conduct, and the public good has obtained a triumph violent over private emolument, it is difficult to conceive the degree of op- tohis'at- position which this indefatigable pathologist had to encounter in tempts. establishing his theory of the disease, and calling the nation to a sense of its own danger. On the one hand all the adulteration was openly denied, and even the use of leaden utensils or cisterns, in cases in which rhachialgia made its appearance. On the other hand he was reminded even by medical writers, who ought to have known better, that lead itself was, to say the worst of it, a harmless material; and that even as a medicine it had for ages been em- ployed as a valuable specific in some of the worst complaints to which the human frame is incident. And when it was retorted that the colic, which at one time was endemic in Poitou, was well known to have been produced by sweetening weak, acid wines, and restrain- * Thes. de Rhachialg. See also Journ, de Med. .Tuin. 17rJ0. cl. I.] DIGESTIVE FUNCTION. [ord. i. 165 ing their fermentation by salts of lead, as Tronchin, Zeller, and Gen. VI. others, had sufficiently established, insomuch that the French go- cc^ca'11' vernment thought it right to interfere, and prohibited the use of such Ri>*chiai- preparations under the severest penalties; it was still obstinately c'oiic of asserted, that the colic induced occasionally by cider was essentially Poitou' unlike rhachialgia. and excited, not by a solution of lead, but either by a mere crudity of fruit, producing, as Dr. Huxham had not long before erroneously suppose!, a gross and acid salt of tartar injurious to the blood; or by cold and obstructed perspiration ; or by a gouty or rheumatic diathesis; or by a variety of other fancies which it is unnecessary to dwell upon. More than half the first volume of the Transactions of the College of Physicians is occupied by different papers written to establish the real nature of this disease. The question was next started, and it has been started again in Whether our own times, whether pure water, as well as acid wine, be not ca- wiifdis* pable of dissolving lead in a metallic state ; and, consequently, ^''^{al. whether the community be not daily running a great risk of being lie state. poisoned by employing this metal in pumps and reservoirs ? The public mind was for a long time very much agitated by this discus- sion, and Dr. Percival thought it right to institute a variety of nice experiments to allay the general apprehension, by showing that pure water is not in any respect a solvent of metallic lead.* Yet it was a course hardly necessary since the daily use of leaden water-cisterns by upwards of a million of inhabitants in this metropolis, without any inconvenience whatever, was then, and still continues to be, the most decisive and satisfactory proof that can be afforded of the inso- lubility of metallic lead in rain or river water. Even saturnine lo- whether tions applied to the surface of the body have rarely, if ever been JotionTbe found deleterious, although these also were at one time suspected of injurious. being highly mischievous. They may perhaps prove so in a few sin- gular idiosyncracies, but they do not affect mankind in general. Lead, however, so minutely divided as to impregnate the at- Atmos- mosphere with its effluvium, has frequently laid a foundation for the {1^^ disease. But whether any preparation under the form of cosmetics wnn lead has proved injurious I cannot undertake to say. The disease has duce'dthe certainly been produced by sleeping in newly-painted rooms, ofdisease- which a striking instance occurred a few years ago to myself. The illustrated patient was a surgeon of highly distinguished character in this me- incase. " tropolis. When I saw him, at his particular request, he had been ill for a fortnight; and, the cause not being suspected, his complaint was conceived to be obscure and anomalous. The symptoms, as they struck me, were evidently those of rhachialgia from lead; and upon pointing out to him my view of the case, 1 found that about a month antecedently he had sent the whole of his family into the country, as his house was about to undergo a thorough repair in painting, while he himself remained at home and slept there. The cause was admitted and acted upon, but the disease had gained too much ground, and was immoveable; his spirits became deeply de- jected, and he fell a sacrifice in about two months from the attack. * Observations and experiments on the Poison of Lead, by Thomas Percival, M.D. 1767. 166 cl. i.] CCELIACA. [obj». i. Gen. VI Spec. II. Colica Rhachial- gia. Colic of Poitou. Peculiar effect on some con- stitutions. Other examples. Water, when aerate! capable of dissdlving lead. Hence leaden re- servoirs for aerated waters should be , lined or combined with tin Msdical treatment. In the Medico-Chirurgical Transactions is a case communicated by Dr. Badeley, in which the patient, a domestic in his own house, lost her speech and became paralytic from being only six hours in a newly-painted room, but quickly recovered from both upon being removed ;* evidently proving the deleterious influence of lead in a state of vapoui ; and at the same time that in different constitutions it will show its effects upon different organs or in a different manner. Is the lead in these cases in a state of regulus, oxyde or salt 1 Is it dissolved in the air, or merely mixed with it ? Sir George Baker asserts, that he has known the disease originate from minute corpuscles thrown off' from the clothes which have been worn by plumbers while at work.j And in corroboration of this remark Dr. Reynolds observed, when he was physician to St. Tho- mas's Hospital, that the colic of all the workers in lead frequently returned, under any management whatever, whilst they were allowed to wear the clothes in which they had been accustomed to labour: on which account, such clothes were never suffered to lie on the painter's bed. Sentin was a witness of the same effect from hang- ing up labourers' wallets, filled with food for the day, in places im- pregnated with the vapours of lead.J And the present author has occasionally met with other instances of the disease from an habitual residence in close damp rooms, filled with newly printed or coloured paper : for the emanation of flake-white, which usually enters into the colour, seems to have the same power of affecting or being af- fected by the surrounding atmosphere, as that of lead in a finely at- tenuated metallic state.§ I have said that pure water does not act upon lead in a metallic form : but while we see lead thus easily disintegrated and reduced to an oxyde or a carbonate by acids existing in the atmosphere, or even by the atmosphere itself, we may readily conceive that aerated waters are capableof decomposing it in a slight degree, and of form- ing oxydes or salts that may be injurious to the health. And hence, where lead is required in the form of reservoirs for waters of this kind, or for culinary vessels, it should, by all means, be united with tin, in equal proportions as recommended by M. Prout,!! or with a slight surplus of the latter as proposed by M. Vauquelin.1T For, first, tin is a harmless metal, as well in its salts and oxydes as in its reguline state, at least in any quantity in which we can con- ceive it possible to be swallowed by mistake. And next, as it is more readily oxydable, and has a closer affinity for all the acids than lead, when united with the latter it must completely draw away all the acid it can come in contact with, and detach every atom of oxygen which might even previously have been united with the lead. The paralytic effect produced by the action of lead is one of the most formidable symptoms to be encountered in the therapeutic process : in laying down which, our first efforts should not be differ- ent from those in the preceding species, excepting that, in an attempt * Vol. ix. p. 2S8. See also Seguin, Annales de Chimie, Lxxxvm 263 t Essay concerning the Cause oi" the Endemial Colic in Devonshire. 176° I Memorab. p. 114. § Med. Trans. Vol. in. p. 420. II Annates de Chimie, Tom. lvii. p. 84. If Id. xxxii p 243 cl. i.J DIGESTIVE FUNCTION. [ord. i. 167 to remove the spasmodic pain, opiates may be allowed to precede Gen. VI. the use of purgatives. The paralytic effect has been attempted to cohct* "' be subdued by the counteraction of other metals introduced into the Rh»chiai- system for this purpose: and especially mercury and silver. Both coi'ie of have, indeed, been given from the commencement of the attack by Howfar many practitioners ; and, as themselves relate, with great success. «he effects Dr. Warren and Dr. Biss were in the habit of persevering in the mer- be'oppo'sed curial process till they obtained a salivation ; and assert, that they by °',her c i ', j ,, . . J ' . . ' J metnls. tountl tne dull griping pain give way as soon as this was accom- Mercury. plished. And hence, perhaps, Dr. Clutterbuck, with the view of turning the tables upon mercury when continued so long as to prove mischievous to the constitution, inquires whether some preparation of lead might not in these cases be given internally to counteract the ill effects of the mercurial medicine ?* The silver employed in Silver-. rhachialgia has usually been in the form of its nitrate or lunar caus- tic, to the amount of four or five grains in the course of the day. Dr. Roberts has published two cases of a cure obtained by this remedy: the one that of a young, the other of an old man. The cases were both of considerable standing, and the joints of the wrists were weak almost to paralysis. Even this symptom, however, yielded by degrees. The salt was given from three to five grains at a dose three times a-day in the form of pills: and in the last case five grains every six hours. It has the advantage of being a laxative as well as antispasmodic : so much so, that a small quantity of opium was on this account added to the nitrate when given in its most fre- quent doses, t Alum was at one time another popular remedy both in our own *lum b°™ country! as well as abroad.§ The German physicians gave it in the proportion of from twelve to eighteen grains three or four times a-day ; and by Dr. Grashuys it was even regarded as a specific.II But Dr. Percival advanced the quantity to fifteen grains repeated every four, five, or six hours, and affirms with unvarying advantage ; the third dose seldom failing to mitigate the pain, sometimes en- tirely to remove it. II In treating of passive hemorrhage we shall have occasion to Opium observe, that whatever deleterious property the acetate of lead vlfeabie" may possess, it is entirely removed by a judicious mixture of opium with it, so as in this state of union to become a most valuable styptic. It is possible that, under the form of an acetate, lead may be less injurious than under some others, for it has not un- frequently been given alone in the same complaint without any rhachialgic pains where the bowels have been kept in a soluble state. But with opium every mischief seems effectually to be guarded against: and the beneficial influence of opium upon lead in this case should induce us to employ it, and that very freely, as an antidote in every case, and especially in the disease before us j * On the Poison of Lead. t Med. Trans. Vol. v. Art. v. t Percival, Essays i. n. Edinb. Med. Coram, u. 305. § Crell. Bald. JS. Mag. B. in. p. 4. Lindt. Diss, de Aluminis Virt. Med. Goet, 1784. [| Tentain. de Colica Pictonum, et App. ? Obsenratio i and Experiments on the Po;>on of Lead. 1767, 168 cl; i.] CCELIACA. [ORD. I. Gen. VI. Spec. II. Colica Rhachial- gia. Colic of Poiiou. First point- ed out by Dr. Rey nolds. Attempts to reduce the acetate to a sul- phate. Oil of tur- pentine: ofcroton. Patients liabie to sub equeni paroxysms and to counteract its constringency by an union with calomel. This rational practice which has been pursued in our own coun- try by several physicians ever since Dr. Reynolds first called the attention of the profession to the corrective power of opium when combined with lead in the case of hemorrhage, lias now for many years been also tried with success in various parts of the conti- nent. In France the dose of opium has been usually only a grain or a grain and a half every night; but in Spain, as we learn from the memoirs of the Real Academica Medica de Madrid, a much bolder and more satisfactory employment of this medicine has been exhibited by a physician of distinguished judgment, Don Ignacio de Luzuriaga, who prescribed a grain of opium every three hours ; and it will often be found necessary to augment this quantity.* As the sulphate of lead is a compound insoluble in the stomach, and consequently altogether inert, M. Orfila has ingeniously attempt- ed to reduce the acetate and other preparations of this metal to the form of a sulphate, by giving large quantities of sulphate of magne- sia ; and he thinks he hereby succeeded in effecting a decomposition in the stomach of two dogs upon whom he made experiments to ascertain this point; and in producing sulphate of lead in their stead. The experiments, however, proved fatal in both instances, though some portion of sulphate of lead seems to have been formed, and the death of the second dog to have been retarded. As the want of complete success may be ascribed to the want of a sufficiency of sulphuric acid in the re-agent employed, it would be better to try the experiment for the future by giving the purgative salt in an infusion of roses, or any other liquid adequately charged with the acid to answer the purpose ; or by a free exhibition of the acid in a diluted state alone. The best purgatives, where the costiveness is severe, are those impregnated with the principle of camphor, as the essential oil of turpentine : and where these fail, the oil of croton in doses of one or two drops in the form of pills. Those who have had this disease, are liable for a long time to fresh paroxysms s and the slightest exposure to the same cause will be sure to reproduce it; yet the appearances in different persons, as well afterwards as during the attack, are extremely variable, from difference of idiosyncrasy : a correct idea of which may be best, perhaps, obtained fivm Dr. Warren's description of thirty-two do- mestics of the Duke of Newcastle's family, then residing at Hano- ver, who were all seized with rhachialgia after having used, as their common drink, a small white wine that had been adulterated with some of the oxydes of lead. They were all attacked in the common way, except one, whose first assault was an epileptic fit. This patient, as soon as the pain in the bowels which succeeded to the fit had ceased, had his head again affected, was troubled with a St. Vitus's dance, and died epileptic in less than a fortnight. Three were feverish from the beginning to the end of the disease. The * Dissertation Medica sobre el Colico de Madrid, inserto in las Memorias de la Real Academia, &c. Madrid, 1796. cl. i.J DIGESTIVE FUNCTION. Lord, i. 169 rest were without fever till the fourth or fifth day, their pulse be- Gen. VI. coming quicker as the pain began to abate. In some the mouth (i0|ica* was made sore by the acrimony of the matter vomited up. Four Rhachiai- fell into a salivation for several hours every day, and said thatcoiicof their pain was abated during the spitting. Many had profusePoitou- sweats, and a few an eruption of red and white pimples just before the disorder terminated. One was delirious during a part of the time, but recovered. All relapsed within four or five days after they seemed to be cured. Some relapsed several times for several years. One only was rendered permanently paralytic and costive.* The most useful means of guarding against a paralytic diathesis, »ath or of removing the paralytic sequel, where recourse can be had to them, are the Bath waters. And where the circumstances of the patient will not allow him to have the benefit of these, the spine may f'X"1""- be advantageously rubbed night and morning with the warm bal- tions to the sams or resins dissolved in spirits : and the common restorative pro-spine cess of air, exercise, friction, and tonic medicines should at the same time be had recourse to, and persevered in for many weeks or even months without remission. SPECIES III. COLICA CIBARIA. SURFEIT. THE PAIN ACCOMPANIED WITH NAUSEA, HEAD-ACHE, AND DIZZI- NESS, BEFORE VOMITING ; AND AFTERWARDS TERMINATING IN A GRIPING LOOSENESS. I have already had occasion to remark, that the stomach is one Gen. VI. of the most capricious organs of the entire system : and hence we ^Juses. often find persons in an unsuspected state of health complaining that even the ordinary meal to which they are accustomed, sits upon it with a less degree of comfort and satisfaction than usual. And it is hence not at all to be wondered at that, when the stomach ^rf^"se is overloaded with plain food, and still more with high seasoned dishes and heady malt liquors and wines, the pain and sickness of colic should ensue, and that those organs which are in closest sympathy with the stomach, and particularly the head, should par- ticipate in the affection. The same effect is not unfrequently produced by swallowing the ™^{^a husks, stones, or kernels of fruit with the fruit that is eaten, all or kernels which the stomach may at the time, or perhaps at all times, be in- of fruits' capable of digesting, and some of which have in a few instances remained so long as to germinate before their rejection; examples of which are given in the author's volume of Nosology. * Medical Transactions, vol. H. p. 36. Vol. I.—22 1?U (.x.i.J CG4LIACA. Lord. j. Gen. VI. Spec. III. Colica ci- baria. Surfeit Incongru- ous food in early infan- cy. The food itself com- bined with mine dele- terious principle. Sometimes septic, sometimes narcotic and acrid. Symptoms of the two sometimes combined. When the stomach of the new-born infant is tilled with any other food than its mother's first flow of milk, which is purgative and re- moves the viscid meconium with which the alimentary canal is gorged, tormenting pains of a like kind follow : for the feeble ac- tion of this canal is incapable of moving this tenacious material downward ; and hence the stomach is overloaded, or the food be- comes acrimonious by retardation. And if much air be extricated, the infant is overpowered with flatulency ; and the present species becomen connected with the ensuing, and exhibits the oppressive distention of wind-colic. These are the common causes of the species before us, which is cha- racterized by a greater or less intensity of the symptoms enumerated in the definition. But we often find it also originating after meals from causes that are more obscure, and with various other symp- toms of a still more violent and distressing nature, as though the food itself had proved poisonous, or some poisonous substance had been intermixed with it. These additional symptoms are of two kinds: in the one, we meet with an intolerable sense of suffocation, the throat constricted, the face and eyes swollen, inextinguishable thirst, a burning heat all over the body, a quick small pulse, an in- tolerable itching or pricking in the skin, and an efflorescence on the surface, sometimes in the form of minute red millet-seed papula?, sometimes in that of weals ; twitching of the tendons, and a pecu- liar kind of delirium ; the cuticle peeling off on the subsidence of the attack : the whole evincing great malignity of action, as though the cause were of a septic nature. Under the other set of symp- toms, in addition to those noticed in the definition, we meet with great anxiety and difficulty of breathing, dejection of the spirits, spasms in the limbs as well as in the abdominal organs and muscles, tenesmus, coldness of the extremities, loss of sight and hearing, convulsions or coma: the whole evincing great exhaustion of the nervous energy, as though the cause united an acrid with a narcotic principle. The symptoms, however, vary considerably according to the ge- neral nature of the constitution. For the most part they are suffi- ciently distinct, but in many persons they are strangely united: and the lethargy, tenesmus, or coldness of the extremities, are combined with the cutaneous eruption. And hence esculent colic may be justly contemplated as ramifying into the three following varieties : u. Crapulosa. Common Surfeit. p Efllorescens. Eruptive Surfeit. y Comatosa. Comatose Surfeit. The symptoms indicating an over- loaded stomach, and usually ceasing on the evacuation of its contents. The symptoms evincing a highly malignant acrimony, the skin covered with an efflorescence. The symptoms evincing great ner- vous irritation, with a rapid ex haustion of the sensibilitv. ■ l. i-J DIGESTIVE II NOTION. |ori>. i. 171 In the first or simple form of the disease the violence of the Gen. VI. symptoms generally works it cure. But if the nausea should exist f t\ dbalfri without vomiting, a simple emetic of ipecacuan should be given to c«poiosa. excite the stomach to a more perfect inversion of its action, which surfeit.0" should be followed the next morning by a brisk purgative. In the Treil,roent- colic of new-born infants from viscid meconium, the purgative alone will be sufficient, and the best medicine for this purpose is castor oil, which, at the same time that it stimulates the alvine canal, in- sinuates itself more easily than most other cathartics between the obstructive slime and the mucous tunic of the intestine. If the congestion should proceed from an enfeebled state of the stomach, and too long a retention of the food in its cavity, it will be afterwards requisite to put the patiei:t on a course of stomachic or general tonics, of which we have taken a sufficient survey in the preceding description of dyspepsy. It is possible that the second variety may occasionally proceed 0£■ «>>>>*"* from a morbid irritability of the stomach operating upon a tolerably scena. full meal of the most bland and innocuous viands : but it more ge- J^."^*8 nerally proceeds from animal foods of a particular description, or Causes. eaten under particular circumstances, as comatose surfeit does from poisonous vegetables intermixed with common food. The animal Deleterious ,, Li-n -i i-ii animal sul>- substances that chiefly operate in the manner above described, pro- stances. ducing a dreadful feeling of suffocation, swelling of the face and eyes, intolerable thirst, a burning heat on the surface, pricking or itching on the skin, succeeded by an eruption of some kind or other, and accompanied with the specific symptoms of griping pain, ver- tigo, and vomiting—are shell fishes, and fishes of a few other kinds, as muscles, which are perhaps the most frequent of all causes, some species of scallops and other coarse ostraceous worms, the land-crab (cancer mricola,) lobster (c. gammarus,) conger eel (muraena ma- jor subolivacea of La Cep6de,) gray-snapper (coracinusykycu* ma- jor,) and yellow-billed sprat (clupea Thryssm Lin.,) the baracuta, the king-fish, and several other species or varieties of schomber, as the bottle-nose and ambar, the smooth-bottle-fish (ostracion gla- bellum,) and the rock-fish (perca marina of Catesby.) There are also many others, but these are sufficient as specimens. As all these are among the edible productions of the ocean, and J["cd^m2tJj" hence are eaten very generally as nutritious foods, it is a question of cos they great importance, and which is yet open to discussion, what are the fiofthe circumstances in which they occasionally disagree with the stomach stomach. and produce the above symptoms ? It has been supposed by many pathologists, that the mischief is occasioned by some poisonous property being conveyed into the body of the fish in the form of food : by others, that it is the result of a change taking place in its general frame by the approach of the spawning season or some other period of life, or in consequence of its removal into a different climate : and by others again, that it de- pends altogether upon the idiosyncrasy or peculiar state of the con- stitution, or of the digestive organs of the persons that are thus a!" fefd. 172 cl. i.] «'(ELIACA. |ord. i. Gen. VI. jt jg not necessary to inquire which of these opinions is best sup- fi c. ciba'- ported, because each of them can appeal to so many facts in their na efflore fav0ur, as to prove very clearly that there is a foundation for the Eruptive whole of them in different cases, and, consequently, that sometimes Aiiule tne cause is of one kind'and sometimes of another. above That many of the animals which prove thus noxious have derived operate in their mischievous quality from some poisonous mineral, vegetable, stance"1'" or animalcule on which they have fed, seems probable from the Exotic poi- well-known fact, that many of the most harmless and easily digesti- ducernnto ble species, if eaten without being disentrailed, grievously disorder t,'ej!to'nacn the stomach, and occasion many of the symptoms above noticed ; that dis- while even the baracuta, which is ordinarily one of the most delete- 85rce• rious in its effects when eaten whole, becomes bland and innocuous to most persons when thoroughly cleaned, gutted, and salted. There is also, in many cases of the disorder hereby produced, a strong me- tallic and especially a coppery taste in the offending substance when rejected into the mouth, and which continues to affect the fauces for a long time afterwards. M. Orfila has accurately noticed this last symptom in several of the cases he has enumerated; and espe- cially in an example of this disorder originating in a mixed company of whites and blacks, who had fed on the conger eel, in the island of Grenada, in April 1791. "The negroes," says he, " suffered more than the whites; they all experienced a coppery taste in the mouth, and a sensation in the esophagus, as if it were excoriated."* Why not ft js jn vain to urge that what is thus poisonous to man must such fishes have been at least as noxious to the animals that fed upon it: for themselves. p0ison js a relative term, and it is highly probable that there is scarcely a vegetable or mineral substance but may be eaten, I do not say harmlessly, but even as a safe and nutritious food by animals of some kind, however destructive to others. The land-c«ab is well known to feed on the manchineel tree (hippomane Mancinella) ; the loxia or gross-beak of the Bahamas on the fruit of the amvris toxi- fera, or poison-ash ; partridges on the leaves, and bees on the flow- ers of the kalmia latifolia, which are death to sheep, to horned-cattle and to man. So the cicuta virosa, or long-leaved water-hemlock, the most virulent plant that grows spontaneously in England, though fortunately not very common to our pastures, is fatal to cows, while sheep and horses eat it with impunity, and goats devour it with greediness ; a fact well known, nearly two thousand years ago, to the first naturalist of ancient Rome, and thus fullv described in his poem, De Rerum Natura : —Videre licet pinguescere sxpe cicdta Barbigeras pecudes, homini qu;e est acre venerium. 1 On the contrary, while horses feed with avidity and thrive to fatness on the agrestis arundinacea, or reed bent-grass, Linneus, as he tells us in his Travels in Shane, found a number of goats perishing in an island in which this was the chief herbage. * Traite sur les Poisons, &«. Tom. n. f> 1006. t Lib. v. 397. cl. i.] DIGESTIVE FUNCTION. [ord. i. 173 This interesting subject is pursued with great spirit, and high ad- Gen. VI. vantage to the most important purposes of practical husbandry, in f c^i'tilL' several articles published in the Swedish Amoenitates Academicae ; efflorescens. which give us tables of the best and most agreeable foods for cattle surfe?t.ve and other domestic animals, deduced from an exercise of that won- S"J^ derful instinctive power of selection, which enables them to discern with great and to crop those that are a nutritious food for their own species, tariousy and to reject the rest. By one of these tables it appears, that, of s^0^'^. four hundred and ninety-four species of indigenous plants of Sweden, Lts!° three-fourths of them are common to our own country, which were ^°reSu?"B offered to horned cattle, two hundred and seventy-six were eaten, and the rest refused; that goats, out of four hundred and forty-nine species, rejected a hundred and twenty-six ; sheep, of three hundred and eighty-seven, would not touch a hundred and forty-one ; horses turned away from two hundred and twelve out of two hundred and sixty-two; and swine, out of two hundred and forty-three made choice of only seventy-two.* In another volume of the same inte- resting work, we have a like series of experiments on a great diver- sity of insects and worms, with a view of ascertaining how many of them are devoured or rejected by our common poultry ;f to which, however, I can only refer, and must leave the reader to consult it at his leisure. It is hence perfectly clear, that no argument against the existence of esculents in the interior of animals, deleterious to the health of man, can be drawn from the position that such esculents must also prove noxious to the animals that feed on them. I am given to understand, that even coppering the bottom of ves- Copper- sels is no security against their being incrusted with serpulas and si°^0™d° other minute testaceous worms, which appear to feed harmlessly on up°" 1?arnv the copper as it becomes decomposed, and perhaps assist in the de- Eea-worms. composition itself. It is not unlikely that some of these may, in their turn, become food to several of the edible fishes and worms before us, and that the coppery taste so common to many of them may occasionally be derived from this source. Yet the general whether origin of a metallic principle in the structure of animals and even principles of vegetables, is among the deepest arcana of nature, and perhaps ^jy""""" will always remain so. And before we attempt to account for the tuined in presence of copper, in an oxyde state in shell-fishes, or what is more generally singular that of gold in metallic streaks in oriental bezoards, it will from ,his ~ . sourc*?. become us to unfold the process by which iron obtains an existence in the blood of our own kind, and this too in an equal proportion, under circumstances of like health, over all the world, whatever the nature of the soil that forms the seat of habitation. It is, at the same time well known, that a considerable change |ome fishes takes place in the taste and nutritive qualities of many species of from season fishes, at various seasons and periods of life, by which they are di- j0;^8"011 of vested of their nutritive power, and are rendered far less easily digest- ible ; and, which consequently lays a foundation for various affec- * Vol. ii. Art. 25. Pan Suevicus. Resp. N. L. Hesselgren. 1749. t Vol. vm. Art. 16S. Esca avium domesticarurn. Resp. P. Holmberger, 1774. 174 cl. i.J CCELIACA. [ord. i. Gen. VI. tions of the stomach. This is particularly the case with the more ft\ci*baria luscious or oily kinds ; as the herring, mackarel, eel, and salmon, efflorescens. an vvhich are unwholesome, if not pernicious when out of season. surfeit.*0 We may also reasonably conclude that climate has a considerable Examples. influence upon them, since the most pernicious species are those that e?.ist in the intertropical seas. The disease Jt is, however, equally certain that the disorder before us is, pemfent" in many instances, rather dependent upon idiosyncrasy or a peculiar upon idio- con(Jitioii of the stomach at the time, than upon any quality essen- or a tempo- tially noxious in the fish itself: for out of twelve or more persons ofUifsto- dining together from the same diet, we often find only a single indi- mach. vidual affected with the disease before us, while all the rest not only escape, but have made a nutritious and a healthy meal. Even in the same family we occasionally meet with almost as many distinct idiosyncrasies in this respect as there are individuals. Of three sis- ters, M. Orfila tells us, that one was incapable of eating muscles, at any time, without great disorder of the system at large, as well as of the stomach ; that the second experienced a like effect from her- rings : and the third, from feeding on strawberries. And hence many pathologists have been induced to ascribe every case of colic, from the variety of surfeit before us, to idiosyncrasy alone. But the frequent examples we meet with of the affection extending through every individual of a large party that has fed on the same food, forbid us to limit our ascription of the disease to this cause only, and com- pel us to unite it with those we have already considered. Principles i'ne principles of cure are of easier comprehension than the etio- Emetics logy. The peccant matter must first be discharged from the sto- mach by an emetic of rapid action, as about half a scruple of white vitriol; shortly after which, the lower belly should be stimulated to a like discharge, so that as little of the material as possible that disa- grees with the digestive organs may remain in them. The history of the symptoms shows us that the living power is rapidly, prodi- giously, and sometimes alarmingly exhausted, whence indeed the tremors, sense of suffocation, faintness, sinking of the pulse, and general depression of strength ; as also the swellings that take place through every organ where the cellular substance exists in consider- able abundance : for, in consequence of this exhaustion, the ab- sorbents, whose action ordinarily closes sooner than that of the secernents, are incapable of carrying off the fluid which is secreted in these parts, and an extensive suffusion takes place of necessity. •timuVa'n'ts It is hence highly important to rouse the system with all speed, by and cordial means of the most diffusible stimulants, and warmest cordials and tomes. tonics, which may be commenced as soon as the stomach has been evacuated: the most useful of which are sulphuric ether, capsicum, and vinegar diluted with water, sweetened and drunk in abundance. The acids obtained by fermentation answer better in this case than any others, because they possess more of an alcoholic principle. beuemin10 And lt is ^ srtiking to notice the almost miraculous power which some cases is sometimes exhibited by this cordial plan of attack. Upon the administration of a single strong dose of ether, the patient, appa- rently in the act of expiring, ha« in various cases felt all his svmn- and cathar- tics. cl. i.J DIGESTIVE FUNCTION. [ord. i. 175 toms vanish in a very few minutes as by enchantment ;* the pains Gen. VI, have ceased ; the absorbents, and indeed every other set of organs, f o?eib!rii recovered their wonted energy ; the general intumescence has sub- efflo'res- sided, and the nettle or other rash disappeared. If, however, the Eruptive system have been shaken more deeply, and the symptoms do notsurfeit- yield with much readiness, the tonic plan must be persevered in for many days or even weeks. The third variety is usually produced by pernicious vegetables, v °- eirmia instead of animals, that have been taken for food, or along with Comatose food : or esculent vegetables that disagree with the stomach as in cu0r^m'onIy the preceding variety, from a morbid state of this organ, or from a from noxi- peculiarity of constitution. I have already observed that the symp- im1^c' toms in this modification of the disease, evince great nervous irrita- Symptoms. tion with a rapid exhaustion of the sensibility. There is severe spasmodic pain in the intestinal canal, with cramp, spasms, or con- vulsions, extending over the system more or less generally, accom- panied with or succeeded by a lethargic drowsiness, from which it is often difficult to rouse the patient; and from which, also, when roused, he instantly relapses into convulsive agitations: evidently proving that an acrid and a narcotic principle are combined in the unsuspected cause. This cause is usually mushrooms or rather Fungi the deleterious funguses that have been mistaken for the genuine edible mon cause. mushroom, or agaricus esculentus. The agaric is so extensive a genus, and many of its species to an unpractised eye have so near a resemblance to each other, that it cannot be wondered at that such a mistake has been committed: though perhaps the plants that through such an error have been most frequently gathered are, the bulbous agaric, the Medusa's head, the raven's eye, the hemlock- mushropm, and the agaricus muscarius. It is possible, indeed, that sometimes even the genuine mushroom itself may prove deleterious to some mushroom idiosyncrasies, or to some stomachs in a morbid state of constitution; ltsslf a but then the mischief is in almost every instance confined to an indi- vidual alone, the rest of the company eating of the same dish with satisfaction and pleasure. As there is no critical mark to determine at once between poison- cautions in ous and salutary mushrooms, we may lay it down as a general rule, mushrooms. that those should be suspected and avoided that grow in moi6t and marshy grounds, and especially in the shade; that have a dirty look- ing surface, and whose gills are soft, moist, and porous. For the most part the smell of these is virulent, and they are covered with a calyptre or veil. There are, however, a considerable number of other vegetables °{Jier vege- that prodace a like effect when taken by accident for food, or along fungous*" with food; as the cicuta virosa or water-hemlock, the leaves ofplanls- which have been mistaken for smallage, and the tap-roots for pars- nips ; the asthusa cynapium or fool's parsley, which has been culled for common parsley; and the secale cornutum or spurred rye. The last is productive of very serious evils in different forms, and we shall hence have occasion to return to it when describing erythematic " Orfila, Tom. iv. fc 1008. Dulong, Gazette de Sante, Oct. 1, 1812. 176 cl. i.] CCELIACA. [okd. i. Gen. VI. Spec. III. y C. cibaria comutosa. Comatose surfeit. Dishes cooked in copper vessels- Medical treatment. pestis, and mildew-mortification, both which also result from its use. Rye becomes spurred or horned in the shape of its ear, apparently from having numerous punctures made by different insects in the fresh pullulating grains of the glume as a nidus for their minute eggs, in the same manner as the nut-weevil (curculio nucis) pierces the young and tender nut of the hazel for the same purpose. And as the effects produced by the grain thus diseased are very different in different seasons or climates, we have reason to believe that its juices are themselves rendered noxious in a different manner according to the species of insect that makes the attack. It is also said that the common garden rue (ruta graveolens), when eaten to excess, is suc- ceeded by the same symptoms of ventricular pains, spasmodic action and coma, though in a less degree: but I have never seen any such mischievous consequences, and have reason to think that they have been much overrated. Most of these symptoms are also produced by feeding on soups* or other dishes, that have been cooked in copper vessels containing verdigris. We have the same violent gripings and muscular com- motions, excited by the acid quality of the plant just noticed, and in almost all instances ache and confusion in the head, and sometimes coma, though the last seems rather to be the result of a determina- tion of blood to this organ by the violence of the vomiting. In all these cases, however, we can easily detect the nature of the poison, by the intolerable coppery taste in the mouth, and the green or greenish-yellow colour of the matter rejected from the stomach. The cure, as in the preceding variety, must be promoted by evacuating, in the first instance, the poisonous principle, as largely as possible from the stomach. Where the local irritation is great, demulcent mucilages should succeed: or soap where the effect has been produced by salts of copper. After which, if there be much general convulsion or other irritation of the nervous system, it must be allayed by opiates. SPECIES IV. COLICA FLATULENTA. WIND-COLIC. PAIN ACUTE, EXTENDING TO THE PIT OF THE STOMACH, OFTEN IM- PEDING RESPIRATION ; ACCOMPANIED WITH GREAT FULNESS AND FLATULENCY: AND RELIEVED BY PRESSURE, BENDING THE BODY FORWARD, OR EXPULSION OF WIND. Gen. VI. This species is produced by crude and flatulent fruits, and whatever o"£. lowe.rs the tone of the alimentary canal; as too long fasting, fear, or grief, and all the causes of dyspepsy, with which it is often compli- cated, and to which the reader may turn. I ike dyspepsy, indeed, it >ecms to depend upon local debility, whose seat is in the small intes- cl. i.J DIGESTIVE FUNCTION. [ord. i. 177 tines, and consequently in the direct neighbourhood of the stomach. Gen. VI. It is often accompanied with great costiveness from the spasmodic coiica'flj" action which runs, in a larger or less degree, through the whole of "j!.e"}a- . the intestinal canal, and considerably adds to the torture, and in- creases the tumefaction and tenseness of the abdomen ; which are sometimes so extensive as to resemble emphysema abdominis or tympany. The last symptom is peculiarly striking and oppressive in persons of an hysteric diathesis, who are attacked with this complaint from very slight causes ; and with whom it is often combined with syn- cope, or clonic spasms of various kinds. In attending to the means of cure, we may here proceed at once Medical with some degree of boldness ; since, notwithstanding the violence of the pain, it is not often that inflammation is to be apprehended, at least in the commencement of the disease : and hence the warm- est carminatives, and even alcohol may be had recourse to: for whatever will carry off the flatulency, will carry off the pain and cos- tiveness. Hence a spoonful of brandy, or, which is better, a dose of tincture of rhubarb, volatile alkali, infusions of herbs containing essential oils, as mint, pepper-mint, penny-royal, are generally con- soling and salutary. For the same reason, the aromatic spices may be had recourse to with success, and particularly in connexion with opiates. Of the spices, the nutmeg, on account of its greater vola- tility than most others', and especially on account of its established reputation for producing quietism and even sleep, as I have already had occasion to observe when treating of dyspepsy, has a peculiar claim to attention. The only disadvantage of opium is, that it has a tendency to di- Opium how minish the intestinal, and indeed all the secretions, excepting that of sweat: and on this account it has been objected to by many phy- sicians : but, from its power of allaying spasmodic irritation, and consequently of producing ease, it becomes of so much importance, that it ought unquestionably to be called into use : and there are cases in which, from this very power alone, it may indirectly act the part of an aperient. The opiate confection, as combining an aromatic with a narcotic principle, is a highly valuable as well as an elegant preparation. And after the pain has subsided, an active purgative according to the course recommended by Dr. Cullen* may be administered with great advantage. Opium may also be given in the form of an injection : but in this case the injection should not exceed five or six ounces, for other- wise it will probably be thrown back. And it will be often of great use to unite with the narcotic a pretty free dose of turpentine, or some of the warmer balsams, especially that of copaiba ; as it will be also to apply rubefacients to the epigastric region. The convalescent treatment may be the same as already recom- mended under dyspepsia. * Mat. Med. Vol. n. p. 219. V'.L. 1.—Z-! 178 cl. 1.1 (XELIACA. [ord. i, SPECIES V. COLICA CONSTIPATA. CONSTIPATIVE COLIC. THE GRIPING PAIN SEVERE ; THE COSTIVENESS OBSTINATE ; GREAT TENSION, WITH LITTLE FLATULENCY : THE VOMITING SOMETIMES ACC03IFANIED WITH FECES; THE COSTIVENESS WITH BLOODY STRAININGS ; TERMINATING, WHERE NOT FATAL, IN A. FREE DE- JECTION OF THE INFARCTED MATTER. Gen. VI. The pain is here produced by indurated meconium, or feces, or Spec V. other intestinal concretions, and especially those which are known by the name of bezoards, and will be hereafter described under the genus Enteroliths : and we hence obtain the following varie- ties : ce Meconialis. From viscid meconium. Colic of new-born infants. & Faecosa. From indurated feces Stercoraceous Colic. y Enterolithica. From bezoards, and other intes- Stony Colic. tinal concretions. Two first The first two of these varieties are the result of a superabundant dependent action of the intestinal absorbents^ or of a deficiency in the peris- on the state taltic power of the intestinal tube ; in consequence of which, from theTntesti- the length of time the confined materials occupy in completing their enLabs°rb descent, the meconium in infants becomes so viscid as not to be urged downwards, and remains in the intestines till it grows acrid from acidity or putrescency : and the feces of later life, exhausted of moisture, harden into one solid mass, possessing the figure of the intestine ; or, separating into smaller pieces, appear, when dis- charged, in the shape of balls or buttons, often as hard as sun-burnt clay, and have been called, though not quite accurately, scybala ; yet sometimes they make a near approach to this substance, and consist of masses of indurated feces combined with a certain portion of mucus or oleaginous matter secreted into the intestines, and pro- ducing a cetaceous or soapy feel. ofthird'6 ^ ^e stonv variety, the following is an extraordinary example variety. related by Dr. Kbnig, of Bern, and inserted in the Philosophical Transactions.* A young woman of twenty-five years of age, by name Margaret Lawer, after an anomalous and general disorder, discharged continually the contents of the intestines, and even the clysters that were injected, by the mouth, and at length a number of stones as hard as flint, some in fragments, some of the size of !>eas. others of that of filberts. A clashing of stones against each f Phil. Tran« Yesiv 16SB. cl. i.] DIGESTIVE FUNCTION. [oi»>. r. 17J) other was felt by pressing the hand upon the abdomen : there was Gen. VI. great constipation, severe gripings, and dysury ; and the urine, when coficacoV- voided, was often loaded with gravelly matter. The aliment and jjjj"11"- injections being constantly returned by the mouth, Dr. Konig de- tive cX*. sisted for four months from offering her either meat, drink, or medi- cine of any kind, excepting occasionally a spoonful of oil of almonds. Blood was now and then vomited from the violence of the spasmodic action of the stomach; and frequently urine to the amount of three or four ounces at a time, of a strong taste and smell. The disease seems to have lasted with remissions from January 1681 to Febru- ary 1683, at which period the history is abruptly dropped, though the patient seems to have been in a state of recovery. It was pre- ceded by the appearance of vesicular eruptions on the skin, and was probably produced by their repulsion. The chemical examination of the calculi is loose and unsatisfactory. The oleaginous purgatives, soap injections, and mucilaginous Processor' diluents, to diminish the irritation of the intestinal absorbents, will cuie' here be found most successful. Small doses of neutral salts, sul- phur, and acidulated drinks, may also be of service in promoting the latter intention. If the griping be severe and the case urgent, tere- binthinate injections, in the last two varieties, will also be highly expedient, and not unfrequently produce speedy relief. In these cases, the injections should be copious, so that the fluid may readily insinuate itself between the imprisoned matter and the coats of the intestines: and the turpentine should not be less than from half an ounce to an ounce, diligently triturated with yolk of egg, so as to be perfectly diffused and suspended in the menstruum. " Thus prepared, we have found it," says Dr. Cullen, "to be one of the most certain laxatives that can be employed in colics and other easels of obstinate costiveness."* SPECIES VI. COLICA CONSTRICTA. CONSTRICTIVE COLIC. A SENSE OF STRICTURE IN SOME PART OF THE INTESTINAL CANAL : OFTEN OF FLATULENCY, GRADUALLY PASSING OFF BY THE STRIC- TURE ; THE BOWELS TARDY ; DISCHARGING WITH DIFFICULTY SMALL LIQUID STOOLS. This species bears a near approach to proctica callosa, or the Gen. VI. callous contraction of the rectum ; which last, however, as accom- h^jJ1' panied with less griping and flatulency, and consequently having tinguished^ less of the character of colic, and more particularly from its being in /acafiosaT most cases within the reach of manual examination and surgical aid, * Mat. Med. Vol. ir. p. 181. 180 cl. i.J (XELIACA. joku. i. Gen. VI. an(j capable of assistance by a different mode of treatment, is entitled Spec VI • -i • Colica'con-to a distinct consideration. Btricta. The proximate cause of the disease before us is a permanent stric- tive c'otic. ture existing in some part of the intestinal canal beyond the reach of c'ausemate tne nr)geri from callosity, scirrhosity, a ring of tubercles or caruncles, or whatever else has a tendency to thicken its coat and diminish its diameter. A proof of this morbid state of the intestine is discover- able during life from the feces being never discharged excepting in a ordinary liquid state, or, if figured, of an extremely slender calibre. After stricture, death the stricture has frequently been traced by dissection, and ac- cording to M. Gauteron, from whom M. de Sauvages and Dr. Cul- len have successively drawn their statements, has been most com- monly discovered in the colon. Other cases are given by Bonet, Wahrendorff, and Morgagni; in some of which it was found, on a post-obit examination, to exist in the rectum ; the coats of which in one instance had coalesced. Haguenot relates a case in which it terminated in an intestinal hernia. These parts, highly sensible in a state of health, are peculiarly irri- table from the diseased action, and the specific symptoms are the consequence of irritation produced by the mechanical pressure of the feces ; and often by acrimony from their retention. In most cases the stricture lies beyond the reach of topical applications. It is Remedial generally a hopeless, but happily a very unfrequent affection. The process. cjcuta jjas, Qf iate^ \>een chiefly trusted to in conjunction with the mercurial pill. But I am not aware that in any case these have proved decidedly advantageous. The spasmodic attacks must be encoun- tered by the remedies already recommended in spasmodic and flatu- lent colic : and the habitual uneasiness felt in the intervals will be best alleviated by a rigid attention to a light, liquid, and aperient diet. Unfrequent as this disease is in general practice, I happen to have at this time two patients labouring under it : one a lady of about thirty-five years of age, who has been subject to it for ten years, and is incapable of passing feces more voluminous than those of an in- fant ; and the other, a man of forty-nine years old, who has laboured under the disease for twenty-one years, and can never pass a motion larger than a crow-quill. Yet, by strict attention to diet, both are able to exist with only occasional inconvenience and pain ; the last married about two years since, and his wife has lately brought him twins. He lives upon liquids altogether. ct. i.J DIGESTIVE FUNCTION. |ord. i. 181 GENUS VII. COPROSTASIS. COSTIVENESS. OBSTINATE RETENTION OF THE FECES IN THE INTESTINES. The generic character is expressed in the generic name, which is Gex. VII. a compound term importing emansion or retention of feces—xo- 7rgoc-Tet. 1. Gen. VII. Ooprostc.- sis. Costive- ness. May be- come a cause of colic and flatulency, but when simple, merely trouble- fourth year, he had only one evacuation every eight or ten days. which interval was afterwards increased to twelve. At thirty, when M. Thomassini saw him, his intervals were extended to twenty-two days. No regimen or medicinal process had produced any benefit. Purgatives, indeed, operated, but occasioned such debility that they could not be persisted in. The heat was natural but the pulse fre- quent.* Hence costiveness is not necessarily connected with colic or flatu- lency, or any other severe pains ; though, as already observed, under particular circumstances it may become a cause of all these. In its simple and constitutional form it is, indeed, rather a troublesome than a violent or dangerous complaint, and may proceed from two very distinct sources ; and as each of these possesses symptoms of its own, and is considerably discrepant from the other, we are ena- bled with ease to contemplate the genus under the two following species : 1. COPROSTASIS CONSTIPATA. 0,----------OBS TI PAT A. CONSTIPATION. OBSTIPATION. SPECIES I. COPROSTASIS CONSTIPATA. CONSTIPATION. THE FECES WHEN DISCHARGED CONGESTIVE AND VOLtTMINGt'S ; THE TEMPERAMENT FIRM AND RIGID. Gen. VII. Spec. I. Occasional causes. In persons of a compact and robust habit, with hearty appetite and strong digestive powers, the intestinal absorbents occasionally evince^an excess of action ; and the feces, while they become har- dened ui consequence of such action, assume, from their copiousness, the figure and volume of the large intestines through which they pa*s. The increased action of the absorbents, which is the common proximate cause of the present species, may be produced by violent exercise, which heats the blood and throws off an excess of fluid in the form of perspiration from the surface ; by too stimulant a diet, particularly of rough port-wine, which, by exciting the sphincter of the rectum to an augmented action as well as the absorbents of the intestines, lays a double foundation for an accumulation of feces ; or by too small a proportion of fluids compared with the allowance of solid substance ; for in this case the recrement, too inspissated from the first, gradually becomes still more so by the severity with which it vellicates the mouths of the absorbents, and thus increases their activity. The same effect may also follow from too astringent a diet: as * Diet, des Sciences Medicales, Art. Cas. Rares. n.9tipa" cation highly serviceable, but it requires a steady and adroit hand B°us,,e em- for its proper direction.* p °ye ' In some instances of very great difficulty, and of an anomalous Affusion of kind, an affusion of cold water has been accompanied with great ^metimea8 success after every other device has completely failed, and oily, resi- Jj1^^^ nous, and mercurial cathartics, quicksilver in its metallic state, anti- monials of various kinds, and injections of every sort, have been tried in vain. Two striking examples of this occur in a letter from Dr. Spence of Guildford to Dr. Reynolds, published in the Medical Transactions of the College. The patients were from fifty to sixty years of age, the one of temperate habits, the other addicted to spirit- uous liquors. As a last resort, they were led into a washhouse, laid on a cold, wet, brick-floor, and the water was dashed over the lower extremities and the pubes for a quarter of ah hour at a time. In addition to wliich, cold wet towels were applied to the abdomen of one of them in his bed. Cold water was also drunk at the same time by the mouth. Both patients recovered. SPECIES II. COPROSTASIS OBSTIPATA. OBSTIPATION. THE FECES, WHEN DISCHARGED, HARD, SLENDER, AND OFTEN SCYBA- LOUS ; THE TEMPERAMENT WEAKLY, OR THE HABIT SEDENTARY. This is in most cases the result of a sluggishness of the peristaltic Gen. Vft. motion, in persons of infirm or delicate health : in consequence of §™' ^ which the refuse matter of the aliment, usually small in quantity, is a duced. long time passing through the intestinal tube, and hence becomes indurated, shrunk, and shrivelled, so to speak, by the length of time it is exposed to the power of the intestinal absorbents, notwithstand- ing they may have no such increased action as occurs in the prece- ding species. This form of costiveness is most frequently found in Most *?* persons of advanced life : in whom the feces, minute in quantity and advanced deprived of moisture, are sometimes discharged in the form of a scroll,llfe' and sometimes in small lumps, of the shape of buttons or balls, as I have already observed when treating of colica constipata; which affection also, as there remarked, is often produced by the irritation that these retarded materials at length excite. So feeble, indeed, is the expulsive power of the intestines in many cases of old age, that it is sometimes necessary, as recommended by Dr. Warren, to * Miscellaneous Works, edited by Ashby Smith, M.D. p. 285, Lond. 8vo. 1821. Vol. I—24 186 cl, i.] COELIACA. [OBD. I Gen. VII. Spec. II. Coprostasis obstipata. Obstipa- tion. Sometimes a contrary habit in advanced life. Remark of Celsus upon this discre-" pancy. Remedial treatment. introduce a sort of marrow-spoon up the rectum for the purpose of bringing away the dry masses that have lodged there. It sometimes happens, however, that a contrary temperament prevails in old age ; that the bowels are irritable, and the motions loose. Celsus has laid it down as a maxim, that when the bowels are loose in youth they commonly become confined in advanced life, and that if confined in youth, in advanced life they are often laxative. Quibus juvenibus fluxit alvus, plerumque in senectute contrahitur ; quibusin adolescentia fuit adstricta, saepe in senectute solvitur.* I cannot say that I have been able to confirm this position by my own observation or experience. In costiveness from this cause, our aperients must be derived from other materials than those recommended under the last species ; for here we have far less reason to be afraid of the warmer and aromatic purgatives. And hence, while we allow a freer use of wine, we may successfully have recourse to aloes, the compound pill of this name, and the balsam of copaiba. The analeptic pill of Dr. James, which combines a preparation of antimony with resinous purgatives, is often a very serviceable medi- cine ; as is also the form recommended by Dr. Parr, which consists of half a drachm of the gum pill, the same quantity of the pill of Rufus, with ten grains of antimonial powder, made into fifteen pills. GENUS VIII. DIARRHOEA. LAX. LOOSENESS. THE ALVINE EVACUATIONS CRUDE, LOOSE, AND TOO FREQUENT J WITH LITTLE OR NO GRIPING OR TENESMUS. Gen.viii. Of all the specific forms of this disease, the chief proximate cause, mate'eauso. as **■ is callet)' or the symptom that gives rise to all the other symp- toms, is an increased peristaltic action throughout the whole or a great part of the intestinal canal: and as this may be produced by various means and under different circumstances, it must often stamp a peculiarity in the character of the disorder, and lay a founda- tion for numerous species. Peristaltic^ The peristaltic action of the intestines may be increased, and, in°creased°W consequently, looseness or diarrhoea occasioned, firstly, by irritating materials thrown into them by the mouth ; secondly, by a morbid change in the fluids which are naturally secreted into the intestinal canal; and thirdly, by an irritable state of the intestines themselves or the membrane that lines their inner surface. Independently of * Meditfin. LVk i. iii. (L.I.] DIGESTIVE FUNCTION. [ord. i. 18? which, the same effect may follow, in a variety of ways, from the Gen.VIII. readiness with which the intestines associate in the action of remote Lax? a organs. Thus sudden passion or commotion of mind will frequently Looseness. excite looseness ; sudden cold or heat applied to the surface of the skin will do the same. So the fluid of dropsies, the morbific matter of exanthems, and even pus absorbed from other cavities, are not unfrequently by a transfer of action, thrown upon the intestines, stimulate them to an increased vermicular motion, and, consequently, produce looseness. But as all affections of this last kind are evi- often oo dently cases of mere sympathy, they must be excluded from the his- sympathy tory of diarrhoea considered as an idiopathic disease : and even in with other • i-ii i-i • organs: their treatment can only be remedied by remedying the primary com- plaint. Dr. Cullen, in his Nosology, has given them a very copious and lJenic^ admission, and, in his First Lines, a very extensive and elaborate to other consideration; but he has hereby deviated from one of the most im- dlseascs' portant rules with which he started, which was to exclude from his genera all the sympathetic species with which the pages of prece- ding nosologists are overloaded ; and has given intricacy instead of perspicuity to the subject. However numerous therefore the subdivisions of diarrhoea that are to be found in the writers upon this disease, who have not been sufficiently on their guard in drawing a line of limitation, those that really belong to it, as genuine and distinct species, may, I think, be resolved into the eight following. 1. DIARRHCEA FUSA. FECULENT LOOSENESS. 2.--------BILIOSA. BILIOUS LOOSENESS. 3.--------MUCOSA. MUCOUS LOOSENESS. 4. -------- CHYLOSA. CHYLOUS LOOSENESS. 5. .-------- LIENTERIA. LIENTERY. 6. -------- SEROSA. SEROUS LOOSENESS. 7.--------TUBULARIS. TUBULAR LOOSENESS. 8. -------- GYPSATA. GYPSEOUS LOOSENESS. SPECIES I. DIARRHCEA FUSA. FECULENT LOOSENESS. THE FECES OF GOMMON QUALITY, BUT IMMODERATELY LOOSE AND COPIOUS. This species generally works its own cure without the aid of Gen.VIII, medicine : for its common causes are food eaten to excess, or in- Co^Emc0'n' termixed with an undue proportion of irritating materials, saline, causes. saccharine, or vinous : in consequence of which they pass rapidly, and not thoroughly digested, from the stomach, and urge the intes- tines to an undue degree of activity. Hence often antecedently to 188 cl. i.J CCELIACA. JORD. 1. ge&.viii. Spec. I. Diarrhoea fusa. Feculent looseness. For the most part easily cured and often cures itself. Sometimes chronic and obstinate ; and then requires a cautious treatment. Examples of sympa- thetic ac- tion. the looseness, there is a sense of sickness, and perhaps a few slight torminal pains. But if the disorder do not prove its own re- medy, it is easily removed by any common purgative. In weakly stomachs, or where the intestines are sluggish, this mode of diar- rhoea is also occasionally produced by a retardation of the aliment, till it irritates from acescency, putrescency, or superabundant accu- mulation ; and where it is not checked in due time, it will occasion- ally, like several of its cognate species run into a chronic form and prove extremely troublesome and obstinate. In some cases it has lasted for two* and even for three years,! and it then requires to be restrained with caution ; for a sudden cure, and especially a sudden transfer to a state of costiveness, has often produced some severe complaint; and in one or two instances epilepsyj and phthisis.§ And the same remark may be applied to the diarrhoea that occurs during dentition, which ordinarily keeps off febrile irritation ; and, when violent, should be moderated but not subdued. This species is also produced occasionally by sudden exposure to cold, and especially by cold bathing ; by great agitation of mind, and particularly that of fright, or anger, sometimes even when those passions have merely existed in dreaming ;|| and occasionally also by the bare sight of a purgative or other medicine which the pa- tient is reluctant to swallow. All these are instances of sympa- thetic action, which has sometimes shown itself in perhaps a still more extraordinary way, where there has been a peculiar irritability of habit. Thus Borrichius relates a case in which it was,produced by introducing a globule of black hellebore into an issue in the arm ;1F Schrader another, where it was occasioned by using, as a collyrium, a solution of crocus metallorum,** which is a sulphuretted oxyde of antimony ; and our own countryman, Dr. Birch, a third, that fol- lowed upon washing the hands in water containing in solution a portion of some other preparation of antimony.ft SPECIES II. DIARRHCEA BILIOSA. BILIOUS LOOSENESS. THE FECES LOOSE, COPIOUS, AND OF A BRIGHT YELLOW . SfmVi?' Fe°M the higWy bilious tincture of the dejections, there can be Proximate' no doubt that the bile, in this species, is secreted in a greater quan- <%we. tity than usual, and perhaps with an unusual degree of pungency: and hence the excess of peristaltic activity. * Riedlin, Cent. iii. Obs. 96. t Forestus, Libr. xxii Obs . i. Ida crates, with more reason, employed for the same purpose emetics,* Gen.VIII. and has been followed by Fontaine and other practitioners; and If^^1, Malvachini, with the same view, recommended diuretics.! Dr. Lindj |Lerosa- and Dr. Adair§ have recommended the native carbonate of zinc, or looseness. officinal calamine in fine powder, apparently with a view of combining Ca,amme- an absorbent with a metallic tonic : and they speak of its having been employed with advantage. In a very obstinate case that fell to my lot a few years ago, in CamPhor i'ii. n piii. andresin- wnicn the patient, a young woman of twenty-four, had, for ten years, ous gums. never passed fewer than nine or ten watery stools a-day, sometimes tinged with blood, and often accompanied with great spasmodic pain, I found the disease yield in a few weeks to camphor mixture and pills of the resinous gums, after that, as I had reason to be- lieve, all the usual routine of astringent earths and salts, astringent purgatives and narcotics, had been tried and spent their force in vain. It is probable that in some cases of this kind the superacetate Superace- p i i • i p ■ i • i • i i pi tateoflead. of lead, in doses of a grain, combmed with three or tour drops of laudanum, might prove equally useful. This disease is also occasionally produced by drastic purges, as Sometimes ■*■ occurs by elaterium ; and is often critically employed by nature, as a metasta- metastasis- sis. to carry off dropsies and other remote accumulation of fluids. SPECIES VII. DIARRHCEA TUBULARIS. TUBULAR LOOSENESS. THE DEJECTIONS CONSISTING MORE OR LESS OF MEMBRANE-LIKE TUBES, WHITISH, VISCOUS, AND INODOROUS. I have never hitherto seen this species arranged, and not often ^n.VIIL described, but it occurs frequently in practice; and appears to de- Nefecr'hi. ' pend upon a peculiar irritability of the villous membrane of the JJ|j£ia£ larger intestines, which, in consequence, secrete an effusion of co- described. agulating fibrin, fibrin mixed with albumen, instead of secreting mucus, occasionally accompanied with some degree of chronic in- flammation. It has a striking resemblance to the fibrous exudation Ration thrown forth from the trachea in croup, but is usually discharged discharged in longer, firmer, and more compact tubes. There is commonly a ,n crouP- considerable sense of heat and uneasiness in the rectum ; and upon evacuations, the sphincter, partaking of the irritability, contracts so forcibly, that the feces are discharged with great pain and of very From the laminated appearance of this effusion, it has generally ?/£Xa„ been mistaken for a separation of the mucous membrane of the in- exfoliation membrane. * ntpv TLoBidv, Lib. in. p. 623. t Utiles Collectiones. t On Diseases in Hot Climate*. S Medical. Commentaries, &c. 19b' cl. 1.1 rcELlACA. [ord. i. Gen.VIII. Spec.VII. Diarrhoea tiibuiaris. Tubular looseness. Howdiffers. Illustrated. Other ex- amples. Discharge in most rases from the large intestines. The secre- tion some- times very abundant. testines; with which it seems to be confounded by Dr. Simson, of St. Andrews, in the Edinburgh Medical Essays ;* but the exudation has no vascular structure, will not bear extension, and loses its form as soon as handled. At the time of writing I have a case of this description under my care, in a lady of delicate habit, twenty- eight years of age, who has been long labouring under a peculiar irritability of the rectum, giving rise to some degree of chronic in- flammation, and a forcible contraction of the sphincter on evacua- tions. She has already discharged this kind of effusion for six weeks, and in tubes so perfect, as at first to have excited no small alarm in the attendants who noticed it. It is now, in some degree, on the decline both in quantity and tenacity. M. Bauer, in his letter to M. de Hahn,t gives similar examples; and a like case is described by Spindler, in which the secretion was worked up into a " materia alba, longa, compacta."J It has some- times assumed the exact shape of the intestine, as though it had cast off a tunic.§ I have said, that the discharge in this species proceeds chiefly from the large intestines: and I have seen it so often as to have had sufficient opportunity for determining with tolerable accuracy the part of the canal affected. From a valuable article, however, of Dr. Powell's, published in the Medical Transactions,,! it appears at times to take place in the narrower portion of the intestinal tube, as high up indeed, as the duodenum ; for we are told that it was accompanied with acute pain in the epigastric region; that the stomach was highly irritable ; and that it was followed by symptoms of jaundice or obstructed bile ; in which case the irritability of the intestine was most probably extended by continuous sympathy to the mouth of the ductus choledochus communis, which had become spasmodically closed. From a small increase in the pulse, and a coating on the tongue, there seems to have been here also a slight degree of inflamma- tory action, though so inconsiderable that Dr. Powell questions whether there was any whatever; but adds, which mf own expe- rience leads me most fully to confirm, that the disease is certainly not " dispjosed to assume that peculiar irritative quickness of pulse which marks enteritis." That the affection described by Dr. Powell belongs to the present species, will appear evident from his description of the material evacuated, which seemed " to have formed parts of an extensive adventitious membrane of no great tenacity or firmness. In the first of the cases," he adds, " which came under my notice, this membrane was passed in perfect tubes, some of them full half-a-yard in length ; and certainly sufficient in quantity to have lined the whole intestinal canal. In others also, the aggregate quantity has been very large, and it has continued to come away for many days, but it has been in thin irregular flakes, of not more than two inches extent, and not, as far as I could discover, of the perfect tubular form." * Vol. v. Part n. Art. lxvii. p. 153. t De Morb. Intest. Dresd. 1747. § Act. Nat. Cur. Vol. v. Obs. 126. I Obs. 45. |l Vol. vr. Art. vii. cl. i.J DIGESTIVE FUNCTION. [ord. i. 197 And he afterwards compares the membranous material thus ex- Gen VIII. creted to that " formed in the trachea, under croup; but the symp- nf^'J"' toms," says he, u are there more violent and destructive from locality tuuuiaris. /•-..- ,, Tubular of situation. looseness. From the acute degree of pain, which the disease thus situated ll?s been produced, and must necessarily produce in the smaller intestines, as "0r choioii- also from the spasmodic, constriction of the bile ducts, and the com- tbus- mon symptoms of jaundice, the passage of gali-stonts was at first suspected, till the character of the intestinal discharge spoke for itself. From a like effusion of fibrin in th<; uterus, Biuinenbach has ■)Iike se- shown, that a tunica decidua has been occasionally produced occurred in through the excitement of an aphrodisiac passion alone, withouttUe uterus- copulation or impregnation ;* and Morgagni has given examples of so perfect a formation of the same membrane by the irritation that takes place in painful menstruation (paramenia dijpcilis,) as to ren- der it difficult to be distinguished from that belonging to an ovum.t So corpora lutea have been formed, and their cicatrices occasionally found, in the ovaries of virgins. The milder preparations of mercury employed as alterants rather Medical than aperients, have frequently proved serviceable ; and the balsam Alterants' of copaiba still more so. The last is indeed generally useful in a "Oip^bnaiof chronic inflammation or irritable condition of the secernents of mu- cous membranes; and in the disease before us, where 1 have not been able to induce the patient to take it by the mouth, I have re- commended it in the form of injections. In one case in which I prescribed it in this form, three drachms intermixed with three ounces of mucilage of linseed, being thrown up three times a-day, it proved eminently useful. . Common emollient injections, moreover, employed in much larger Copious quantities, where the sphincter will allow the pipe to pass up, afford felons. temporary ease : and a diluent and anodyne injection of warm water 4 and laudanum alone, repeated twice a day, still more so. For the water is absorbed by the hot villous tunic of the intestine very rapidly, which is hereby rendered lax and inflexible, while the muscular fibres associate in the change. " 1 have known," says Dr. Cullen, " two pounds of water absorbed from the rectum in the space of an hour." In the meanwhile, the mercurial preparations just adverted to, and especially the blue pill, or Plummer's, which is still better pjumpiil\°r (the pil. hydrarg. submur. comp. of the London College), should be taken in a dose of four or five grains every night: and, if neces- sary, the bowels be kept open by two drachms of sublimed sulphur dailv. * Comment. Soc. Reg. Scientise Gotting. Vol. ix. t De Sed. et Cans. Moib. Ep. xlviu. 12. 198 cl. i.J CGELIACA. [ord. 1. SPECIES VIII. DIARRHCEA GYPSATA. GYPSEOUS LOOSENESS. Gen.VIII. Sp. VIII. Compared with the two pre- ceding species. Calcareous earths formed or secreted by all animals. In man for various purposes. Hence often secreted morbidly, and pro* during many dis- eases. Its combi- nations in the intesti- nal tube. In the pre- sent species diffuse and UHCO11- bined. Described by Dr. Baillia THE DEJECTIONS LIQUID ; GYPSEOUS ; WITH A FROTHY SCUM. The present, like the two preceding species, is produced by an irritability in the excretory vessels of the intestines, occasioning an increased secretion. But in each of these species the secretion dif- fers considerably. In the first, it is dilute and serous : in the second, viscid and compounded of fibrin : in the present, serous and com- pounded of earth of lime. Almost all animals are possessed of a power of forming this earth, or separating it from the blood, for we do not precisely know which, for various important purposes; as that of giving firmness to the bones, or induration to the shell. It is hence a power that we trace in animals of all classes and all ages, and that shows itself in a state of health or disease in almost all organs. Among mankind it commences and grows with the foetus ; it accompanies us through mature life ; and in advanced years not only continues without failure, but occa- sionally increases with the failure of other secretions, so as to con- vert the blood vessels, in a greater or less degree, into bony canals. It enters, as a constituent part, into the saliva, settles in the form of tartar around the necks of the teeth, and is found in nodules, or masses, on the surface or in the substance of the lungs. It lays, therefore, a foundation for many diseases, and in the next genus but one, that of enterolithus, will be seen to exist occasionally in the form of large balls in different parts of the alimentary canal. There is no difficulty, therefore, in tracing the source of the gyp- seous or limy material, which forms the peculiar character oftlie disease before us. In general, when this is secreted into the intestinal tube in superfluity, it unites itself with some glutinous animal matter, assumes solidity, and augments by a deposit of fresh concentric layers. In gypseous diarrhoea, however, from some cause or other, no such tendency to a combination exists ; and the earthy particles are dif- fused loosely and separately through the fluid with which they are dis- charged. The disease, however, has never hitherto, so far as I am acquaint- ed with, entered into the arrangement of any nomologist; and for its description { am chiefly indebted to a valuable paper of Dr. Baillie, communicated to the London College, and published in its Transac- tions.* "The evacuation," says he, "consists of a matter resembling in its appearance a mixture of water and lime, which is Generally very frothy on its surface. When the disease is violent, the discharges are copious and very numerous, of a pale colour and sour smell, and the froth looks hke yeast. When it changes to a milder form, the ovacua- * Vol. v. Art. xii. cl. i.] DIGESTIVE FUNCTION. [ord. i. 199 tions are still more or less pale, but of the consistence of pudding, and Gen.VIII. do not occur oftener than two or three times in twenty-four hours. The rjfarriL'a1' appetite is often good, but sometimes defective. The countenance gyiwata. thin and sallow, but not much emaciated. The pulse varies but little luosenow. from the standard of health, but is rather disposed to acceleration. The tongue is generally covered with a white fur of moderate thick- ness : the urine of a somewhat deeper hue than natural, generally clear, occasionally turbi-. An examination of the abdomen disco- vers nothing unnatural. The bowels are apt to be distended with wind, but there is no tumour or sense of pain upon pressure." The disease occurs most commonly in persons who have resided Cons*itu- for a considerable time in a warm climate, or who have suffered from chiefly at- affections of the liver : but it is sometimes met with in persons who J*ched by have never left England, or been conscious of any hepatic complaint. It takes place more commonly in men than in women, though chiefly so, perhaps, because men endure the evils of hot climates more fre- quently than women. Sometimes, there will be a state of amendment indicating a cure. {5o0"^*d The motions become figured and of a darker hue, but rarely of the improve- deep colour of health. This improvement, however, is mostly of deceitful. only a short duration, and the patient soon relapses into the habit of frothy dejections. Those who are afflicted often live for several years, but the disease continues with the changes just noticed ; and they hardly ever fully recover. Tiie mind, as in oilier diseases of A;rfiC(ed bv irritable temperaments, seens to exercise so/ne influence ; for the the mind. symptoms are aggravated, or the exacerbations appear more fre- quently, under the embarrassments of business, or the agitations of anxiety. Repeated returns of the complaint at length wear out the constitution, and the patient sinks from corporeal exhaustion. The influence of medicine Dr. Baillie estimates as very incon- Medical siderable, and rarely permanent. Haifa grain of calomel, three grains of pilulae hydrargyri, or a few of the hydrargyrum cum creta, taken every night or second night, have occasionally produced some advan- tage, by stimulating the liver to a better and more plentiful secretion of bile, without impairing the strength of the constitution : and bitters, as cascarilla, or cusparia, combined with a few drops of laudanum, have also occasionally had their use, by rendering the motions more solid and less frequent, and increasing the strength of the constitution. But the benefit is too often merely temporary, and cannot be depended upon. It is in truth a chronic malady evidently dependent upon a broken or Remote very infirm state of the digestive organs ; for the symptoms enume- rated show sufficiently an impaired secretion of bile, and, if 1 mistake not, great debility in the general action of the stomach, and the secre- tion of gastric juice ; for to this we are chiefly to ascribe theperpe- Treatmen-. tual acidity and flatulence, the frothy appearance, and sour smell of the evacuations, the abdominal distention, and perhaps the secretion of lime, by which the disease is characteristically distinguished. We call it a secretion of lime, because it has all the appearance of being so ; but I have promised Dr. Baillie, who has just seen this sheet while passing through the press, to add, that its calcareous character has not yet, been put to am chemical test. 200 cl. i.J CCEL1ACA. [ord. x. GENUS IX. CHOLERA. VOMITING AND PURGING. ANXIETY, GRIPINGS, SPASMS IN THE LEGS AND ARMS ; WITH VOMITINt, AND PURGING ; OR FLATULENT ERUCTATIONS AND DEJECTIONS. Gen. IX. Cholera has, by several late and present writers of distinction, guished keen regarded as a mere species of some other genus, as diarrhoea, from diar- which is the view taken of it by Dr. Young ; or as a mere variety of vomitus! some particular species, as vomitus, which is the place it holds in Dr. Parr's nosology. It is not always, however, accompanied with a diarrhoea ; and, even where it is so, the constant tendency it evinces to an extensive chain of spasmodic actions, gives a striking charac- ter to the disease, and justifies its being arranged and trt ated of as a distinct genus. From vomitus, it is still more widely discrepant. Origin of The term cholera is of ancient use, for we trace it in the ternf.nne"C writings of Hippocrates. Celsus derives it from ^Xr, and 'feu, literally, bile-flux, anfl Trallian from %Ier»Morbjl>Prig'i.diisPflffus.? Pan's, lii'k cl. I.} DIGESTIVE FUNCTION. [ord.-i. 203 knew it rejected in any case of cholera. Infusion of spear-mint Gen. IX. proves, also, a good anti-emetic, but it should be made with leaves cholera fresh from the garden. Sydenham prescribed weak chicken-broth |^j?s*g" for the same purpose, and applied it by injection to the rectum, as choiera- well as to the stomach. Linseed-tea or barley-water, with a little ^mlhl gum-acacia dissolved in it, may answer as well. As soon as the fresh plant. alimentary canal is thus cleared of acrimonious matter, and the sick- ness subsides, opium, with or without relaxants, should be adminis- Opium. tered in repeated doses to subdue the spasmodic action. Sydenham employed it alone, and in his favourite form of liquid laudanum, varying the dose from twelve to twenty drops in mint-water. Dr. Fordyce, with still more judgment, united it with small doses of ™*™|f- antimonials, and thus increased its relaxant power. But if the onset of the disease be very violent, and the pulse and JJ™^ the general health sink rapidly, opium must be given, and very freely, um from from the commencement. Cholera is in all cases a very acute dis- Ue rsU ease, and of short duration. I have already observed that it has de- stroyed in twenty-four hours ; these Cases, however, are rare. The symptoms generally abate on the second or third day, and the patient recovers rapidly. If there be any considerable degree of weakness ^a™ ana on the decline of the disease, it may be necessary to have recourse nics. to the warm and bitter tonics, of which columbo will be found one of the best. SPECIES II. CHOLERA FLATULENTA. WIND CHOLERA. THE VOMITING AND PURGING RARE, OR ABSENT ; GREAT AND OP- PRESSIVE FLATULENCE ; RETCHING ; FLATULENT DEJECTIONS AND ERUCTATIONS. This species I have continued from Hippocrates, who denomi- Gen^ IX. nates it, from the absence of liquid discharges, cholera |^», as Syden- The cholera ham, by translating the Greek term, has done, cholera sicca* mppofrates In this species, the bile, instead of being excessive in its flow, is and Syden- obstructed or diminished in its quantity, and perhaps secreted with too ham- low instead of too high a degree of pungency. The fiver is evi- dently torpid and enfeebled ; and as flatulency is always a sign of debility, we have a full proof that the stomach and intestinal canal are in the same state. We have here, therefore, cholera grafted ^^ upon a dyspeptic habit; and as in dyspepsy some quantity of air is ^dpre- let loose from most foods, whether solid or liquid, and an immense c1a8upg°eB3,ng portion from many kinds, we are at no loss to account for theflatu- ^^. lencv. The absence of evacuations is partly from spasmodic con- r«vea, ■* Feet. iy. Cap. ir. 204 cl. i.] CCELIACA [ORD. I Gen. IX. striction, and partly from a want of wholesome bile, and the retching cholera U" does not pass into vomiting, because the diaphragm, on whose ex- flatuienta. pUlsive co-operation the action of vomiting chiefly depends, forms a lera. ° '" link in the entastic chain, as is obvious from the increased anxiety of the pragcordia. Constitu- When cholera, therefore, is an epidemic malady, it will show itself LabieCto"i?.y under this form in persons of a highly dyspeptic idiosyncrasy, still The disease more generally than when it appears as a sporadic disease. But the rnonf"1" form is not a common one: and hence in the epidemic cholera of 1669, Sydenham declares that he met with not more than a single instance of it: " unicum," says he, " duntaxat exemplum me vidisse "hected b memini ineunte hujus anni autumuo."* And on this account Dr. Cuiien from Cullen has rejected the species altogether; as others have trans* cationfaod ferred ^to tne genus Colica. But as the disease does exist, though by others it does not occur often, and as the distinguished symptoms of anxiety coUc"; but and spasms of the extremities, which peculiarly draw the line be- improperiy. tween cholera and colic, are equally present in this and the other species, we cannot disjoin them without confusion. They are pro- duced by the same occasional causes, as surfeit, cold drinks upon a heated body, cold vegetables, as melons, inedible fungusses mis- taken for esculent mushrooms, poisonous animal and mineral sub- stances ; they all take place sporadically, and all are at times epidemic. Occasional Worms have also proved an occasional cause of the disease under one or other of these forms ; and sOmetimes gout. In very irrita- ble habits, indeed, it has been produced by suddenly drying up a chronic issue; and in a few instances by terror or some other vio- lent emotion of the mind. curative The cure should be commenced with warm cathartics alone, or intermixed with opium, as the compound tincture of rhubarb, or of aloes. Usquebaugh, or the tincture of capsicum, has often also been found useful: and when the paroxysm is removed, the restorative plan should be pursued which has been already recommended for dyspepsy. process. SPECIES III. CHOLERA SPASMODICA. SPASMODIC CHOLERA. THE DEJECTIONS WATERY ; INEFFECTUAL RETCHINGS, OR VOMITINGS OF A WHITISH FLUID ; SPASMS SUCCESSIVE AND VIOLENT, OFTEN EXTENDING TO EVERY ORGAN ; GREAT DESPONDENCY AND PROSTRA- TION OF STRENGTH. Gev. IX. There is no species of disease that has of late years attracted Spec. III. more, perhaps none so much, attention, both at home and in the east, as the fatal cholera we are now about to consider. * Sect, it. Cap. u. cl. I.] DIGESTIVE FUNCTION. [ord. i. 205 We dare not say that it is an epidemy of modern origin, since it Gen. IX. is distinctly described by Bontius, and is supposed by some writers, choier'a"1' though without sufficient authority, to be glanced at by several Greek Spasmo- physicians, and even by Celsus. But we may, at least, affirm, that Spasmodic it has of late years assumed an activity, fatality, and extent of range, Howftr an that it does not seem, from any history that has descended to us, to epidemy of have possessed in earlier times ; and that cannot be contemplated ^erD °"" without horror; on which account it has been compared by Mr. Orton to the sweating sickness, and various other pestilences, that, with great fury and mortality, have ravaged the world in former pe- riods.* Some of the cases that occurred to Dr. Sydenham in the first spe- w{?eUVir. cies of cholera, and which we have already noticed, were so rapidly Sydenham; fatal that this distinguished pathologist has also been conceived to have been acquainted with the.present species, and to have included it under them. But his description does not seem to warrant any such conclusion. Dr. Cullen, in like manner, upon a cursory view, »' bF Cui- might appear to have had his eye directed to it; for he has loosely copied Sydenham's remark that cholera is sometimes so severe in its symptoms as to destroy life in twenty-four hours. But on a more The de- attentive survey, it will be perfectly clear, that Dr. Cullen does not theiastdoes even, under this character, refer to the species before us ; for he not»ppiyt° considers an increased secretion and discharge of common or yellow bile as a symptom belonging to every species of the genus : and contends that those cases which have not this remark are samples of diarrhoea, or some other disorder, but do not appertain to cholera. His mode of treatment, moreover, shows evidently that he regarded nor hi* it in no species as a serious complaint; for he prescribes nothing treatment. more for its cure than " a plentiful exhibition of mild diluents," without evacuant medicines of any kind, which " are not only," says he, " superfluous but commonly hurtful." To which he adds, " that when the redundant bile appears to be sufficiently washed out, and even before that, if the spasmodic affections of the alimentary canal become very violent, and are communicated in a considerable de- gree to the other parts of the body, or where a dangerous debdity seems to be induced, the irritation is to be immediately obviated by opiates, in sufficiently large doses, but in small bulk, and given either by the mouth or by glyster."t Sauvages seems to have regarded cholera in all its species as a Not noticed less momentous disease than even Cullen ; for though he professes geS. auva to follow Sydenham altogether in the mode of treatment, he takes no notice whatever of Sydenham's remark, that its symptoms are sometimes so violent as to destroy life in twenty-four hours. He has given, indeed, from Dellon, a species which he calls cholera In- dica, but which differs very materially from the present, in being dis- tinguished by delirium, a strong though unequal pulse, and a tree flow of urine, both red and white, yet always limpid ; as though the complaint were accompanied with a cautna or inflammatory * Essay on the Epidemic Cholera of India, passim, 2 vols. 8vo. Madras, 182a + First Lines, Book in. Sect. m. Chap. x. 206 cl. i.] CCELIACA. [ord. i. Gen. IX. fever. Yet in the curative process he advises to abstain from bleed- choter'a.111' ing, and to administer only the milder purgatives. Spasmo- Jt is to India, then, that we must look for the most striking, if Spasmodic not the only, form of this species of cholera ; and our information Found1' must be derived from those who, in modern times, have incidentally chiefly in noticed it as travellers, or professedly written upon it as practition- ers. And from the last quarter we have lately received so extensive a mass of communications, much of it of very great importance, that we are no longer in any degree of ignorance of the general na- ture of the disease, how much soever we may still be of its remote cause. By whom Among those who have distinctly noticed it, though in a cursory noticed, way, are Sonnerat and Bartolomeo : the first of whom tells us that it is called by the natives mordezym, a term which, according to Bar- tolomeo, Sonnerat has transformed, rather than translated, into mort de chien ; but which I am more disposed to think is a corrup- tion of the Arabic mordekie or mordechie, the very name by which Dellon says the natives denominated it, and which significantly im- Why called ports " the death-blow :" according to Golius, actio inferens mor- Mortde fem . anci hence synonymous with "mors repentina," or "mors violenta." By the name of mort de chien, however, in what way soever de- rived, it is, according to Mr. Curtis, most generally known in the present day, and particularly at Madras ; and under this name, there- fore, he has described it. To this gentleman we are indebted for one of the earliest histo- ries of the disease that within the last fourteen or fifteen years have reached our own country ; and which, added to Dr. Girdlestone's statement, began first of all to draw the attention of British practi-. tioners to its truly formidable character. Since which time, and es- pecially within the last three years, the accounts have been so nume- rous, that it is impossible to pay that attention te all of them which Sources of they deserve. The friendship of Sir James M'Grigor, who has Aawnfr'om kindly given me an access to all the documents, both printed and by the au- manuscript, which from time to time have been received at the Army Medical Board, has put me into possession of such of them as I have required ; but in the ensuing sketch 1 have chiefly availed myself of the labours of Mr. Curtis, Dr. James Johnson, to whose bold but judicious practice the hospitals of the east are principally indebted for the means of combating this fearful enemy with success. Dr. Heyne, Mr. Orton, and especially the comprehensive imports of the Medical Boards at Bengal and Bombay. I have also felt greatly indebted to a very valuable letter from Mr. Corbyn of the Bengal Establishment to my learned and distinguished friend Sir Gilbert Blane, Bart, inserted in the transactions of the Medico-Chirurgical Society, which details at full length the history of the cholera as it appeared in and devastated the provinces under the Bengal govern- ment, during the years 1817 and 1818. By^Jjom Mr. Curtis, whose history was published in 1807, regarded it, at spasmodic that time, as a new disease ; and, finding no name for it in the noso- choiora. logical classifications, proposed, from its leading symptoms, to call cl. i.J DIGESTIVE FUNCTION. (ord. i. 207 it spasmodic cholera ; and as a better name cannot be invented, Gen. ix. it is thus denominated in the present work. From the absence of Cholera!11' yellow bile, and perhaps of bile of any kind, by which the disorder s.pasmo- is peculiarly distinguished, some of the writers in India have objected spasmodic to the term cholera, as conceiving that such a term necessarily im- Name j'usti- ports a redundancy of this fluid, and that, too, of its natural colour, fiod. and other qualities ; yet, as I have already had occasion to show that there is no such necessity whatever imposed on the term, but merely an understanding that the bile is morbidly affected in its secre- tion, either in quantity or quality of any kind, there is no reason for changing the term on .this ground. Nor are there always spasms in any part of the body; for the disease, at least as it has of late shown itself, in some cases destroys instantaneously, and before it has assumed its regular character ; but I do not remember to have met with a single instance of its having run on for twelve hours without having developed this essential symptom. It appears, nevertheless, to have raged with much greater and more sudden fatality in 1817 and 1818, than when Mr. Curtis wrote, and it is highly probable that at that period there was no case in which spasms did not occur. Mr. Curtis informs us, that soon after the attack " the spasms Description began to affect the muscles of the thighs, abdomen, and thorax, and Curtis.3' lastly passed to those of the arms, hands, and fingers : but I never, says he, then or afterwards saw those of the neck, face, or back at all affected. The rapidity with which these spasms succeeded the attack, and their severity, especially as affecting the muscles of the thorax and abdomen, denoted in general the degree of danger in the case. The affection is a fixed cramp in the belly of the muscle, which is gathered into a hard knot with excruciating pain. In a minute or two this relaxes ; is again renewed, or the affection passes to others ; leaving the miserable sufferer hardly an interval of ease ; and lastly it passes from one set to another, leaving the former free." This account is supported by Dr. Johnson in his valuable " Essay on the Influence of Tropical Climates." Yet, as a proof that the Proof of eastern cholera has of late assumed a severer and more fatal charac- verftyirT ter, not only in the Bengal presidency, but in that of Bombay, it is r.eceat only necessary to observe that the subsequent cramps regarded by Mr. ' Curtis, and no doubt justly so, as indicative of the highest degree of danger, have since, as will appear in the sequel, been hailed as less ominous than many of the symptoms with which the disease now occasionally opens ; and contemplated as a reaction of the system, struggling against the first shock ; proving that it has not been totally and instantaneously exhausted of sensorial power, as a Ley den phial is exhausted of its electricity by the discharge of the brass rod when applied to it. The later and more fatal ravage I am now referring to, commenced Cholera of its attack in Aup-u. i. 211 we may form some idea,from the report to the Medical Board at Bom- Gen. IX. bay, by George Ogilvy, Esq. secretary. The population in this dis- cholera.1"' trict alone is calculated at from 200,000 to 220,000 ; the total num- dP**mo- ber of ascertained cases amounted to 15,945: giving a proportion of Spasmodic seven and a-half per cent. Of these cases 1294 sick had been with- bSJ out receiving medicine, or medical aid; and there is reason to believe proof of be- that of these every individual perished. Mr. Ogilvy, indeed, expressly medical aid. asserts, that it was not ascertained that any case had recovered in which medicine had not been administered: while it is gratifying to learn, on the other hand, that, among those who had received the advantages of the judicious and active plan concurrently pursued, the proportion of deaths was reduced to 6.6 per cent.; an alarming mor- tality still, but a marvellous improvement upon the natural course of the disease. In other parts of India, indeed, the deaths, under the same plan of treatment, seem to have been still fewer: for Dr. Burrell, surgeon to the sixty-fifth regiment, at Seroor, out of sixty cases, makes a return of only four deaths; and Mr. Craw on the same station, asserts, that, on an early application for relief, the disease, in his opinion, " is not fatal in more than one in a hundred cases." The curative plan, pursued with so much success, consisted in PIa" of bleeding, according to the strength of the patient : calomel in free treatment. doses of from fifteen to twenty grains in a dose ; with one or two grains of opium, repeated, if necessary, every four, three, and in some cases every two hours, till the urgency of the symptoms abated : to these were added a liberal use of the most diffusible stimuli, as the spirit of nitric ether, ammonia, camphor, hot arrack and water, mixed with spices and sugar, camphor-mixture, essential oil of peppermint, the hot-bath, stimulant embrocations ; and sometimes the antimonial powder in doses of five grains given in conjunction with the calomel. We are informed of a fortunate blunder in one instance, capable of being laid hold of and applied with great practical advantages. " By mistake, twenty grains of calomel and sixty minims of laudanum were given at an interval of less than half an hour. The patient was in- clined to sleep; nothing more was done ; and in two hours and a half he was as well as ever he was in his life." Many of the cases proved successful without the use of the lancet: Estimate of but, from a return of Dr. Burrell, the hazard of omitting it, whenever from vene- blood could be made to flow, seems rather unjustifiable : for accord-section- ing to this return, out of a hundred patients eighty-eight were bled, and twelve not; of the former, two died, being one to forty-four; of the latter, eight, being two-thirds, or nearly thirty to forty-four. The fact appears to be that scarcely any case occurs without an alarm- ing congestion in one or more of the larger organs; and hence it is highly hazardous to depend upon stimulants alone, and to boast of their power to subdue the disease without^ active evacuants in the beginning of the curative process, as Hufeland, and other writers on the continent, appear to have done, without a sufficient knowledge of the real nature of the disease formerfy,* if, indeed, it be this species * N. Annalen. 1.4W. Gazette Salntaire de Bouillon, 1787. 2U cl. i.J CIELIACA. [ORD. 1- Gen. IX. which they have undertaken to describe, of which there is great rea- Chotera111' son to doubt: and as Dr. Rankeen of the Bengal station has recom- spasmo- mended still more recently, who treats calomel with as much con- s'pasmodic tempt as the lancet, and depends exclusively, from the first, upon andTaTge lai¥e doses of opium, and highly pungent and diffusible stimu- dosesof lants.* Remote' Of the remote cause of this extraordinary malady we know nothing. cause of the That it is an epidemy, and of a most malignant character, is un- unknown, questionable : but whether dependent upon an intemperament of the atmosphere, or upon specific contagion, is by no means ascertained. The first was the most obvious mode of accounting for it, and that which was earliest adopted; but by many practitioners it has been intempera- rejected, for the following reasons. The disease instead of spread- atmosphere ing from a centre to a circumference, or following the course of the objected to. ^^^ or 0f the sun, or obeying any other meteorological power, marched by a chain of posts, often in direct opposition to all kinds of atmospherical influence, and in the immediate track of human intercourse. " It prevailed," observes Sir Gilbert Blane, in his re- marks upon Mr. Corbyn's letter, " to a degree equally violent at all seasons of the year : in regard to temperature, from 40 or 50 degrees of Fahrenheit to 90 or 100 ; in regard to moisture, during the con- tinuance of almost incessant rain for months, to that dry state of the atmosphere which scarcely leaves a vestige of vegetation on the surface of the earth." ' To which I may add, that it often fought its way in the very teeth of the most powerful monsoons, and left untouched various districts that bordered on its career, and whose less salubrious features seemed to invite an acquaintance with it. It appeared also and vanished in all the changes of the moon, and in all states of atmospheric electricity : and at sea as well as at land. Mr. Corbyn, indeed, gives an account of its having made an attack upon the Las- cars of an Indiaman, in its passage from England to the Cape of Good Hope, in 1814 ; and that too in the month of January, when the weather was intensely cold.t Whether It has, hence, by many pathologists been supposed to have been from speci- propagated by a specific contagion ; and in support of such opinion fie conta- they have endeavoured to show, that it appeared in no town or dis- trict where a direct communication had not been maintained with tothesu*- some place m which it was prevalent. In this endeavour, however, position, they do not seem to have been successful. Nor is it easy to reconcile the suddenness of its appearance and disappearance with the laws of contagion, so far as we are acquainted with them ; a subject we shall have occasion to examine at large, when treating of fevers. Mr. Allardyce, surgeon to his Majesty's thirty-fourth, informs us, that in this regiment the disease appeared on the twenty-first of September, and committed dreadful ravages before night. On the twenty-fifth it abated remarkably, and in three days more entirely vanished. J In like manner, the severe attack which was experienced by the Ben- * Edin. Med. and Sur. Journ. Jan. 182S, and compare with Dr. Robson's History. t Treatise on the Epidemic. \ Reports communicated to the Bombay Medical Board. ;l. i.J DIGESTIVE FUNCTION. [ord. i. 213 gal and Madras troops at Nagpore, occurred at the end of May 1818. Gen. IX. On the tenth of June, the rains appeared with great violence, when chcdera111' the epidemy abated, and immediately afterwards ceased. Neither is spasmo- the idea of a contagious propagation reconcileable with the escape spasmodic of the great body of persons exposed to the influence of the disease, cholcrai considering that, from its not being apprehended to be contagious, no means, as is usual in other cases, were employed to avoid the infection. The state of the atmosphere, as described by Mr. Allardyce, did not differ materially from that in Nagpore. The disease made its at- tack in close and sultry weather, and vanished after thunder storms and heavy rains. But we can draw no conclusion from these phe- nomena ; since it seems to have shown itself quite as frequently and fatally after a long succession of rain ; and, as already observed, sometimes in very cold and dry weather. The remote cause, there- fore, of this mysterious scourge remains yet to be ascertained ; and affords further proof, if indeed proof were wanting, of our general inacquaintance with the nature and economy of epidemics. Dr. Rankeen, who was with the army on the Bengal station in No known' 1818, has ascribed it, since the first edition of this work, to the con- tion of joint operation of sudden changes of weather, humid soil, and damp causes- atmosphere, in connexion, more especially, with a diet of rice or other grain, vitiated by the wet of the season.* But we have already traced its existence in cold and dry, as well as in swampy quarters, and have seen it yield to sudden changes of weather, instead of being introduced by them : while the grain and other food of such wet seasons is usually the product of the year before, which may have been peculiarly dry and healthy. With the exception of the plague, there is no epidemy on record General ^ that seems to have been so strikingly marked by violence and irregu- tion ; larity of action, and especially by a rapid exhaustion of living power ; the patient, as we have seen, often expiring within twelve hours from the attack, and sometimes sooner. The first characteristic feature that occurs to us on a review of the disease, is the total absence of the bile from the whole range of the alimentary canal in every case, while this fluid was as generally found in abundance in the gall-bladder : and, perhaps, the next is, the turgid, and, in some instances, the ruptured state of the liver from the quantity of blood with which it was distended. The and deduc- general battery of symptoms appears, therefore, to have been opened by a spasmodic constriction of the bile-ducts; for without such an obstruction, we cannot account for an exclusion of all bile from the intestines. From this point, as from a centre, the spasmodic action seems to have spread in every direction, and under a clonic or en- tastic form to have seized upon almost every organ : preying with greater violence according to the greater degree of debility, and hence, perhaps, of irritability of the system ; into which law we are to resolve it, that the natives, supported by a less rich and nutritive diet than Europeans, suffered more severely, and died more fre- * Edin. Med. and Surg. Journ. Jan. 182& 214 cl. i.J CQELIACA. [°bi>. i. Cholera spas in o- dica. Spasmodic cholera Explana- tion of various symptoms. Gen. IX. quently. The stomach and intestines, generally speaking, first par- EC*IIL ticipated in the spasm of the bile-canals, and hence the griping pains, the nausea, and violent commotions which spread from the one to the other. In all cases of nausea, from whatever cause, we see the brain and the surface of the body peculiarly diminished in their energy, whence the skin, to the remotest extremities, collapses beneath a deadly chill, and the heart sinks with insupportable languor. In the ordinary course of sickness, the nausea subsides, and the general organiza- tion recovers its balance, or it terminates in full vomiting, which excites an universal re-action. And where any such reaction oc- curred in the disease before us, it was hailed as a favourable change ; and hence, the wisdom of the stimulant plan, so frequently had re- course to by the medical staff for the purpose of producing a revul- sion. But where this was not accomplished, the living power, feebly recruited from its fountain from the first, or not recruited at all, became exhausted in every organ apace, the strength failed, and hope gave way to despair. While the general mass of blood, thrown back by the contraction of the vessels of the surface upon the deeper and larger organs, produced effusion, congestion, and extravasation, wherever they yielded most readily ; and hence chiefly in the liver, which in hot countries is almost always in a debilitated state. In the midst of these accumulated evils, the spastic diathesis, instead of being subdued or even checked, "became, by the very resistance it met with, more forcible and aggravated. Every organ successively or simultaneously submitted to its torturing cramp ; the heart was fixed and incapable of propelling the blood through the arteries, the muscles of respiration were incapable of expansion, the lungs were collapsed, and suffocation was threatened every moment. None of the natural secretions took place ; the bladder was shri- velled and empty; the bile, while in the gall-bladder, became dis- coloured and dark; there was no fluid, or only a morbid fluid, in the pericardium, and the intestines were no longer lubricated with the refreshing moisture of health. But while these secretions were put a stop to, others took place in different organs from the mortal struggle of those organs themselves, and chiefly where the struggle was severest. And hence those morbid fluids, and other materials, exhibiting almost every degree of consistence, which were found in the intestinal canal, and often ejected by the mouth and anus ; va- rying from the nature of chyle, thrown back, perhaps, by a retrograde spasmodic action of the thoracic duct, to the nature of that mucous and unctuous matter which the intestines are sometimes capable of forming, even under other circumstances, and of which we shall have occasion to treat when we enter upon the genus knterolithus, or intestinal concretions. Sensorial I have said that the living power during the whole of this melan- times dis- choly contest seems to have been recruited very feebly from its ahfewehounrs wuntaini or not recruited at all. The latter appears to have been without any the case in the island of Ceylon, where the disease raged with even recruit; m0re violence than on the Indian continent; and the patient very frequently expired in twelve or fifteen hours from its attack. A dis- cl. i.J DIGESTIVE FUNCTION. [okd. i. 215 section of those who perished thus early in this quarter, has put us Gen. ix. into possession of some interesting facts, varying in a few particulars oholer"*1"' from those that occurred on post-obit examinations in the island of ■p,,»«- Bombay, and which will, I trust, uphold me in making this remark. Spasmodic The brain was in these cases chiefly the congested organ, the liver cho,enu sometimes appearing to have no congestion whatever; and hence the inactivity produced in the brain by the nauseating state of the stomach must have been greatly augmented by oppression. Con- sentaneous herewith, we are told by Dr. Davy, that in some of the cases which he dissected in this region, there was a flaccidity of all the muscular parts, as in animals killed by electricity or hunted to death. There was also a tenderness of the muscular fibres ; while, antecedently to death, as in many of the Bombay cases, there was no difference in the colour of the arterial and venous blood, and no instance of a buffy coat on the blood that was drawn ; which in re- ality was so loose and uncoagulable, that when venesection was ne- cessary, the vessels were opened with the greatest caution, from the difficulty of restraining the blood afterwards. In all these cases there can be little doubt that the supply of the living power from the brain was spent profusely, and soon altogether exhausted : in some instances, indeed, nearly momentaneously ; like as br * the effects produced upon the animal frame by a stroke of lightning, lightning. a violent blow on the stomach, or any other accident that occasions instant death by a total and immediate discharge of the vital energy. In other cases, the oppression on the brain, produced by conges- The disease tion, seems to have put an end to the conflict before the living power faSf before had completely failed, and while it was still acting with irregular a total di!- accumulation in various organs ; for, in these, the muscles of the living9 ° extremities, and even of the face arid lower jaw, were observed to Power- move in a convulsive manner, and sometimes to be drawn into tre- mulous knots, fifteen or even twenty minutes after death had closed the scene. So the heart of the traitor, when extirpated after he has been beheaded, from a like accumulation of sensorial power, has been seen to palpitate, and even to leap up, for several times in suc- cession, after its removal from the pericardium. Commonly, however, the living principle seems to have been ex- Living hausted more generally and progressively; and the muscles, and, mwily indeed, most of the organs, freed from the tetanic power that at first "hausted ^ constringed them, to have been gradually relaxed and flaccid ; and ally. hence, that comparative absence of pain that occurred so frequently a short time before death, with the flow of a cold sweat over the surface of the body, and of bile into the smaller intestines. I have thus endeavoured to follow up and explain the different symptoms of this complicated disease, many of which appear, at first sight, to be incongruous with each other, and of difficult recon- ciliation. And we may hence see how well calculated the plan of treatment pursued by the different medical boards was to meet them, and may trace the ground of its success. The grand objects before General them were : to equalize the flow of the living power ; to counteract "mentions the spastic action so common to the irritable diathesis of hot coun- *>»iy«rf 21b' cl. i.] C03LIACA. [OKU. L sfEN* m' *r*es ' to Suar**>. *• that almost all animals are endued with a power of separating or secreting lime and other earths from the blood for particular pur- poses, as that of forming a shell-covering in insects and worms, and of giving hardness to the bones in all other animals. Under a morbid action of single organs, or of the system generally, this se- cretion often takes place in an undue abundance, and is poured forth into cavities where its accumulation and crystallization must be at- tended with mischief. Such, at times, is the case in respect to the stomach and intestines. But, independently of concretions derived from this source, we often meet with others produced by an aggluti- nation or crystallization of the juices which are contained in the ali- ment, and which, not unfrequently, give immediate proof of their origin by the aromatic taste, smell, or other qualities which they ex- hibit. There is also a third species of concretion, occasionally to be traced in the alvine channel, of a harder or softer structure, and of a cetaceous or saponaceous feel, which consists of feces or the refuse matter of the chyle, more or less combined with oil or mucus, and sometimes consisting almost entirely of the two last. As the subject has been never before pursued with a view to any critical examination or systematic arrangement of the tribes of sub- stances that appertain to it, we have not yet perhaps arrived at a knowledge of all their different forms or combinations, as met with in the intestines of man, or the animals of the mammalian class, to which man is degraded by Linneus : but we may at least venture upon the three following, each of which will furnish a distinct species : 1. ENTEROLITHUS BEZOARDUS. 2. -----'---—----- CALCULUS. 3. ———------- SCYBALUM. SPECIES 1. ENTEROLITHUS BEZOARDUS. BEZOAR. FOUND IN CONCENTRIC LAYERS, CLOSELY AGGLUTINATED OR CKYS- TALLIZED ; CAPABLE OF A FINE POLISH ; FREQUENTLY WITH A METALLIC LUSTRE ON THE SURFACE OF EACH LAYER, AND AN AC- CIDENTAL NUCLEUS IN THE CENTRE ; OF A SPHEROIDAL FIGURE : CHIEFLY CONSISTING OF VEGETABLE MATTER. BEzoARDus,or bezoar, is derived from the Persian compound Padi- Specitic " z*her, or Pad-zehr, corrupted into bedzohr, and bezoar. Literally wwe de- translatedi il is depellens venenum, and consequently a direct sy- rived. nonym with the Greek term alexipharmic. S* II is wund occasionally in the stomach of some of the camel tribes. found. BEZOAR. INTESTINAL CALCULUS. SCYBALUM. «:l. i.j DIGESTIVE FT ACTION. [ord. i. 219 but more frequently in that of the smaller ruminating quadrupeds, as Gen.X. the goat, and two or three species of the antelope genus, as the cha- Enre^oii- mois, or wild-goat as it is sometimes incorrectly called, (the antelope tnus Be2°- rupi-capra of Linneus,) and especially that beautiful and elegant ani- Bezoar. mal the gaz/ial (antelope Gazella. Linn.,) thetzebi (ox) of the He- brew poets, or roe of our Bible versions. The bezoar was formerly employed as a febrifuge and alexiphar- Employed mic in medicine, and worn as an amulet by the superstitious, who medioi- have sometimes purchased a single one from the east at six thousand an" e*teem. livres when very fine, and hired them in Holland and Portugal on ed of high particular occasions at a ducat a-day. It is not quite satisfactorily ascertained that this species has ever Not quite been found in the human stomach; we have, indeed, assertions to whether this effect in various foreign miscellanies,* and 1 have hence intro- ?ver fouml j 1 • ■ i i t» • \ • p. in man. duced it into the present place. But it does not often appear that the substances referred to were examined with sufficient attention, while the authors seem to have used the term bezoar in a very loose and indefinite sense. In one of the volumes of the Annales de inonein- Chimie, however, the analysis seems to have been scientifically con- parentiyPso. ducted. It was made by M. II. Bracconot, from a quantity of con- crete materials voided by a female under the care of Dr. Champion, of Bar-le-dac, which were found to be genuine bezoars.j The bezoar, as already observed, is chiefly obtained from the sto- Exier?af • mach of the smaller ruminating animals, whose food, from the com- caiproper- plexity of the organ, lies for a long time quiescent in a state of sub- UeB' action, and is thus enabled to give forth the whole of its juices under circumstances that afford them a much easier opportunity of agglu- tinating or crystallizing than in many other animals. In the goat kind these concretions are called .Tgagropilae, a Greek term signifying mountain-goat balls. They are of different sizes and figures, the last being chiefly determined by the nature of the nucleus, which in dif- ferent individuals, is marcasite, talc, flint, gravel, straw, glass, seeds of plants, &c. In colour they are white, yellow, or brownish ; that of the gazhal is greenish blue ; and, when recent, highly aromatic from the odour of the plants on which the animal feeds. The most singu- lar circumstance belonging to them is the bronze or metallic lustre that appears on the surface of the different layers, and does not strike deeper than the surface. This, however, is said to be a property peculiar to the western bezoar, and seldom or never to be found in those of the east, which are often of as beautiful a glossy white as ivory. Daubenton ascribes the gilt appearance to a vegetable dye fixed by the tartaric acid of the plants in which the dye exists ; and observes, that he has remarked a like appearance on the grinding teeth of many of the ruminating tribes. A few of them rattle on being shaken, the nucleus having contracted and become loose. La Fosse J asserts that he has occasionally met with genuine bezoars or sega- gropila; in the stomach of the horse; and similar concretions seem at times to be formed out of the animal body, as tubercles to the roots * Samml. Medicinischer Wahrnehmungen, Band. II. p. 418»—Perri, Galena in Minerva. 1696. .... + Annales de Chimie, Tom. xx. . J Conrs d' Hippiatnqne, p. 158. 320 *cl. i.] CCELIACA.- [ord. i. Gen. X. Spec. I. Enteroli- thus Bezo- ardus. Bezoar. Spurious bezoars. Of what compound- ed. Spurious- ness how detected. or other parts of certain plants : for Fourcroy affirms, that in the cabi- net of Jussieu he was shown some curious bezoars of the Oriental ap- pearance, white or yellowish, glossy as ivory, and of a spheroidal figure, which were said to be produced by the cocoa. From the supposed value of bezoars in medicine, they were at one time imitated, and the false sold as genuine. These supposi- titious stones, according to Bomare, were compounded of lobsters1 claws and oyster shells, levigated On porphyry, made into a paste with musk and ambergris, and formed into balls of the shape of bezoars; and, where the metallic lines were aimed at, afterwards rolled on gold leaf. The pierres de Goa or de Malacca, as they were called, were, at least, generally factitious bezoars of this kind; and their spuriousness was capable of proof, by drawing a line with them on a piece of paper previously rubbed over with cerusse, chalk, or lime : the line of the genuine bezoar turns greenish or of an olive- yellow ; that of the factitious remains unaltered. The imposition, however, seems to have been very unscientific, as formed principally of earths, instead of being elaborated from crystallized vegetable juices, which produce this change of colour. SPECIES II. ENTEROLITHUS CALCULUS. INTESTINAL CALCULUS. RADIATING FROM A COMMON CENTRE, OR FORMED IN CONCENTRIC LAYERS ; MOSTLY WITH AN ACCIDENTAL NUCLEUS ; MORE OR LESS POROUS ; SPHEROIDAL OR OBLONG ; ADMITTING AN IMPERFECT POLISH ; COMPOSED CHIEFLY OF EARTHS AND ANIMAL MATTER. Gen. X. This species is treated of so fully in the commentary to the Noso- Swc. II. i0gicai Synopsis, that I have not much to add to what is there ob- served. It is by no means unfrequently found in the human stomach and intestines, but far oftener, as remarked above, in the digestive chan- nel of other animals, and particularly in the larger ruminating quad- rupeds, or those with a long complicated digestive organ, where the food, as in the formation of the bezoars, is slowly carried forward ; and in tardy draught-horses, particularly those of millers that are fed largely on bran, which seems to yield a ready basis for these concre- tions* In Dr. Watson's case, the disease had existed for years: the animal died aged twenty-two, near foaling; but gave no sign of pain or inconvenience till three months before her death The cal- culus weighed 151b. 12 oz.; average diameter 8£ inches by 8 inches. Where ehiefly found. il. Trans. *iv. 1705, Thoresby. Id. xuv. 1746. Bailey, Id. xtvin. 1754, cl. i.] DIGESTIVE FUNCTION. [obd. i. 221 When chemically analyzed, they are chiefly found to consist of a Gen. X. triple or ammoniaco-magnesian phosphate, like the earthy or white- Emeroii-1' sand calculi of the human bladder ; though it is difficult to conceive J""8 Caicu- from what quarter the magnesia is obtained. In the case of millers' intestinal horses some portion of this earth may perhaps be derived from the comical bran, in which it is always to be traced : but the difficulty still re- analysis. mains with respect to other animals. The figure, whatever be the size of the calculus, is usually spheroidal, except where broken into separate fragments : the matter is deposited for the most part, as in the former species, upon a nucleus of some sort or other ; as a small piece of flint, an iron nail, a seed or husk, a piece of hay or straw— the structure sometimes radiating from such common centre to the surface, and sometimes evincing distinct plates more or less united to each other. In the human subject these calculi vary from the size of a pea to that of a filbert, chesnut, or hen's egg, and are often still larger. In the case of Margaret Lawer, (related under Colica J11™"!,"1^ constipata,)* they were usually of the two former sizes, and appear examples. to have been formed in great abundance and with wonderful fa- cility—for her abdomen, upon pressing it, often rattled from the quan- tity it contained, with the sound of a bag of marbles. Many of these were rough and sharp-pointed at the edge, evidently fragments or nodules of larger concretions, and gave great pain in the rejection, whether above or below, for they were discharged both ways. The larger-sized weighed rather more than two drams ; and Dr. Kbnig, who relates the case, calculated that the whole that were discharged during the continuance of the complaint pould not amount to less than 5lb. avoirdupois. In a case related by Mr. Martineau,t some of them, much larger than the preceding, were voided per anum, by a poor woman in the third month of pregnancy, after having suffered from colic about four or five days : of these, the largest, 8 inches in circumference and Gf inches in length, weighed two ounces, sixteen pennyweights, and twelve grains. In this case, and in various others, the calculi seem to have been in the intestines for a considerable pe- riod of time without inconvenience ; for it is hardly possible to con- ceive that all these should have been produced in the course of a week. In another case in the same journal ;| related by M. Mack- arness, a calculus of this kind was extracted with some difficulty from the anus by the surgeon who attended, which weighed eight ounces and a half, and was ten inches and a half in circumference. It is described as " a hard, unequal, ragged, flinty stone," but was not examined chemically. There is some doubt whether this h d not forced its way from the bladder into the rectum ; but there is little doubt that it had been present in the one organ or other, and nearly of its full size, for several years before its extraction ; for the patient's stools were always obtained with difficulty ; and three children, which she had successively borne in the three preceding years, were all marked with a large hollow or indentation in some part of the head ; in one instance, of sufficient extent to hold the moiety of a small orange. * Ut supra, p. 178. t Phil. Trans. Vol. xxxn. 1722—1723. t Phil. Trans. Vol. xli. 1739—1741. 222 cl. i.J CCELIACA | ORD. I. Gen. X. Other examples, however, have occurred both of as large a size, E.fteroiiIL and of as firm or flinty a crystallization. Thus in a foreign mis- thu« Calm- cellany of authority, we have the case of a calculus discharged by imestinai the anus of half a pound weight;* and M. Daabai has published a calculus mjj account of fragments of stony calculi (saxea fragmenta) evacu- ated from the same organ :| as Sir H. Sloane has another case in whicn the concretions amounted to two hundred. J Found Li drau^nt-hurses a>d oxen this species of calculus is generally dVaSuegh"- found single and much larger, and often of little inconvenience for horses, &c. years, 'i hey vary m size from three pounds auvoirdupois to ten or twelve. Of this last weight the author once met with an instance in a horse belonging to Mr. If ayward, a respectable miller of Brun- don, near Sudbury in Suffolk ; and Mr. Watson gives an account of two considerably heavier, one already noticed, and the other weighing nineteen pounds, exclusive of the outward shell or crust which was broken off in several pieces, with a circumference of twenty-eight inches. Both these were laminated, but " had the ap- pearance of a pebble ; yet the specific gravity was much lighter, the first weighing in water not more than six pounds. At other times the crystallization is more like that of gneis, or of grit-stone, and almost always light and porous.§ Sometimes Occasionally, however, this species is found gregarious instead of gregarrous soiitarv frfr vVatson, in the article just quoted, mentions a case of several found in the intestines of a mare, and presented to the Royal Society by the Duke of Richmond in 1746, the nude-is of two of which was found to be an iron nail. And, by turning to another volume of the same journal,!! we find these calculi described by Dr. Bailey (for the two articles appear to relate to the same case) as consisting of five in number, of different sizes, some triangular, and resembling a horse-bean, of an olive colour, and finely polished ; and one much larger, weighing nearly sixteen ounces troy, and measuring twelve inches by eleven. Apparently Several of these concretions, we have observed, had the appear- Srit-«to°ne ance of crystallized gneis, or of grit-stone ; and it is probable that they were partly of these very minerals ; for it is of such that mill- stones are very generally composed : and, by the friction they are perpetually undergoing, there can be little doubt that much of the mill-dust intermixed with bran, with which millers' horses are fed so largely, is derived from the powder furnished by these stones. in man, In man, the calculus is often dependent upon a like accidental K^nlljo. ori?in : for il not u,lfrequently follows upon a long, free, and inju- djciojis use dicious use of prepared chalk, magnesia, or other calcareous earths, "eoSs cu~ for the purpose of correcting acidity in the stomach. 1 have known earths. this in many instances in dyspeptic cases : and once attended a lady who, from the same cause, laboured under a most painful constipa- tion, till a large mass of what may be called intestinal mortar was removed by a scoop from the rectum. The case related by Dr. S. Fitzgerald, of Mullingar, was apparently produced by a like cause. * Samml. Med. Wahrn. Band. ix. p. 231. t Discursus Academicus de Esthera Norra. Land. 1715. 8vo. I Birch, Hist. 1685. {j Phil. Trans. Vol. xxxiv. No. 398. || Vol. xi.lv. 1746 cl. i.] DIGESTIVE FUNCTION. [ord. i. 223 The lady had suffered great torture in the hypogastric region, par- Gen. X. ticularly towards the back and os sacrum, for eighteen months ; |n,*r30,H_11' during the last three of which she could not leave her bed, except thus caicu- for tepid bathing, which afforded her transient ease. Upon the rejec- intestinal tion of an emollient anodyne clyster, she discharged with it a large tnl0tluts'd hard calcareous ball of an oval figure, weighing eight ounces and three drams, exceeding in size an ordinary orange, and so solid that nothing less than the stroke of a hammer could break it. A total liberation from pain immediately followed, and the patient progress- ively recovered.* The curative process may be comprised in a few words. If the Curative concretions proceed from an injudicious use of calcareous or magne- pi°c sian earths, both these must be avoided for the future : and the cal- culi actually existing be diminished in their diameter by the use of mineral acids, and quickened in their passage by cathartics. If magnesia be pretty certainly the agglomerating base, the sulphuric acid will be preferable; as this will have a tendency to convert it into Epsom salts, and thus produce a purgative as well as a solvent effect. If we have reason to suspect a calcareous diathesis as a sole cause, since this diathesis usually depends upon debility, we must endeavour to invigorate the system generally, and the stomach more particularly, by the course of regimen and medicines already pre- scribed under dyspepsy.! SPECIES III. ENTEROLITHUS SCYBALUM. SCYBALUM. CONCRETION SOAPY OR UNCTUOUS ; MOSTLY CONTINUOUS ; SOMETIMES IN LAYERS ; SPHEROIDAL OR OBLONG ; CONSISTING CHIEFLY OF MUCOUS OR OLEAGINOUS MATTER, MORE OR LESS INTERMIXED WITH INDURATED FECES. This species has not hitherto been sufficiently attended to ; and Gen. x- even Fourcroy and Walther seem to have mistaken it, for a biliary n^fiieen ° calculus ; an error which the writer has seen in several instances re- hitherto peated in this metropolis. The specific character sufficiently ex- tended to. presses the general nature of the concretion, and is drawn up from various examples that have occurred to himself, or have been shown him by others. The concretions belonging to this species, if carefully watched Threeen found on the shores of the West Indies ; whence Waller :— on the coasts. Bermuda, wall'd with rocks, who does not know That happy island, where huge lemons grow ? Where shining pearl, coral, and many a pound, On the rich shore, of ambergris is found. Sometimes Sometimes, however, it is traced in great abundance in the intes- ed whSkSr tines of whales tnat are harpooned, and which, probably, would soon have died of an obstruction in the bowels, if they had not been taken. A captain in the Southern Whale Fishery, examined before the Privy Council in 1791, related, that he had found three hundred and sixty-two ounces of this substance in the intestine of a female, struck off the coast of Guinea; part of which was voided from the rectum on cutting up the bladder, and the remainder traced in the usually intestinal canal.* The mass is usually loaded with hard bony frag- iviatheother ments, by the seamen called squids, which are the beaks of the materials, cuttle-fish, on which the whale is known to feed. When recently taken, the smell of ambergris is very strong, and rather fetid, but, by keeping, the offensiveness goes off, and it acquires a faint musky odour. It has scarcely any taste. Its colour is ash-gray or brown, somewhat mottled : its hardness is sufficient to render it easily friable, but not to bear a polish ; when broken down, it has a soapy feel like steatite. How ac- Sir Everard Home has endeavoured to account for the produc- B°yU8ir E.°r tion of all these varieties of scybala, in an ingenious article pub- Home, lished in the Philosophical Transactions, in which he attempts to show that, while it is the office of the stomach and intestines to fur- nish nutriment for the muscles and membranes out of the finest part of the food which is separated from the rest for this purpose, it is in like manner the office of the larger intestines, and especially of the colon, to convert a considerable part of the refuse matter into fat, by combining it with the bile, and to send it, thus changed in its nature, by channels of which we know nothing, into the circulation, and deposite it in almost every part of the body, to lubricate the whole, and especially to promote the growth of the animal frame in youth.t It is unquestionable that, with all our advances in the knowledge of physiology, we are, to this hour, in great ignorance of the means by which the fat of the different parts of the body is produced, or objection the quarters from which it is drawn. But it militates against the theris.hyP° hypothesis before us, that we have no instance of the existence of fat in the larger intestines when they are in a state of health ; and that to produce scybala of every kind, and particularly those that are more oleaginous, a weak and diseased condition of the intestinal canal appears to be indispensable. Whilst in the second case related by Dr. Babington, in which the fatty material seems to have * Phil. Trans. Vol. i.xxxr t W. for 1813. Art xxl cl. i.] DIGESTIVE FUNCTION. [qbd. i. 227 been elaborated in its most perfect state, the bile does not appear to Gen. X. have been at all transformed from its natural to any new charac- Entero'u- ' ter, nor indeed to have been in any degree operated upon ; for we »hus scy- are expressly told that the material when voided had " an unusually Scybaium. yellow tinge," notwithstanding that it was " quite fluid like oil." The subject, however, is worth pursuing : and Sir Everard has "yp^Js endeavoured to support his views by a later article inserted in the bythetrans- satne work, on the transmutation of the tadpole into a frog,* in ihe'fadpaie* Avhich, after showing that the intestines of the tadpole are much larger and more complicated than those it possesses in its frog state, he argues that this more extensive and elaborate machinery is for the purpose of forming a larger abundance of oleaginous matter as food, at a period when the animal is less capable of obtaining food from without; and he observes further, that the intestinal canal of the tadpole is surmounted with, and, in some species, imbedded in fat. GENUS XI. HELMINTHIA. INVERMINATION. WORMS. WORMS OR LARVES OF INSECTS INHABITING THE STOMACH OR INTESTINES. The subject of our last genus, I observed, was new, or nearly so, Gekt. XI. to the science of pathology : that of the present is equally new to new to Je nosological arrangement: for it is a singular fact, that while almost ^siAc*-*' all systems contain a distinct genus under the name of phthiriasis, tion. or malis, or cocyta, and some of them two distinct genera, for the purpose of arranging such insects, larves, or vermicles as are occa- sionally found infesting the surface of the body, and which to avail ourselves of a significant term derived from old English botany, may be called animal dodders, few or none of them comprise any division whatever for intestinal larves or worms, notwithstanding the infinitely greater mischief they often produce, and the far greater difficulty of getting rid of them. Dr. Cullen, indeed, in the latter part of his life, was sensible of JJ^gj^ the importance of this omission, and would most probably have cor- theomis- rected it in his own system, had he found leisure or inclination for ?n™ndaed\o a revisal of it, since he has introduced the term vermes into his supply it. " Catalogus Morborum, a nobis omissorum, quos omi?fsse fortassis non oportebat.'" * Phil. Trans. 1816. p. 301. £2S ex. i.] CCELIACA. [ord. i. Gen. XI. llelminthia. Invermina- tion. Worms. The omis- sion abun- dantly atoned for by patholo gists ; especially of the Lin nean school ; who have referred most dis- eases to Termina- tion. The physiologists, however, and pathologists have, in many in- stances, abundantly supplied the deficiency ; for there is scarcely a disease of any kind which has not been referred by some of them to vermination as its origin. This is particularly true of the school of Linneus, though it is not confined to that seminary. Thus Linneus himself laboured hard to prove that dysentery is the effect of a pe- culiar larve or grub belonging to the acarus or tick genus, which he has ventured to introduce into his Natural History under the name of acarus dysenteries. So Kircher has ascribed the plague to another kind of animalcule; Langius, the meazles ; various authors, the itch; Siggler, petecchise ; Lusitanus and Poncellus, small-pox ; De Sault, lyssa, or canine madness ; Hauptman, syphilis ; Martin and Udman, both pupils of Linneus, elephantiasis ; and Nyander, another pupil of the same great teacher, contagious diseases of most, if not of all kinds. Some, again, have ascribed piles to the same source ; others, the inspissated and vermiform mucus squeezed out occasion- ally from the excretory ducts of the small mucous glands of the fore- head, in the present system described under the genus and species ionthus Varus; and others again, the tooth-ache ; which last opinion seems at one time to have been adopted generally; for we find Shakspeare making one of his best-drawn characters exclaim— What! sigh for the tooth-ache ! Which is but a humour or a worm. Extensive It is not very wonderful, therefore, to behold the extensive use to of the tsnTa which the taenia hydatis, or hydatid, is applied in modern times, so hydatis. as to be regarded as the parent of almost every limpid cyst discover- able in the body ; nor that cancer of the breast should be ascribed to a similar generation ; and the less so, since it is not a century ago that it was gravely argued by the most enlightened physiologists of Man himself the day, and supposed to be ocularly and irrefragably demonstrated, sed to "rise' that man himself is, in every instance, the progeny of a similar kind from a like 0f maggot, which, it was said, might be seen by any one who will take the pains to look for it, vivaciously frolicking in the vast ocean of a drop of male semen. Mischief of We are, at length, approaching to more sobriety in our observa- BuchSextra- tions and inquiries ; and it is high time such a period should arrive ; vagances for we were jn great danger of running into the wildest fancies of logy. equivocal generation, and of equally relinquishing all principles and Real origin all limits in natural history. We now know that an incipient stage of putrefaction, or a very short quiescence and exposure of animal fluids to a warm atmosphere, is sufficient to load them with animal- cules of some kind or other ; not, indeed, by fortuitously converting the constituent and decomposing principles of such fluids into the simple forms of microscopic life (for of this we have no proof what- ever,) but rather, by affording to some few of the myriads of invisible ovula with which the atmosphere swarms, and which it may convey to them, the proper nidus, or the quickening stimulus they stand in atmosphere. need of. Proof of the That the atmosphere is freighted with myriads of insect-eggs that assertion. ^u(je Qm senseg_ an£n. I have seen, as probably many who may read this work have also, a BiightVn hop-ground completely over-run and desolated by the aphis humuli, g°0pu*nds, or hop green-louse, within twelve hours after a honey-dew (which is Honeydew, a peculiar haze or mist loaded with a poisonous miasm) has slowly w a' swept through the plantation, and stimulated the leaves of the hop to the morbid secretion of a saccharine and viscid juice, which, while it destroys the young shoots by exhaustion, renders them a favourite re- ]Ta jou'iteh sort for this insect, and a cherishing nidus for the myriads of little aphis dots that are its eggs. The latter are hatched within eight-and-forty burauli- hours after their deposite, and succeeded by hosts of other eggs of the same kind; or, if the blight takes place in an early part of the au- tumn, by hosts of the young insects produced viviparously ; for in different seasons of the year the aphis breeds both ways. Now, it is highly probable that there are minute eggs, or ovula, of Ovuia float- innumerable kinds of animalcules floating by myriads of myriads mosphere through the atmosphere, so diminutive as to bear no larger propor- ^^bY11" tion to the eggs of the aphis than these bear to those of the wren, or less than the hedge-sparrow ; protected at the same time from destruction by aphis.0 tha the filmy integument that surrounds them, till they can meet with a proper nest for their reception, and a proper stimulating power to quicken them into life ; and which, with respect to many of them, are only found obvious to the senses in different descriptions of ani- mal fluids. The same fact occurs in the mineral kingdom ; stagnant The same water, though purified by distillation, and confined in a marble basin, in°he°mine- will in a short time become loaded on its surface or about its sides ™'ae'" *? with various species of confervas; while the interior will be peopled cai king- with microscopic animalcules. So, while damp cellars are covered jj.°m,;d aIg0 with boletuses, agarics, and other funguses, the driest brick-walls occasion- • ally in are often lined with lichens and mosses. We see nothing of the buildings. animal and vegetable eggs or seeds by which all this is effected ; but we know that they exist in the atmosphere, and that this is the medium of their circulation. How far the tales may be true, of Possibly in living animals found in abscesses in different parts of the body, and and «xan- especially in scirrhous and pustulous exanthems, this is not the place thems- to inquire ; but, conceding the fact, we can only account for it by supposing their respective ovula to have been admitted into the sys- tem with the air or food we take in; and to have been separated as soon as they acquired possession of a proper nursery. We have strong reason to believe, however, that many of the eggs n^"^*)11" or animalcules that are traced in animal fluids, occasionally find other esgs are receptacles out of the body that answer their purpose as well, and capable of seem to keep up their respective species ; and, consequently, that ^'t"fed in provide a stock of eggs, larves, or insects, prepared to take pos- other sub- session of any decomposing animal substance as soon as it is ready tha"c arii- for their reception. And we are hence able to account for the pre- ^f^i413, sence of animalcules, in such situations, without being driven to the cuies not necessity of supposing them to have been generated therein ; and prodS^ «ee how it is possible that they should continue to exist in a regular by sponta- r - ° neous gerre- rntron. 230 c.l. i.] CCELIACA. [OBD. I. Gen. IX. Helminthia, invermina- tion. Worms. The opi- nion illus- trated by discoveries in natural history. Rolander. Lister. PalmErus. Lioneag. Doubts upon the subject, whence de- rived. First, from the different appear- ances of the same ani- mal in different periods of life. Examples. Secondly, from a dif- ference of appearance produced by a difference of food. Examples. chain of succession, instead of being produced anomalously and equivocally by the bildungstrieb, (as the German physiologists call it) or formative effort of a living principle, in substances in which life has confessedly ceased to exist. Thus, Rolander, who, like Linneus, ascribed dysentery to the dysentery-tick, or acarus dysenteric, and who himself laboured under this disease while residing in Linneus's house, contended that he had discovered the same insect in a water-vessel made of juniper- wood ; and conceived that it was conveyed in great numbers into his body by the water which he drank from the cistern. So Lister affirms that he has seen the ascaris vermicularis (the maw or thread worm) which is usually found burrowing in the lower part of the intestines, infesting the surface as well. In like manner, Palmaerus has rendered it at least probable, that the young, or ova of the fas- ciola hepatica, or fluke, found so abundantly in the liver of sheep that die of the rot, and the origin of which has so much puzzled the na- turalists, are swallowed by the sheep in marsh or stagnant waters. And Linneus himself pointed out that the taenia Solium, or tape- worm, the cause of whose existence in the alvine channel has been a source of equal difficulty to the physiological inquirer, exists, though much smaller, in muddy springs ; and notwithstanding that Pallas, at first, expressed doubts upon this point, the assertion has been since confirmed by additional and satisfactory observa- tions. Nor is it surprising that doubts should at times exist in the mind of the precise and cautious inquirer in many cases of this kind, which can only be removed by a long and attentive investigation of the history of the minute animals which give rise to them : for, first, the very same species assumes so different an appearance in different stages of its existence, that nothing but the most patient prosecution of the same individual through all his metamorphoses, could induce us to put any faith in its individuality. For who, for example, if he did not know it by the repeated experience of himself or of others, could believe that the black and the white carrion-vulture of Ameri- ca, (vultur Aura, Linn.) which, when teased, emits a cry like a mouse, are the same bird, merely changing from white to black as it grows old? Who could divine that the tadpole, possessing gills and a fish-tail, and without legs, should be the same animal, only younger, as the four-legged frog that has neither tail nor gills ? or that a like identity should apply to the caterpillar, the aurelia, and the winged moth ? But, secondly, we often see an almost equal change produced in a few generations of the same species, and oc- casionally in the same individual, by a change of food or habitation, or both. How widely different is the domestic sheep from the ar- gali; or the ox from the bison ! yet these are the stocks from which they have proceeded. A difference of food alone produces a growth and developeinent of the sexual organs in the honey bee, and con- verts what have hitherto been called neuters (but which are really imperfect females) into queens, or bearing bees. In many instances we can trace changes as considerable (and shall presently have oc- casion to remark them) in worms, or the larves of insects, introduced «:l. i.J DIGESTIVE FUNCTION. [ord. i. 231 accidentally into the human intestines from without. Several °fH1*M,tfI* these, however, are animals with the whole of whose history we are inven"ina- acquainted ; but we are not acquainted with the whole of the history wo'tms. of the ascarides, the taenia, and various other intestinal worms ; and hence might not know them out of the body, even though we should actually meet with them under some form or other. As animalcules are parasitic to plants, so are plants at times Planls Pa" .,*. p ■ ■ i A p rasiticto parasitic, to animals. I have seen funguses spring up night after animals. night on the sheets of patients with gangrenous limbs, where the corrupt discharge has soaked into the sheets, and rendered them a quickening nidus. Several species of clavaria grow on the chry- salis of one or two species of cicada, and even on the perfect insect itself, as others do on the May-fly.* Were this indeed the proper place for pursuing so interesting a study, I could show not only that there is scarcely an animal of any class or order, from the highest to the lowest, but is a prey to other animals of a minuter form that infest its interior as well as its surface, but that there is scarcely a vegetable, which has not also its parasitic plunderers, and is infested in like manner. But the subject would carry us too far : yet a few additional hints in relation to it are given in the comment to the Nosological System, and those who are desirous of extending the study may turn to them at their leisure. The various kinds of worms traced in the human stomach and ^ff^£ intestines have been differently arranged by different writers: butmentofhu- they have been chiefly assorted into round and flat worms ; or into ^different indigenous and exotic: in other words, into those which we are told w"te«; are generated in the alvine channel, and those which enter it from without. The first method is too limited ; and the second, as we b(^.n?ne. have already seen, not only hypothetical, but built on a false basis ; correct"1 y for we have reason to believe that every species found in this channel primarily existed out of it. In unfolding, therefore, the subject Jj[®w "J t further, we shall employ a different arrangement, and comprehend, proposed. under the genus helminthia, three species of diseases, equally dis- tinguished from each other by symptoms and by the different tribes of animals which give rise to them ; viz. those which are nourished and find a proper habitation throughout every part of the alvine canal; those whose proper habitation is limited to the extremity of the canal; and those which have no proper habitation in any part of it, and enter it erroneously or by accident. 1. HELMINTHIA ALVI. ALVINE WORMS. 2.-----------PODICIS. ANAL WORMS. 3.-----------ERRATICA. ERRATIC WORMS. * Memoires sur des Insects sur lesquelles on trouve des plantes, par M. Fougeroux de Booderoy. Vide Hist, de l'Academie Royale des Sciences, An. 1769. £32 ex. i.] CCELIACA. [ord. I* SPECIES I. HELMINTHIA ALVI. ALVINE WORMS. WORMS EXISTING AND FINDING A PROPER NIDTJS IN THE STOMACH OR ALVINE CANAL, CHIEFLY OF CHILDREN, AND SICKLY ADULTS ; PRODUCING EMACIATION, A SWELLED HARD BELLY, GNAWING OR PUNGENT PAIN IN THE STOMACH ; PALE COUNTENANCE, FETID BREATH, AND IRRITATION OF THE NOSTRILS. Gen. XI. The worms that chiefly infest this region, and produce these Spec. I. Symptoms, may be arranged under the following varieties : et Ascaris lumbricoides. p Trichocephalus. y Taenia Solium. $* Taenia vulgaris. £ Fasciola. Long round-worm. Long thread-worm. Long tape-worm. Broad tape-worm. Fluke. a H Alvi. Ascaris lumbri- coides. Long round- worm. Habits and effects. How differs from the earth- worm. The head of the long round worm is slightly incurved, with a transverse contraction beneath it; mouth triangular ; body transpa- rent, light yellow, with a faint line down the sides ; gregarious and vivacious ; from twelve to fifteen inches long. Inhabits principally the intestines of thin persons, generally about the ileum, but some- times ascends into the stomach, and creeps out of the mouth and nostrils : occasionally travels to the rectum, and passes away at the anus. Frank notices an instance of eighty of these worms rolled up into a ball, and expelled during a fever : and gives another case in which the whole intestinal canal from the duodenum to the rec- tum was crammed with them.* This animal will sometimes remain so quiet in its proper region, as to give no signs of its existence but by its discharge. Frequently, however, it is a troublesome and mischievous intruder, producing an intolerable feeling of faintness, great emaciation, and most of the symptoms enumerated under the specific definition. In its general appearance it bears so striking a resemblance to the earth worm (lumbricus terrestris, Linn.), that by many naturalists it has been re- garded as the same. Yet to an attentive observer, there is a consi- derable difference both in their form and movements. The body of the intestinal worm is round, its colour is a pale red, its head is furnished with three vesicles placed triangularly, and, in moving, it curls its body into circles, from which it extends its head. The earth worm is flat towards the tail, and has bristles on its under-side which it can erect at pleasure. Its colour is dusky red; its head * De Cur. Morb. Hoin. Epit. Tom. vi. Lib. vi, cl. i.] DIGESTIVE FUNCTION. [ord. i. 233 has but one vesicle, and it moves by a continuous course of action Gen. XI. propagated from ring to ring. oftlwi'" The body of the long thread worm is, above, slightly crenate; Ascaris beneath, smooth ; finely striate on the fore-part; head obtuse, and coide" furnished with a slender retractile proboscis ; tail or thinner part J^. twice as long as the thicker, terminating in a fine hair-like point, w°rm. about two inches long ; in colour resembles the preceding : grega- Trichoce'" rious, and found chiefly in the intestines of sickly children ; generally S^1"8, in the caecum. It is found also in many animals besides man, as the thread- horse, boar, fox, and mouse. Goeza considers the proboscis as the wonn' male organ. In the long tape worm the articulations are long and narrow, Y H.Aivi. with marginal pores by which it attaches itself to the intestines, one num. on each joint, generally alternate ; ovaries arborescent: head with ^°Jm.laper a terminal mouth surrounded by two rows of radiate hooks or holders ; and a little below, on the flattened surface, four tuberculate orifices or suckers, two on each side: tail terminated by a semicir- cular joint without any aperture : from thirty to forty feet long, and has been found sixty. Inhabits the intestines of mankind generally at the upper part, where it feeds on the chyle and juices already animalized. Is sometimes solitary, but commonly in considerable numbers : and adheres so firmly to the intestines that it is removed with great difficulty. It is said to have a power of re-producing parts which have been broken off; but this assertion wants proof The animal is oviparous, and discharges its numerous eggs from Genuine ™~ character* the apertures on the joints. Werner asserts that it is hermaphro- dite. The broken-offjoints have, when discharged, the appearance of gourd-seeds: and it is hence denominated gourd-worm by many medical writers ; and is the lumbricus cucurbitinus of Dr. Heberden. In the collections of the Medical Society of Copenhagen Dr. Sib- barngaard gives the case of an adult female patient who was infested with a tape-worm of enormous length, measuring not less than thirty-eight yards, or one hundred and fourteen feet. It was expelled from the anus after taking three doses of a bolus, consisting of two drachms of tin-filings and half a drachm of jalap mixtup with honey.* The articulations of the broad tape worm are short and broad, <5 H Alvi. with a pore in the centre of each joint, and stellate ovaries round garis!" T r them : body broader in the middle, and tapering towards both ends ; Broad tape- head resembling the last, but narrower and smaller ; tail ending in a rounded joint. Like the last, inhabits the upper part of the intes- tines, and feeds upon the chyle ; from three to fifteen feet long : usually in families of three or four. The body of the fluke is flattish, with an aperture or pore at the « h. Alvi. head, and generally another beneath ; intestines flexuous; ovaries l^ke0.'*' lateral: hermaphrodite, and oviparous. Of all intestinal worms this is one of the most common to animals Found ex- of different classes It is sometimes, though rarely, found in man ;t almoItaV but in different species, or under different modifications, we meet an'"191* * Socictatis Medica? Havniensis Collect. Vol. ii. 8vo. t Doever, Verm. p. 54. Clerk, Lumbric. p. 119. Vol. L—30 234 cl. i.] CCELIACA. l^u. i. Gen. XI. with it very frequently and very abundantly in quadrupeds of almost £ Il am!' all kinds, reptiles, fishes, and even in worms themselves of a larger Fascioia. growth, for it is occasionally met with in the intestines of the cuttle- fish. Its ordinary seat is in the stomach or alvine channel ; but in swine, black-cattle, deer, and sheep, its favourite haunt is the liver, to which it probably creeps forward through the bile-ducts, and where it Cause of burrows and breeds in innumerable hosts. This is particularly the the rot In case with the faseiola hepatica, as it is called by way of emphasis, sheep. found so commonly and so abundantly in the liver of sheep that labour under the disease called the rot; though whether it be the cause or the effect of this disease, has not yet been ascertained. Most pro- Most probably the effect: for the rot is certainly an infectious com- pter j'and plaint, and is sometimes caught by a whole flock in a single night. duced'b^a ^ne cause ^as been supposed to be hydrogenous gas ; but of this floating we have no proof. There can be little doubt, however, that it is miasm. produced by some deleterious miasm in the atmosphere originating in the pasture itself, or conveyed there in the form of a haze, in the same manner as vegetable plantations are often blighted, of which I have just offered an example from hop-grounds. Yet by what means the liver of sheep rather than any other organ, is hereby debilitated and rendered gangrenous, we have still to inform ourselves. As the animal is oviparous, the minute eggs may be borne by the haze itself, or exist in the stagnant atmosphere of the sheep-ground ; or they may already, in the body of the parent worm, be infesting ffie alimentary canal, and only waiting for accidental circumstances to Flakefound exert the full range of their prolific powers ; for it is not in the rot eases than* alone, but in other cases of visceral diseases, that this animal is traced the rot. m gheep^ and especially in dropsy, whether connected with the rot or not; and in both diseases they are frequently found vomited up in brooks. View of the As the treatment of all the species should be established on the postponed same principle—that of invigorating the Alimentary canal and sur- remaining rourKnng viscera,— and the vermifuges adapted to many of the dif- species ferent tribes, though not to all, are the same, it will be better to noticed?" reserve this subject till the nosological characters of the remaining species have passed in review before us. cl.i.] DIGESTIVE FUNCTION [ord. i, 235 SPECIES II. HELMINTHIA PODICIS. ANAL WORMS. WORMS, OR TIIE LARVES OF INSECTS EXISTING, AND FINDING A PROTER NIDUS WITHIN THE VERGE OF THE ANUS, EXCITING A TROUBLE- SOME LOCAL IRRITATION, S03IETIMES ACCOMPANIED WITH TUMOUR ; FREQUENTLY PREVENTING SLEEP, AND PRODUCING PAIN OR FAINT- NESS IN THE STOMACH. Under this species are included the following varieties : *|EN- ^r. x Ascaris vermicular is. Thread-worm. Maw-worm. <3 -------Scarabaeus. Beetle-grubs. y ------- CEstrus. Bots. The head of the thread-worm is subulate, nodose, and divided «H-Po . ... ,. ' pi, i ■ • i where de- cioaria, or pantry-fly; or perforate and lay their eggs in cheese, posited. bacon, hams, or other salted and high-tasted viands as, m. putris, the larves of which are known to the housewife by the name of hop- Hoppers. pers, as those of all of them are by that of maggots; which last has often, though in a looser sense, been applied to the grubs of insects generally. From the deposite of the eggs of these species of the fly in so many How reach branches of the common food of man, there is no difficulty in con- intestines. ceiving how they may pass into the human intestines. In a sound state of the stomach, indeed, we have little reason to believe that they could be hatched and live in that organ ; but they may find a convenient nidus, and live comfortably in a debilitated stomach, and apparently through the entire range of the intestinal canal. The cases of this affection are numerous. One of the best re- Examples lated, is that of Dr. White in the Memoirs of the Medical Society of London. The patient, aged thirty, was emaciated, of a sallow com- plexion ; had gripings and tenderness of the abdomen; costiveness, rigors, and cold extremities. Took columbo root, and occasionally calomel and Other purgatives. In a month was better, and the ap- petite good. The next purgative brought away an immense num- ber of pupes or chrysalid worms ; some of which being preserved, were transformed into the musca cibaria. We have also examples of the larves of other insects that have en- tered the stomach by some accident or another. Thus Mr. Church, to whose entomological skill Dr. White confided the examination of the above paper, asserts, that he once knew a child discharge a larve of the caddy insect (phryganea grandis) ; and that the phalama pin- guinalis lives and is nourished in the stomach ; and, after sustaining several metamorphoses, is thrown out, and proves its proper genus.t Mr. Calderwood has published a fike case;| Riedlin, examples of ^eeiod^ed other fly-maggots ;§ other writers, of the larves of the beetle, or the testines. bee discharged by the anus after violent gripings ;|| while Planchon describes a live spider thrown forth from the same opening. IT Spider.; Weikard gives an instance of a triton palustris discharged by vo- Tr,iton. miting ;** and many of the continental writers have examples of re- jection by the same passage of the lacerta aquatica, unquestionably lacerta swallowed when minute and unperceived, with the water obtained * London Med. Observ. and Inq. I. 68. t Vol. n. T Edin. Med. Com. ix. 223. § Cent. in. Obs. 85. [| Obs. Med. Cur. de excretione vermis nunquam ante excret. Wolffenb. 1723. IT Journ. de Med. iv. p. 203. ** Vermischte Schrifter, iv, p. 127. Kl. Schrift. p. 82. 240 cl. i.] COSLIACA. [okd. I. sites. T. ex. I.] DIGESTIVE FUNCTION. [ord. r. 251 lice. And hence it appears to exercise some poisonous effect on Gen. XF. worms, though harmless to the human stomach. nTv'erlnina.-' From its want of sensible qualities, however, it has been perpetu- ^£"; ally varying in its reputation. It was esteemed in the time of Galen Treatment. and Dioscorides; appears afterwards to have sunk into oblivion; 1™mJi,B and again rose into reputation in the days of our venerable country- reputation. man Gerard, who not only enumerates its virtues, but establishes the dose in which it should be taken. " The roots of the male fern," says he, "being taken to the weight of half an ounce, driveth forth long flat worms out of the belly, as Dioscorides writeth, being drunk in mead or honeyed water ; and more effectually if it be given with two scruples, or two-third parts of a dram of scammony, or of black helle- bore. They that will use it," he continues, " must first eat garlick. The female fern is of like operation with the former, as Galen saith."* After the time of Gerard, it appears again to have fallen into obli- vion ; till it was once more called into notice by various successful accounts of its utility, published by Messrs. Andry and Marchant about a century ago. It again became neglected in medical prac- Character • o o o * revived bv tice till about the year 1770, when it was revived in Switzerland and Madame' France by the celebrated Madame Nouffleur, who, under her own pro- Nouffleur- cess of using it, boasted of it as a specific; but kept the process to her- self. The secret was at length purchased by the king of France, and Her patent liberally communicated to the world. The patient, according to Mr. rrepara Baumfi's statement,! after being prepared at night by an emollient clyster and a supper of panada, is, early the next morning, to take three drachms of the fern at a dose, and to repeat it instantly if the stomach should reject it. Two hours after which he is further to take a bolus, consisting of twelve grains of calomel, twelve grains of resin of scammony, and five grains of gamboge, which, it must be confessed, seems admirably calculated for a triumphant issue in some way or other ; for it will probably either kill the worm, or kill the patient. It is by no means necessary to give so violent a cathartic. It is far less difficult to account for the. real or supposed specific Indian- virtues of the Indian-pinks, or worm-grasses, for there are two spe- worm-0' cies of the spigeiia that have been employed for this purpose ; s. srasses- Anthelmia, and s. Marylandica; and for those of the Indian scabious Indian sea- shrub, called by the natives cattu schiragaam. These are all acrid ahm™! narcotics; in large doses, as above, two drachms, or two drachms narcotic* and a half, sometimes purging violently, sometimes producing verti- go, dimness of sight, drowsiness, and clonic convulsions; and some- times producing all together: and hence, the same violent effects being excited, perhaps in the parasitic worms as in the patient it is not to be wondered at that they should fall a sacrifice to them, or endeavour to save themselves by a timely and rapid escape. The scabious shrub, however, seems to act more feebly than the Indian- pinks, and is little to be depended upon; while the latter are far too acrimonious for general use. * Hist, of Plants, p. 1130. t Elemens de Pharmacie.— Precis de Traitement, &c pubhe par ordre dis RoL Parb, 1775 252 cl. i.] CCELIACA. [ord. i. Gen. XI. Helminthia. Invermina- tion. Worms. Treatment. Electricity as an an- thelmintic. Mare's milk in cases of uenia. Illustrated. from Kor- tum. Before closing the subject, I will just observe, that Dr. Friske, of Brunswick, has lately employed electricity as an anthelmintic, or rather with a view of killing the worms in their mucous domiciles, by passing powerful shocks through the abdomen. He thinks he has by this plan destroyed even the taenias ; yet he does not choose to rely upon this practice without the use of active cathartics. There is also a much milder remedy that has for some time been adopted in Germany, upon the efficacy of which I cannot speak from personal knowledge, but which is well worthy of attention ; and es- pecially in respect to patients of irritable stomachs and emaciated constitutions ; and that is, the use of mare's milk, and particularly in cases of taenia. While this worm appears fond of cow's milk, there are various facts that seem to prove it has a very strong antipa- thy to that of the mare ; and that, upon being exposed to its action, it either quits the intestines a few days after its use, in a living state ; or, if it remain beyond this period, is expelled piece-meal and in a corrupt condition. Dr. Kortum, of Stalberg, has related a striking case of this kind in Hufeland's Journal. The patient was a lady, between thirty and forty years of age, whose stomach was in such a state of irritability as to reject whatever vermifuges had hitherto been tried. Having heard of the success of mare's milk, drunk morning and evening when fresh drawn, she took two tea-cups of it one evening, and soon afterwards complained of violent pains in her bowels, which conti- nued till the morning, when she took an additional cup. The pains, from this time, gradually subsided ; and in a few days a long piece of a dead and offensive taenia was discharged; and not long after- wards, another piece, with the narrow tapering end of the worm. After this, all the symptoms of disease disappeared. ' i<-1.] DIGESTIVE FUNCTION. [ord. i. 253 GENUS XII. PROCTICA. PAIN OR DERANGEMENT ABOUT THE ANUS, WITHOUT PRIMARY INFLAMMATION. The name for this genus has been taken from Linneus ; Sagar Gen.XII. and Macbride having formed a like genus, under that of Proctalgia. In the scope in which it is here employed, it will include the six fol- Scope of lowing species; all of them occasionally met with as idiopathic dis-the genus' eases, though several of them are perhaps, more generally found as symptoms or sequels of other affections. 1. PROCTICA SIMPLEX. 2. ------- SPASMODICA. 4. 5. 6. CALLOSA. TENESMUS. — MARISCA. — EXANIA. SIMPLE PROCTICA. SPASMODIC STRICTURE OF THE RECTUM. CALLOUS STRICTURE OF THE RECTUM. TENESMUS. PILES. FALLING DOWN OF THE FUNDAMENT. SPECIES I. PROCTICA SIMPLEX. SIMPLE PROCTICA. SIMPLE PAIN AT THE ANUS. This, when a primary affection, and unconnected with any other Gen.XH. disease, is usually produced by cold, especially by sitting on a damp causes! ' seat, as a piece of wet timber, a wet fragment of a rock on the sea- coast,, or moist grass. Local irritation will also produce it; as hard- ened and constipated feces, passed with considerable straining, and especially in irritable habits. It is sometimes intolerably severe, and has all the characters of chronic rheumatism. In the last case, I have known hard local pressure of essential ser- Treatment. vice in diminishing the pain and shortening the paroxysm. On other occasions, it has best yielded to an opiate pill, introduced within the verge of the anus, or to a local warm bath, obtained by sitting in a bidet prepared for the purpose. 254 cl. i.] CCELIACA. foRD. 1. SPECIES II. PROCTICA SPASMODICA. SPASMODIC STRICTURE OF THE RECTUM. PAIN IN THE RECTUM REMITTENT, SOMETIMES INTERMITTENT ; IN- CREASED DURING EXPULSION OF THE FECES ; VOLUME OF THE FECES SLENDER BUT VARIABLE ; RIGID GKASP OF THE SPHINCTER ON INTRODUCING THE FINGER ; STRUCTURE OF THE BOWEL SOUND. Gen XII. Strictures of the rectum are produced by a spasmodic contrac- Spec. II. tion 0f jts sphincter muscles, or by a thickening and induration of cause™118 its coats. The first forms the species before us : it is the simplest and least formidable of the two affections, though generally very ob- stinate ; it also occurs by far the less frequently, and has hence at- tracted but little of the attention of medical writers. The second, which often terminates in a scirrhous disease, will be found to con- stitute the next species. Predispos- The glandular structure of the rectum renders it peculiarly irrita- iog causes. W(^ and the natural arrangement of the fibres of its sphincters, give From the it an habitual tendency to contract. It is hence easy to conceive, raneeme'nt that any undue stimulus may excite an inordinate degree of contrac- of the fibres tion in the sphincters, which may be propagated to a greater or less sphincter, degree of ascent through the muscular tunic of the bowel. This in- ordinate action will, at first, be disposed to cease on a cessation of the stimulating cause ; but if the stimulating cause be frequently re- peated, or of long duration, the contraction may become permanent. and continue to exist after the cause has been removed. From a A like predisposition to inordinate and permanent contraction may ofCtheir" y take place, as Mr. Copeland has ingeniously remarked,* from the different* *" Pecuuar structure or peculiar extent of the sphincter fibres in par- individuals, ticular individuals. Anatomists have not come to an unanimous agreement, whether these fibres, issuing from the exterior and the interior surfaces, of the extremity of the rectum, and freely decus- sating and intermixing in its substance, be two distinct muscles, or only a single one. The older anatomists seem to have been of the latter opinion; Dr. Baillie, M. Petit, and M. Portal speak of them, and describe them as distinct sphincters. Be the fact as it may, we sometimes find that the two layers of fibres do not act correspondently, and that the contractile power of the one follows, instead of keeping pace with that of the other, or evinces some other mode of inaccordancy, so that the entire muscle is seldom left in a state of perfect rest and relaxation. And we also find, that in some individuals, even where the action is harmonious, the con- tractile organ is too broad or too powerful to be overcome by the expulsory power of the abdominal muscles ; and, consequently, * Observations on the Principal Diseases of the Rectum and Anus. Sect. i*. cl. i.] DIGESTIVE FUNCTION. [ord. i. 255 that the feces are expelled less frequently and less freely than they Gen.XU. ought to be; whence a habit of costiveness is induced, and the con- pfocuca^' fined excrement, becoming acrimonious by its lodgment, forms a Bi-asmo- permanent source of irritability, and is constantly augmenting the spasmodic contractile propensity. stricture of . u ■ 1 • • • i • i • the ivctum. Any other local irritation, under such an irregularity of muscular Habitual structure, must have a like effect: as a daily use of acrid ptirga- active tives, in small quantities, with a view of counteracting costiveness ; positives. irritable caruncles, or excrescences at the verge of the anus; a turgescent, and especially a varicose state of the internal hemor- rhoidal vessels. And even where there is no such irregular con- struction of the sphincters as we are now contemplating, any of these accidental sources of stimulus, in a debilitated and irritable habit, or a debilitated and irritable state of the alimentary canal, in which all of them are most prone to occur, may lay a foundation for the same complaint. Yet the complaint does not appear to have occurred frequently, Thisspecies though it is probable that it has occasionally been mistaken for the frequently. indurated and thickened contraction which forms our next species, and described and treated accordingly. A few cases of it, and only a few, have occurred in the course of my own practice ; but as one of these was the lot of a near relation, my attention was turned to it very minutely : and it is from the observations I have hence been induced to make that I have drawn up the specific definition. Mr. Copeland has favoured the world with some valuable and B*.tbd^" b ingenious remarks upon this disease ;* but the only writer who has dpeiand, hitherto, so far as I am acquainted with, distinctly described it, by what may be called a close and full length portrait, is Dr. Baillie ;| a,d BaiUie* and, as his account minutely corresponds with what I have been an eye-witness to, I shall avail myself, to some extent, of his words, as containing a more correct expression of the complaint, than any I could hope to offer. After noticing that strictures of the rectum are almost constantly produced by a thickening of its coats, in the progress of which ulceration very commonly takes place on the inner surface of the bowel, and the patient is ultimately destroyed, as the ulcer has no tendency of itself to heal, and the art of medicine has hitherto failed in communicating to it any healing disposition ; this distinguished pathologist proceeds as follows :— " Another kind of stricture, however, occasionally occurs in the nesI?ri.p'ion ...... , . , '. ,i hy limine rectum, much less formidable in its nature, which is very rare, and has hitherto been taken little notice of by practitioners. This is not at- tended with any diseased structure of the coats of the rectum, but de- pends upon a contraction, more or less permanent, of the sphincters of the anus. " A good many years ago, a very well marked case of this kind fell under my notice, an account of which it may not be improper to communicate to the College. * Observations on the Principal Diseases, &c Sect, tv * Mpduced in an irritable habit from mere other dis- terror, excited by a threat of applying a red-hot iron to some part of the body.* CLASS I. CCELIACA. ORDER II. SPLANCHNICA. DISEASES AFFECTING THE COLLATITIOUS VISCERA. Class I. OrderII, Splanch- nica, its various senses. Its meaning in the present ar- rangement. Organs included under it. DISQUIET OR DISEASED ACTION IN THE ORGANS AUXILIARY TO THE DIGESTIVE PROCESS, WITHOUT PRIMARY INFLAMMATION. The order of diseases upon which we now enter is in the present classification denominated Splanchnica (EflAArXNlKA), as pri- marily affecting, and being seated in, the viscera that are directly adjuvant to the function of digestion. The term Splanchnica is thus reduced to its more limited and emphatic sense ; for, in a loose and broader signification, it imports, like its Latin synonym viscera, all the larger bowels or internal organs to whatever cavity they appertain, and consequently includes the brain : but in its stricter and more ex- act meaning, it was formerly confined to those of the upper and lower belly, comprising what we colloquially call the Entrails ; and more especially those which were consulted by the aruspices, and consti- tuted the chief parts of the sacrifice : in which sense it is mostly employed by Homer, and the Greek tragedians. The organs, therefore, to which the term is here intended to be applied (for the alvine canal forms the subject of the first order,) are the liver, spleen, pancreas, mesentery, and omentum ; and as, in the physiological proem to the class before us, we took a general survey of the structure of these organs ; and, so far as we are ac- quainted with them, of the parts they respectively fulfil in accom- plishing the economy of digestion, we shall proceed, without farther delay, to a consideration of the diseases which belong to them under the proposed arrangement. * M'emoK*. Cent. x«r vl. i.] DIGESTIVE FUNCTION. [ord. ii. 275 The order embraces four genera:— Class. I. I. icterus. yellow jaundice, II. MELjENA. black jaundice. III. CHOLOLITHUS. GALL-STONE. IV. PARABYSMA. VISCERAL TURGESCENCE. Of these, several comprise numerous species, which will be jioticed in their respective places. GENUS I. ICTERUS. YELLOW-JAUNDICE. YELLOWNESS OF THE EYES AND SKIN ; WHITE FECES; URINE SAF- FRON COLOURED, AND COMMUNICATING A SAFFRON DYE ; THE COURSE OF THE BILE OBSTRUCTED. This disorder was by the Greeks denominated icterus (IKTEPOS) ^^a as above, and by the Romans, as Celsus particularly notices, Mor- by the bus arquatus or Morbus regius : but on what account either of these Ro^an,*1"1 names has been given to it, we have no satisfactory information, fr?m «»icer- Arquus means a rainbow, which requires more explanation than has iog"ies.ymo hitherto been given ; and the meaning of regius, as expounded by Celsus, will, I apprehend, content very few. " Its cure," says he, " is to be attempted by exertions of every kind, luso, joco,ludis, las- civia, per quae mens exhilaretur ; ob qu.e regius morbus dictus videtur :"*—' by play, jests, sports, and dalliance, on which account it seems to be called Morbus regius, or the royal disease.' It has also been named by many writers, ancient as well as modern, Aurigo, evidently from its golden hue. But of the origin or mean- ing of icterus we are left altogether in the dark by the critics and lexicographers. It appears to the present author, however, pro- Jg»w« bable, if he may venture upon a subject which has hitherto been both the^ tried in vain, that all these terms are expressive of a common idea ; i«a" and, though not derived from a common root, are employed as names. equivalents to express its meaning. Icterus (txnpt), as it seems to him, is the Hebrew term TO with a formative ' producing -ir^1 or * icier,' and importing as a verb, * to surround, circumfuse, encompass;' and, as a noun, ' a royal crown, or golden diadem.' Icterus was a term also given to the golden thrush or golden phea- sant, on account of its golden plumage ; and hence the bird was fabled to be connected with the disease; and it was believed, ac- cording to PUny, that if a person labouring under the jaundice * Medicia. Lib. m. Sect. xxiv. 276 cl. i.J CCELIACA. [ord. ii. Gen. I. should look at the pheasant, the bird would die, and the patient Yenow- recover. Regius, arquatus, aurigo, are not indeed univocals, but jaundice. verv clearly equivalents, and equally import gold, golden crown, golden bow, or circumfusion ; the colour of the disease, and its other dis- encompassing the body. There are other diseases, however, that marked b°y produce, or are accompanied with a yellow tinge of the surface as finge'oTthe weu" as jaundice; as aurigo,* and sometimes porphyra or scurvy. surface. Frank mentions a case of the latter, in which there was an intense yellowness of the whole skin, chiefly proceeding from broad ma- culae, even to the palms of the hands, and soles of the feet.j But in all these cases the albuginea is little or not at all affected, and the urine does communicate the saffron dye of jaundice. what the There is, however, a far more important inquiry immediately biie;° ' e connected with this subject, which 1 am afraid will be still less easily settled. We are sufficiently acquainted with the seat of jaundice, which is the liver, and of its proximate cause, which Con- or of the sists in an impeded flow of the bile ; but who shall explain to us the real use of the bile, or even the final use of the liver that se- cretes it ? Considering the large size of the liver in all animals The Hver that possess it, and at the same time how very generally it is pos- a°nimaisof sessed, being to all red-blooded animals as common as the heart eve1°Strank- itself, there can be no doubt that it is of great importance in the ' animal economy, notwithstanding our uncertainty of the part it performs. and Me Even below the rank of red-blooded animals we often discover even where it, and of great extent, as in the snail, oyster, and muscle; and dUcove"8 frequently, too, where we cannot trace an organ answerable in abie. structure and appearance to the liver, we are obliged to admit the existence of an organ that supplies its place ; for there are many insects, as the larves of the cynips querci, or gall-fly, and that of the curculio nucis, or nut-weevil, that secrete bile in such quantity as to tinge with a brownish yellow the tender branch, nut, or other sub- stance, in which they find a habitation, and to give them a taste as bitter as ox-gall. ^ether Whether the liver serves, as has been supposed by Fourcroy, to separates separate any excrementitious material from the blood, or to produce memuious' any other effect uPon i4»is hi£hly doubtful: we can trace no such matter. effect, and know nothing of such excrementitious matter. Its direct and obvious office is the secretion of bile, which, in most animals, is suffered to accumulate in a pear-shaped reservoir, ad- hering to its concave surface, and denominated a gall-bladder. def wantL Yet in many animals> even of different classes, we perceive no such in many ° reservoir, as the elephant, rhinoceros, stag, camel, goat, horse, pedVu" trichecus, porpoise, rat, ostrich, and parrot: while we do not know Whichu.tdw °f a reptlle that is destitute of it. Upon the whole, however, it may be may be observed, that a gall-bladder is common to all carnivorous cxpected. animals possessing a liver, and that it seems to be only wanting in those that feed on vegetables alone. Yet while we see the dis- t Class vi. Ord. m. Gen. x. Spec. iv. X De Cur. Horn. Morb. Epit. Tom. vi. Lib. vi. cl. i.] DIGESTIVE FUNCTION. [ord. ii. 277 tinction, we are ignorant of its cause, and incapable of applying it. Gen. I. In the human subject it has sometimes also been wanting, of which YeiiX- Dr. Cholmeley gives a singular example in the Medical Trans->undic„e- * 1 . i_ , p ■ \ ,..„ Ci»se of an actions :*■ but such a deficiency has only occurred m infants, who infant in have fallen victims to it soon after birth ; before which period, as ^not' there is no transit of feces through the intestinal canal, and perhaps found- no peristaltic action, it does not appear to be necessary. Perhaps, ^ante"0 indeed, antecedently to birth there is no bile secreted. In the case cedentiy to related by Dr. Cholmeley, although the whole of the bile, as fast birth- as it was secreted, seems to have been carried back into the system, the sallowness of the skin is not noticed to have occurred till the day after birth : from which time the child exhibited a deeper and deeper hue, till it died of convulsions at the end of five weeks. It has reasonably, therefore, been supposed, that one chief use of weh^i}1eer the bile is to stimulate the lacteal vessels and maintain the peristal- acts as an tic action of the alvine canal. Yet in jaundice the lacteals perform "p^",^ their office ; and in lientery the peristaltic action is peculiarly brisk, intestines. though the intestines are without this fluid. Hence Dr. Fordyce Not always regarded the bile as of no service whatever in promoting the diges- dwSrT0 tive process ; and Sir Everard Homej has given an example of a child that fed heartily, seemed to digest its food well, and had regu- lar stools, and was nevertheless without a gall-bladder, or even a duct of any kind leading from the liver to the duodenum. And how- ever stimulant the bile may be to the coats and emunctories of the intestines, it has a sedative rather than a stimulative power upon the And a blood ; and, instead of rousing to additional energy, produces weari- the blood!0 ness and inactivity. There are also a few other circumstances relating to the bile, that yet stand in need of explanation. The hepatic bile, or that Diffidence secreted into the hepatic duct, is mild and sweet; the bile found in hepatlc^d the gall-bladder is pungent and bitter ; whence we might infer that cystic bile- it is the gall-bladder that secretes the bitter principle. Yet in chil- dren the gall-bladder bile is as sweet as that of the hepatic duct: and in various insects, as We have already seen, a bile powerfully bitter is secreted without either gall-bladder or liver. Who shali de- why this velope the cause of these discrepancies ? Who shall unfold to us the dlfferencel use of the bitter principle of the bile, or explain why it is necessary to the animal economy in an adult state, and not necessary in a state of infancy ? Yet, whatever be the use of the bile, or the office of the liver, we obstructed know that the general symptoms of jaundice depend upon an ob- thecauseof struction of the flow of the bile into the alvine canal, and its retro- jaundice. grade passage into the blood. It has been supposed, indeed, that the bile mighty after entering into the intestines, be absorbed and car- ried into the Mood, and by this mean produce a jaundice and a jaun- diced hue, without any obstruction to i ■ s flow into the intestinal channel. But. in this case, it seems impossible that the stools should not be tinged with a yellow, instead of presenting a white hue, which is one * Vol. vi. Art. iv. t Phil. Trans. 1813, pp. 156, 157. 278 CL. I.] CCELIACA. |_ORD. 11. Gen. I. 0f the common characters of the disease. In order to constitute jaun- dice, there must therefore be some obstruction to the passage of the bile through its proper ducts into the intestinal canal. And this ob- struction may proceed from five sources ; each of which may be ac- companied with peculiar symptoms, and consequently furnish us with the five following species : Icterus Yellow- jaundice. Produced from live distinct sources. 1. ICTERUS CHOL.EUS. 2. ------- CHOLOLITHICUS. 3. ------- SPASMODICUS. 4. ------- HEPATICUS. 5.-------INFANTUM. BILIARY JAUNDICE. GALL-STONE JAUNDICE. SPASMODIC JAUNDICE. HEPATIC JAUNDICE. JAUNDICE OF INFANTS. The disease is also found symptomatically in pregnancy, colic. and fevers of various kinds ; especially epanetus icterodes, or yellow fever. SPECIES I. ICTERUS CHOL^US. BILIARY JAUNDICE. THE COURSE OF THE BILE OBSTRUCTED FROM ITS OWN VISCIDITY : GENERAL LANGUOR ; NAUSEA ; DYSPEPSY ; AND OCCASIONAL PAIN OR UNEASINESS AT THE STOMACH. Gen. I. The specific term choloeus (#oA««j?) is here restored from the Spec. I. Greek writers, among whom it has been common from the time of Hippocrates. Species not Dr. Cullen has not noticed this species : but it occurs in Bonet, Dr^cuiien Amatus Lusitanus, Forestus, Sauvages, and most of the later wri- but by ' ters. It is easy, indeed, to conceive that bile may become inspis- other"9 sated from various causes ; and particularly from an absorption of Bile may be jts aqueous or thinner parts by the lymphatics of the ducts themselves, from vari or of the gall-bladder ; from an augmented secretion of the albumen, jus causes or^ ag j3erzelius considers it, the mucus of the gall-bladder dissolved . in the bile ; and from too viscid a texture of the bile in its secretion in the liver. And in effect there are few observant practitioners but must have remarked that the evacuations, whether by the mouth or the anus, when the obstruction is just removed, consist at times of nearly pure bile, peculiarly tenacious and high coloured. Founimost This species is found most generally in the autumn, when the [neqtherUy ^ner Parts of the animal fluids have been for some weeks or months autumn, carried off disproportionately by the heat of a summer sun. The mences.1" disease, in many instances, commences slowly and insidiously ; there Fvmotoms? ls ^ a general restlessness, diminution of appetite, disturbed sleep at night, and disinclination for exertion of anv kind : the urine is of symptoms. cl. i.] DIGESTIVE FUNCTION. [ord. ii, 279 a deep yellow, and deposites perhaps a pitchy sediment; the bowels Gen. I. grow sluggish, the dejections are clay-coloured, or whitish ; the eyes ,^rEu^ u and surface of the body look yellower than usual, and there is a very choueus. troublesome itching of the skin. In this species, however, there is jaundice. little or no pain in the right hypochondrium, and little or no sickness at the stomach, though a frequent sense of nausea. In an early stage of the disease, free vomiting is of essential ser- Medical vice. During this action, the diaphragm and abdominal muscles Fr*omen' contract concurrently ; and the whole of the viscera of the abdomen v°mitins: are forcibly pressed upon. Such a pressure must necessarily there- fore affect the gall-bladder and biliary ducts, and oblige them to pour out their contents very freely : nor is there a more powerful mean in our possession of unloading the liver of any viscous or stag- nant fluid, or of restoring and invigorating its circulation. For with emi- this purpose the antimonial emetics are preferable to those of ipeca- Emetics. cuan. They are less readily rejected, and excite a stronger stimulus from the first; and hence the vomitings they produce will continue for a longer period of time. To these should succeed a brisk pur- Brisk pur- gative or two, with a copious use of diluting, sub-acid drinks, which gatlvea> in ordinary cases, will easily remove every symptom. But if the Effects disorder, from the obscurity of its march, be not soon suspected, the ^ic?" cI"° impeded passages will become more obstinately obstructed, the gall- bladder and bile-ducts will be distended ; there will be a general feeling of fulness in the right side ; with great irritation, and fever ; which last will often continue for a week or a fortnight after the ob- structing cause has been removed. This species, however, sometimes makes its appearance suddenly, The disease and is accompanied with very violent effects from the first; and suddeliTand effects which are apt to lead the practitioner astray from the real jjf^f,^" nature of the disease. Two cases of this kind occurred to me in the its effects course of September 1820. I was sent for express to a gentleman "g^s* of about thirty years of age, who was suddenly attacked with a slight illustrated, haemoptysis, without any other preceding symptoms than a disinclina- tion for food, and a rather more than usual sense of fatigue after exertion. As he had lost two brothers in succession from phthisis, in the prime of life, a few years before, the attention of the patient's friends, and of a very respectable practitioner whom he had sent for at the moment, was directed exclusively to the organ of the lungs, under the full belief of their being in a diseased state, and in fearful apprehension of the result. On my arrival, I found he had expe- rienced another slight return of haemoptysis a few hours after the first; had taken an aperient draught, and had lost ten or twelve ounces of blood. I found him labouring under a very considerable degree of fever, with a rapid though not a hard pulse, beating upwards of a hundred strokes in a minute, a hot and dry skin, great thirst, and a clammy tongue ; but without the slighest cough, beyond an occasional hawking of mucus, untinged with blood, from irritation about the larynx and upper part of the trachea. He had no pain in the chest, could lie with equal comfort on either side, and inhale a deep breath without uneasiness. He had no head-ache, or irregu- hr action at the heart, and the stomach was quiescent. The ape- 280 cl. i.j CCELIACA. [ord. ii. Gen. I. rient draught he had taken had produced one or two evacuations, but Icterus^" ' their quality had not been noticed. choireus. Upon examining the right hypochondrium, it appeared to be jiu'ndL. rather more than usually full, though without pain ; while the urine oflhfreai was sma11 in quantity, turbid as though chalky, and without the nature of slightest tinge of yellow. These two symptoms decided me. It the disease. wag c]ear that ^ geat of pyrectic irritation was the liver and its appendages ; which were so gorged or otherwise obstructed, that the usual quantity of bile that gives the natural yellow to the urine could not be absorbed and carried back into the blood vessels; and it was equally clear that there was no primary disease in any other large viscus; and that whatever blood had been discharged from the mouth was merely a secondary disease resulting from such obstruction, and a plethora necessarily produced in other organs, from the infarcted state of the liver. coTse tone * hence prescribed calomel and other active purgatives freely; but pursued. the bowels were so torpid as not to be affected by them, even after the exhibition of several doses. I then ordered a strong cathartic injection, which was thrown into the rectum with great difficulty, from an accumulation of flatus, that the operator found almost im- possible to overcome. In the course of a quarter of an hour, the injection was returned, and brought with it a few dried, dark- coloured, slender, and cylindrical scybala; which were soon after- wards succeeded by copious and numerous dejections of a viscid bird-lime-like substance, of a deep chocolate colour verging to greenish ; and which, in its general appearance, had a near resem- blance to the meconium evacuated by infants soon after birth. All the pyrectic symptoms abated with this discharge, and continued to abate as the motions were repeated, which amounted to not less Beneficial than ten or twelve, and continued for ten or twelve hours. The strength, instead of being diminished, rose in the same proportion ; loose feces of a deep yellow were at length dejected ; and, from the general reaction which was now evidently taking place in the liver, in both directions, the urine not only recovered its proper dye, but was of a higher colour than natural, while a slight suffusion of yellow covered the whole surface of the body. Through the course of this violent commotion, acidulous and diluting drinks were taken very freely : but a considerable degree of general debility was felt for many weeks ; and, probably from the imbecile state of the liver and a diminished secretion of the bile, the peristaltic action of the bowels was extremely sluggish ; and the warm and bitter aperients, often varied or changed in succession, were called for almost daily. No haemoptysis or other pulmonic affection returned at any time ; but for a month afterwards there was so much weakness and relaxa- tion about the larynx and fauces, that the voice was extremely feeble, and the tonsils and uvula considerably enlarged ; evidently showing that the hemorrhage, which had excited so much alarm, had taken place from the upper extremity of the trachea, rather than from the lower ; and probably from an anastomosis, rather than 3 rupture of the bleeding vessels. Q6. x.] DIGESTIVE FUNCTION. [ord. ii. 281 It was fortunate that the surplus of blood was directed to this Gen. I. outlet, where it could flow without mischief; for I was consulted, ,cb^'L about the same time, by the friends of a lady of delicate habit, aged choieus. sixty-three, who was attacked with an apoplexy while bathing in the JSe. sea, and was brought home in a state of utter insensibility. Before ^metiES" I had reached her, she had been seen by Sir Matthew Trerney, who takes a"* had prescribed for her with his usual judgment; but her insensibility Swl continued with stertor, and an entire hemiplegia of the left side. There were several circumstances that induced me to regard this disease as secondary, and proceeding from the same primary cause as the preceding haemoptysis, the blood vessels of the head giving way in this case, instead of those of the larynx. I pursued, therefore, the same plan, and almost with as full a success. The discharge from the bowels was of a like kind, though not quite so copious ; and as the liver hereby became disgorged of its glutinous contents, and the circulating power recovered its balance, the mental faculties gradually aroused themselves; and under a stimulant and tonic course of medicines, the whole of the muscles of the affected side have, in succession, resumed their activity, with the exception of those of the leg, which are still weak, though they are capable of motion, and enable the patient to walk about the room with the aid of a crutch or an assistant. About a week after the first attack, she had a second, but much slighter, and which I ascribed to a fresh haemorrhage. She has had none since. As soon as she was able to travel, she came to town to consult me generally, but I did not suffer her to continue here : I sent her to Bath, and she is now at her own home in Gloucestershire, where she has been free from any fresh attack for upwards of four years from the present time. Where the substance of the liver has been free, and the ducts Accumuia- alone obstructed, the quantity of bile that has accumulated in the in°the0gaii-e gall-bladder has sometimes been enormous. In one instance, which bladQ*:r • lr-ni- • p i p i sometimes terminated fatally, this reservoir was found, after death, to be so enormous. considerably dilated, as to be loaded with not less than two Scot's pints, or eight pounds of this fluid.* In these cases there is often a paresis or hebetude of action in the bile-ducts themselves : and where we have reason to suspect this, it will be most effectually relieved by the blue pill, or small doses of calomel, or Plummer's pill, which is better than either, continued for two or three weeks at a time. If the liver partake of this torpitude, and no acute symptoms occur, the disease is apt to run into the fourth species, and must be treated accordingly. * Edin. Med. Essays,Vol. n. Art. xxx. Vol. l.—3b 282 cl.lJ CCELIAGA. [okd. il SPECIES II. ICTERUS CHOLOLITHICUS. GALL-STONE JAUNDICE. THE COURSE OF BILE OBSTRUCTED BY BILIOUS CONCRETIONS IN THE DUCTS, WHICH ARE AT LENGTH PROTRUDED AND DISCHARGED WITH TIIE FECES ; FREQUENT RETCHING ; ACUTE PAIN IN THE HYPO- GASTRIC REGION, INCREASED UPON EATING. Gen. I. This species is the icterus calculosus of most of the Nosologists. Spec. II. jt is s0 closely connected with the genus chololithus, or gall-stone, connecyted forming the third in the present order, in its general origin, symp- BtneSor" toms, and mode of treatment, that the reader may be referred tor choioiitbus. almost all these to the latter. Yet it is necessary to give the two distinction, affections distinct places : for the yellow die of the skin and urine, which forms a pathognomic symptom in icterus, occurs often, as we have already seen, without Chololithus, even in its passing species and acute state, and very generally in its quiescent state. The liver itself is, in many cases, sound :* but it is often connected with a morbid condition of this organ, and proceeds, perhaps, in some instances, from a morbid secretion of bile, by which it becomes more disposed to crystallize. Dissection has shown that the seat of obstruction is most frequently in the cystic duct; next in the ductus choledochus ; and then in the hepatic. The rest will be explained under the genus chololithus. SPECIES III. ICTERUS SPASMODICUS. SPASMODIC JAUNDICE. THE COURSE OF THE BILE OBSTRUCTED BY A SPASMODIC CONSTRICTION IN THE COURSE OF THE BILE-DUCTS ; THE DISEASE COMMONLY PRECEDED BY ACRIMONIOUS INGESTA, HYSTERIA, OR SOME VIOLENT PASSION OF THE MIND ; AND SPONTANEOUSLY SUBSIDING WITHIN A FEW DAYS AFTER THESE ARE REMOVED. Gen. I. Spec. III. The general symptoms of this affection are those of the preceding toT^eceo- sPecies, or of chololithus means, which so closely agree with the ing in preceding: but the causes and the mode of treatment are different: symptoms: but not in ■node of - * Heberden, Medical Transactions, Vol. ii. p. 124 cl. i.j DIGESTIVE FUNCTION. [ord. h. 283 and it is necessary to attend to their specific signs, in order that they Gen. I. may be distinguished. Spec. M- Spasmodic jaundice occurs for the most part in those of irritable Spasmodi- habits, or whose liver, from a long residence in hot climates, from an Spasmodic- undue indulgence in spirituous potations, or high-seasoned dishes, ^okT-V or from any other cause, is in a state of chronic irritability. So far as I have observed, it occurs more frequently in women than in men; probably from their passing a more sedentary life ; and chiefly after menstruation has ceased, and the general form assumes a more corpulent shape. There is also very commonly, in those who are subject to it, a sallowness of the skin, indicative of irritability and increased action of the hver, and of a larger regurgitation of bile into the blood-vessels than is necessary for the purpose of health. Dr. Heberden has observed that the liver is sometimes perfectly sound ; and there is no doubt that this is a fact; for the irritability may originate in, and be confined to, the ducts ; but it more generally commences in the liver itself, and is hence extended to the ducts, which, from their structure, are far more irritable as well as more sensible than the parenchyma, or general substance of the liver, and consequently far more susceptible of pain and spasmodic contraction. The primary cause of this disease we cannot always trace ; but it Causes. is easily reproduced in those who are subject to it, by flatulent, acri- monious, or indigestible food, or by violent mental emotion. It is often also reproduced, or even primarily excited, by cold in the feet, drinking cold water when the body is greatly heated, and a transfer of atonic gout from the extremities to the stomach or any part of the intestinal canal. We have hence a clear proof of the strong Sympathe- sympathetic connection which exists between the liver and various ufe^iiv'e0"0 parts of the body. An affection of the brain will also often produce with oth*r jaundice ;* and hence a frequent exciting cause is a sudden and violent burst of the depressing passions, as terror, jealousy, and despondency. It is, indeed, most probable that the torpitude induced directly in the organ of the liver from the exhausting heat of tropical climates, is also greatly augmented by the operation of the same cause on the skin, and the sympathy of the liver with this organ. The disease is ushered in by a sense of fulness at the stomach, ac- Description.. companied with great languor and nausea ; a violent pain at the pit of the stomach soon succeeds, with an almost incessant sickness, and an utter inability of retaining either food or medicine of any kind. The pain grows intolerable, and shoots towards the left shoulder, or spreads round the loins, and girds them as with a cord. The epi- gastric region is greatly distended, and cannot endure the pressure of the hand; while the pulse exhibits little variation. The bowels are for the most part costive and moved with difficulty; the urine soon evinces a deep saffron tint, and the sooner in propor- tion to the violence of the other symptoms, and especially of the retching ; and the surface of the body, and especially the fine scle- rotic coat of the eye, assumes the same livery. And if the disease * Cases of Jaundice. &c, by Henry Marsb, M.D. Dublin Reports, Vol. m. 2'84 cl. i.j ('CELIAC A. [ord. ii. Gen. I. Spec. Ill, Icterus spasmodi- cus. Spasmodic jaundice. Yellow tinge uni- versal. Milk affect- ed latest. Why a bit- ter taste in the mouth. Whether objects appear vellow. become chronic the yellow die is not confined to the skin or even to the fluids, but pervades every part of the body, the most compact as well as the most porous ; so that the pericardium, the heart, the peritonaeum, the meninges, the substance of the brain, the cartilages, and even the bones, are clothed with the common colour. Stoll,* Lieutaud,| Bartholin,! anc* Morgagni,§ give various examples of this, though the last observes that a yellow tinge of the brain is a rare occurrence. One of the latest fluids that becomes tinctured is the milk in ic- teric wet-nurses ; probably in consequence of its rapid passage and elaboration from the fluids introduced into the stomach. Dr. Heber- den has remarked, that in wet-nurses the milk is never tainted with the bile, either in taste or colour ; but this assertion is too general, and at variance with the observations of other pathologists. Reidlin lays down the fact more correctly, in affirming that all the humours are sometimes coloured yellow.ll And hence, indeed, the only rea- son we can assign for the bilious and bitter taste that is often present in the stomach, insomuch that every thing the patient eats or drinks partakes of this quality ; while the common bile-duct is locked firm, the intestines are without bile, and the stools are whitish or clay-co- loured. The fact is, that the whole mass of blood is so impregnated with bile, that the saliva, and all the other lubricating secretions of the mouth, fauces, and esophagus, and probably the gastric and pancreatic juices, are loaded with the same material, so that the sense of taste cannot be otherwise than affected. The jaundiced have, from a very early period, been said to see all objects of a yellow hue, as they appear to us when looking through a yellow object-glass ; from which we may judge that the humours of the eye, hke the other fluids of the body, are also tinged, as Cel- sus observes,1F with the resorbed bile, and communicate the tinge to the picture thrown upon the retina. Lucretius, so far as I know, is the earliest writer, of those that have descended to our own day, who has made this remark, which he introduces as illustrative of another subject, and appeals to as a familiar fact: Lurid a praterea fiunt, quaequomque tuentur Arquatei; quia luroris de corpore eorum Semina multa fluunt, simulacris obvia rerum ; Multaque sunt oculis in eorum denique mixta, Quae contagesua palloribus omnia pingunt.** The jaundiced, thus, see all things round them clad In yellow; every object as it flows Meeting new tides of yellow, from their forms Thrown forth incessant; and the lurid eye, Deep, too, imbued with its contagious hue, Painting each image that its orb assails. ?y hS? Dr' Herber<*en, however, affirms, that all the jaundiced patients den and he has at any time attended, have contradicted this opinion with the Frank. r ' * Rat. Med. Part m. p. 386, et passim. t Hist. Anat. p. 190. | SSSfit tf-Feb, Obi ? ** * ^ ""*• Ep" ™ Art« "' It Medicin. Lib. m. Sect. xxiy. ** De Rer. Nat. it. 333. cl. i.J DIGESTIVE FUNCTION. [ord. ii. 285 exception of two females, whose testimony he is disposed to hold sGen*ii,t lightly; and Professor Frank is decidedly of opinion that no such inlerus affection takes place. Yet from a single case in my own person, spasmodi- produced, when a student, by long-continued pressure of the epi- Spasmodic gastrium against the edge of a table in copying my short hand mi- ^uthorts nutes of medical lectures, I can confirm the general opinion : for w case- the first suspicion I entertained of my being affected with jaundice was from the yellow tinge with which every object around me appeared to be arrayed. To produce this effect, however, it is necessary, as circum- already observed, that the crystalline lens, and perhaps all the hu- necessaryto mours of the eye, should be tinged and acquire the yellow hue oflms effect' the sclerotic coat. This certainly does not at all times take place ; and where the humours are unaffected, objects must certainly be seen in their proper colours ; but where they are thus tinctured, and form a yellow transparent medium, it seems difficult to conceive how a picture transmitted through them can avoid catching their own die; and hence we may see why some persons labouring under the jaun- dice perceive objects coloured with yellow, and others in their proper hues. I have said that this species of jaundice, and the remark may be chronic applied to all the species except the last, sometimes assumes a disease. chronic form. In this case the distressing symptoms of severe spasmodic pains, intumescence, and sickness subside ; but the bile does not flow freely into its proper channel, and continues in a greater or less degree to be absorbed and carried into the circu- lation. The cause of this seems to be an insensibility and paresis approaching almost to a paralysis in the bilious tubes, and a chronic irritability in the hepatic absorbents. Under these circumstances, moreover, the bile that thus tardily finds its way into the duodenum must be grosser and more vicious than in a healthy state, and hence another cause of retardation and irregular supply. There is also a Changes change in the colour as well as in the consistency of the bile fre- ducedyinr°" quently to be met with in the chronic state of the disease ; which the bile- may sometimes be the result of a morbid secretion, but is perhaps more generally that of a chemical decomposition from the joint influence of delay and animal heat. And under these circum- stances the bile has at different times, and in different persons, been found acid, acrid, saltish, insipid, whitish, black, green, eruginous, and versicoloured. It has been found as dense and dark as elder- rob ;* as tenacious and limpid as the white of eggs ;| and is crowded and granular as the spawn of frogs.| In this chronic form jaundice has sometimes run on for a long often of period of time, occasionally for a twelve-month. It has alternated ifnuanc^ itself with intermittents ; proved a salutary crisis to fevers ; or has itself been carried off by exanthems of the more violent kind ; and especially by miliary and scarlet fever. The general functions, without when it has assumed this form and the constitution has become "Schief. habited to it, are sometimes so little disturbed that we see people * Eph. Nat. Cur. Dec. hi. Ann. iv. Obs. 86. t Stoerck, Ann. Med. 1.124. I Eph. Nat. Cur. Dec. ii. Ann. tx, Obs, 9. ' 2b6 cl. i.J CCEL1ACA. [ob». " Gen. I. Spec. Ill, Icterus spas modi- cup. Spasmodic jaundice. Therapeu- tic process. Emetics and cathar- tics how t;u useful. Venesec- tion. Opium in pills. Blisters mostly in- efficacious. Tartar emetic ointment. Ceneral regimen. Particular i emedies. Millepedes. of the middling and lower ranks of life, who cannot afford to keep at home, and who would certainly be the worse for it if they could, going about the streets with the jaundice hue covering their hands and faces, and not prevented from engaging in any of the ordinary concerns of life in which no great degree of exertion is required. In the treatment of this species, emetics and cathartics, so highly beneficial in icterus choltms, are of doubtful advantage. Where we have strong reason to suspect that acrimonious materials have formed a lodgment in the ducts or alvine canal, they will prove useful by evacuating them : but in all other cases they must add to the disease by increasing the irritation, and should give way to blood-letting, if the patient be in vigorous health, succeeded by opiates, the warm-bath, or warm and anodyne fomentations applied to the epigastrium. Frank, indeed, rejects venesection as well as emetics and purgatives ; contending that all evacuations and de- pletions are not only useless but hurtful. The opiate should be given in pills, for the stomach will often for many hours reject liquids of every kind. Two or three grains of the extract of opium may be tried at first, and if this be insufficient, the same or even a larger dose should be repeated half an-hour afterwards, and con- tinued till the pain abates. Blistering the seat of pain has been advised by many; and I have often tried it, but without any decided effect. If useful at all, it is rather in preventing a return of the paroxysm than in shortening or mitigating it when present; and will hence be most advantageously resorted to in the interval. The ointment of tartarized antimony, so warmly recommended by Dr. Jenner, has a much fairer chance of success; and, in the author's practice, has at times effected a cure where other means had been found useless. A hazel-nut of the ointment should be rubbed every night into the epigastric region, till the ordinary erup- tion appears. The general soreness upon pressure, and the excitement of the hepatic absorbents, as already observed, continue very frequently for several weeks after the spasm itself has subsided : and, conse- quently, there will be great languor, indisposition to labour, and a tawny skin. For all this, a generous diet, cheerful company, and moderate exercise, and especially riding on horseback, go very far towards effecting a cure ; and perhaps farther than any course of medicine whatever. The bowels, however, must be kept open with warm aperients, and the stomach and abdominal viscera invigorated by bitter tonics. There are few diseases, nevertheless, that have boasted a greater number of specifics: and no specifics so little worthy of the name. The curcuma, chelidonium majus (greater celandine,) and polytri- chum (English maiden-hair) the panacea of Geoffroy, highly as they were extolled a century or two ago, are now never heard of: and of millepedes, which, at one time occupied a place in perhaps every pharmacopoeia of Europe, it may be sufficient to observe, after Dr. Lewis, that two hundred have been swallowed dailv for cl. i.J DIGESTIVE FUNCTION. [obd. ii. 287 some time without producing any effect worth noticing* The Gen- *• cherry laurel (prunus lauro-cerasus) has sufficient recommendation fc^rus"1" on the score of activity ; and, in the opinion of many, has proved spnsmodi- a highly useful deobstruent in icteric cases: but the mischief it Spasmodic- produces is so certain, and its real advantage so doubtful or unes- C^8' tabhshed, that I have neither tried it myself nor can recommend its lauro-cera- trial to others. sus" Of the seeds of the common hemp (cannabis sativa, Linn.), I am Cannabis equally'incapable of speaking from personal knowledge. In the satIva' form of an emulsion they are much commended by the German writers, and are said even during spasmodic pain, to afford relief with astonishing rapidity. Herliz eulogizes this emulsion as having been highly successful in an epidemic icterus which pre- vailed at Gottingen. The seeds themselves have sometimes been swallowed, being boiled for this purpose in milk till they are cracked. The dandelion (leontodon Taraxacum, Linn.) has also been Dandelion. highly extolled by many writers of established reputation in all obstructions of the liver, and, indeed, in obstructions generally; and has been used in its roots, stalks, and leaves. All these abound with a milky, bitterish juice, which was at first supposed to be saponaceous, and hence warmly commended as a resolvent by Boerhaave. Bergius, Murray, and Dr. Pemberton have since con- tributed to support this character, and they are consequently in daily use even in the present day. The plant has no doubt, therefore, deobstruent virtues ; but it has not fallen to my lot, though I have many times given it a fair trial, to add my suffrage in its favour. Its most obvious character is that of increasing the flow of urine. Soap and alkalies, however, seem to have much better pretensions Soap and to favour : and have been still more widely employed in this dis- do not act ease, and pretty extensively regarded as general, and hence as as stents; hepatic, solvents. Yet, that they do not act as solvents in hepatic cases, is clear from a striking instance related by Dr. Heberden, who tells us that he once attended a person, who, for a stone in the urinary bladder, had been in the habit of swallowing an ounce of soap every day for seven years. His body was opened after his death ; and notwithstanding such an extraordinary quantity of soap had been taken, a great number of stones were found in the gall- bladder, without the slightest marks of having been operated upon by any decomposing power.j Soap, however, and other alkaline preparations may, perhaps, be yet useful useful in another respect: I mean, in becoming a substitute for the tutes for" deficient bile, and cleansing the bowels by their possessing some-b,le' thing of the same chemical properties. Yet too much stress must not be laid even upon this virtue ; for large quantities of acids, as lemon-juice, have at times been taken with so much apparent benefit, as to gain, also, the credit of a cure. There is one draw- * Mat. Med. Aikin's Edit. Vol. n. p. 111. • Medical Transactions. Vol. u. p. 165. 288 gl. i.} C03LIACA. [om>. V, Gen. I. back against whatever may be the remedial powers either of soap lSus 1U' or of the alkalies ; and that is their frequent and easy decomposition spasmodi- m me stomach, in consequence of its containing at all times some Spasmodic quantity, and occasionally a very large proportion, of acidity. We iToften may often> perhaps, introduce so much of these medicines as shall too easily be more than sufficient to neutralize the acid ; but where a large sedTthe" quantity is wanted for this purpose, it is better to employ the alkali stomach. aione tban combined with oil, as less troublesome to the stomach. And where this is done, the best, because the most manageable, preparation of the alkalies, will be that which is the purest and most concentrated, as the liquor potassae; nor does it appear that the other alkalies would answer better if we had forms for elabo- cheuenham rati them m the game manner# The Cheltenham spring has un- Bath water, questionably been serviceable in the relics or sequelae of the dis- ease, and where exercise and a tonic plan are decidedly indicated. But where we have reason to believe that the bile is secreted in a depraved condition, and particularly where the disease is connected with a morbid state of the liver, the Bath waters, used both inter- nally and externally at the same time, will be found more beneficial than those of Cheltenham. Scott's There is yet another remedy to be spoken of, which of late years bath?'68"1 has excited great attention, and is now surmounting an ungenerous prejudice that was at first very extensively directed against it: and that is, the diluted aqua regia bath, invented by Dr. Scott, of Rus- sell-square. For nearly thirty years he has been in the habit of using this preparation, and has tried it in almost every variety of strength, and almost every variety of proportion, which the two acids that enter into the composition may be made to bear to each other. How ern- jje commenced his experiments in India, where on account of the India. greater degree of torpitude the liver is apt to acquire than in more temperate climates, he was in the habit of forming his bath stronger and making it deeper than he has found it proper to do in our own country: and where, upwards of twenty years ago, he plunged the , Duke of Wellington into one up to his chin, for a severe hepatic affection he was then labouring under, and thus restored him to health in a short time. . inland. *n England it is not often that he finds it necessary to raise the bath much above the knees, and frequently contents himself with a mere foot-bath or common wash-hand basin alone In both which eases, however, the attendants on the patient should sponge him at the same time with the diluted aqua regia, over the limbs, and occa- sionally over the body. of the acids. ^he aqua regia snoum' be compounded of three parts in measure of muriatic acid and two of nitric acid ; and in preparing them for use, a pint of the combined acid is to be mixed with the same measure of water. This constitutes the diluted acid, or diluted aqua regia. The acid bath is to consist of three ounces of this diluted acid to every gallon of water. It should, however, be ob- served by those who are inclined to form this mixture extemporane- ously at their own houses, that, if either of the acids be poured immediately on the other, a large volume of vcrv offensive gas cl. i.] DIGESTIVE FUNCTION. [obd. n. 289 will be disengaged; on which account, it will be better to pour Genj I. them separately and slowly on their proper measure of water. £„,ffl" If the acids be of adequate strength, the mixture subdiluted for spasmodi- bathing will, to the taste, have the sourness of weak vinegar, and, Spasmodic perhaps, prick the skin slightly, and excite a peculiar rash if very Measure' of delicate, but rarely otherwise, after it has been applied to the surface its strength. for half an hour. But since these acids vary much in their degree of concentration, as distilled by different chemists, there will be some variation in their power. The strength of the bath, however, should not be much greater at any time than the proportion here laid down ; for otherwise it may excite a troublesome rash, and give a yellow hue to the nails and skin of the feet or whatever other part is exposed to its action. A narrow tub for a knee-bath, just wide enough to hold the feet and reach the knees, should contain three gallons of the prepared bath liquor, and consequently about nine ounces in measure of the diluted aqua regia. For a foot-bath, half a gallon may be sufficient, and a common wash-hand basin may be employed as a vessel for the purpose. The feet should remain in the bath for twenty minutes or half an hour ; and the legs, thighs, and abdomen be, in the mean time, frequently sponged with the same. In the winter, the water may be used warm : but this is not necessary in the summer. The bath may be employed at first daily for a fortnight or three weeks, and afterwards every other day or only twice a-week. Dr. Scott affirms that he has employed this process with decided Has been advantage in almost all cases dependent on a morbid secretion of fui in an bile ; whether the secretion be superabundant, defective, or de- "^idbfle. praved. He finds it often within a few hours of the first bathing, increase the flow of bile and meliorate its character ; and, in con- sequence hereof, excite an expulsion of dark-coloured feces, bright- coloured bile, or bile of a brown, green, or black colour, like tar mixed with oil. He has told me also, that when employed in the midst of a paroxysm of severe pain from spasm of the biliary ducts, or the passing of a gall-stone, he has often known it to ope- rate like a charm, and produce almost immediate ease.* From the rapidity, therefore, with which it acts in some cases, he *>what is inclined to think that it operates, not by the absorbents, but by acts, the nerves : and has made various experiments to show that it is the chlorine of the muriatic acid alone, by the present process decom- posed and set at liberty, that produces the benefit of the bath. To prove this, he employed a bath of water saturated with chlorine, obtained from the muriatic acid by mixing it in a retort with the black oxyde of manganese : and the same salutary effects followed : and he has given this saturated solution in doses of half or three quarters of an ounce three or four times a-day, mixed with the same quantity of spearmint, or any other distilled water, with evident benefit, in very numerous hepatic cases of great obstinacy. This account may be rather overcharged, from the ardent mind J^tS^" of its intelligent inventor : but the process is worth following up, babiy over- charged. * gee, too, his article on this subject, Med. Chir. Trans., Vol. viiL Vol. L—37 £90 cl. l.j CCELIACA. |obd. u Gen. i. and varying in other proportions, as well as employing in other nierns"1' families of diseases. My own use of it is at present.too limited to kpasmodi- speak with decision ; yet, so far as I have tried it, it has certainly sp^modic appeared to me to allay irritation and produce a tonic effect. In jaundice. two or tbree instances the advantage has been decisive ; and pa- tients, who had hitherto been seldom two months without a severe return of the complaint, have entirely escaped, and apparently lost the morbid predisposition. In a few other cases it has completely failed. But now jd Jt is, now, however, in a course of experiment in the hands ot rietce°rmrina-f several intelligent practitioners, and we may hope soon to be put ouTerbex- mto P09session of its actual powers. Mr. Wallace has been em- perfmen'ts. ploying it in the form of gas, obtained by a mixture of muriatic acid with the black oxyde of manganese, as well as diluted with aqueous vapour ; and he regards the peculiar eruption as a favour- able sign.* SPECIES IV. ICTERUS HEPATICUS. HEPATIC JAUNDICE. THE COURSE OF THE BILE OBSTRUCTED BY A DERANGEMENT OF THE LIVER FROM SCIRRHOUS OR OTHER INDURATIONS ; OCCASIONAL RETCHINGS AND DYSPEPSY : LITTLE OR NO PAIN IN THE RIGHT HYPOCHONDRIUSI. Gen. I. In the preceding species, the appendages to the liver, as the gall- Spec" * bladder or gall-ducts, are the chief seat of disease, at least in its dfsease! 'he commencement. In the species before us, the disease is chiefly seated in the liver itself. It may be a result of the preceding spe- cies when they have assumed a chronic form ; but as the liver itself is often affected from the first, it is entitled to be treated of as a distinct species. The course of the bile, indeed, is evidently ob- structed, but rather in its secretion or separation from the substance of the liver, than in its transmission by the biliary tubes. Siier- , This sPecies is noticed by Boerhaave, by Sauvages, and by Dr. de'crib d ^alIen"i"nis Synopsis, though he has offered no remarks on it in Different ms *,irst Lines. In Boerhaave, however, it imports altogether a writers. different disease, for it is jaundice produced by hepatitis,! or inflam- mation of the liver ; and is hence a mere symptom, to be removed alone by a removal of the idiopathic complaint. Yet the species in Sauvages is copied from Boerhaave. pSatt •„ lt is more accurately described by Richter, who confirms and causes. illustrates the opinion of Vogel and Selle; all of \yjiom suppose it a/h^T*"*'* retpei£n&hf. Medl'cal Powers of Chlorine, particularly in Diseases of the Liver, &c. by W. Wallace, M.H.I.A. London, 1822. T Van fewiet. Comment. Hepatitis et Icterus multiplex, Tom. in. §914. cl.i.] DIGESTIVE FUNCTION. [qrd.il 201 to depend upon some peculiar irritation in the liver itself; or in the Gen. I. whole hepatic system, but an irritation not dependent upon or £"£IV" directly leading to inflammation. This irritation is of various kinds, hepatic™. and produces different effects, all of which become causes of ob- "undicl struCtion to a free flow of the bile into its proper channels. One of the most common effects which operate in this manner, is a scirrhous enlargement of the whole, or of some particular part of the liver. Another is an accumulation of calculous concretions in its substance ; of which Richter gives a striking and complicated example in a person, who, after death, was found to be without a gall-bladder, and whose liver was filled with whitish calculi of dif- ferent forms and sizes, from that of a pea to that of a cherry. In this case there can be no question, that the bile, whose colouring matter was diffused over the entire body, was not only formed in, but immediately absorbed from, the penicilli, or pores of the liver, in consequence of obstruction, without being collected into a reservoir. This is the worst state in which jaundice can possibly make its In wl,at appearance : for though there is little or no pain, it shows disease paXdwith in the structure of the liver, and is frequently a mark of a broken- danser- up constitution. It is in fact found rarely in the young and vigorous; but almost always in those who have drunk hard, or lived hard, and especially have been exposed to much labour in hot climates, or have suffered under repeated attacks of quartans or other chronic intermittents. The art of medicine can here do but little ; and we have too Medicine often to witness the picture drawn so feelingly of the Athenians avail!e during the plague : —Defessa jacebant Corpora ; mussabat tacito Medicwa timore.* It is only in an early stage of this disease, if happily we should be Except in so soon consulted, that mercury has any chance of being successful; stagTofthe and it should be given rather as an alterant in small doses pertina- fj;sease- i p n i i • ■ Mercury ciously followed up, than in large proportions so as to excite a ptyal- how best ism ; for we have here neither local nor general strength to draw emPloyed- upon without injury. Small doses of calomel in combination with General conium appear to have been serviceable in some cases : and I have resim certainly found benefit from covering the hypochondriac region with a large plaster of the emplastrum hydrargyri cum ammoniaco. For the rest the patient must be put upon a general tonic plan: his diet should be generous without being highly stimulant; he should use such kind of exercise and in such proportion as best agrees with him; and the chalybeate springs, corrected as those of Cheltenham chalybeate by neutral salts, form the best mineral invigorant to which he can 8pnnss' have recourse. Possibly in this malady also, the diluted aqua regia Aqua regia bath may be of service, employed as recommended under the lastba,h' species. * Ludr. fle Ref. Nat.>i. 1176. 292 t'L. i.] CGELI.VCA. [ord. il SPECIES V. ICTERUS INFANTUM. YELLOW GUM. JAUNDICE OF INFANTS. THE COURSE OP THE BILE OBSTRUCTED BY VISCID MECONIUM ; WITH- OUT PAIN OR DYSPEPSY ; EASILY REMOVED BY PURGATIVES. Gen. I. This is the mildest form under which jaundice makes its appear- Spec.V. ancei and that which is carried off with least trouble. In ordinary cases, the only symptoms are the pathognomic colour, and a degree of languor and drowsiness beyond what is common to infants on birth or shortly after. hueUnot -^ yellow hue, however, on the surface of infants is not necessarily necessarily a symptom of jaundice, properly so called ; for Lentin,* Cullen, and ofjaundice. many others, have well observed that such a discoloration may also be the result of a peculiar yellowness of the serum of the blood, un- connected with bile ;t analogous to the golden tint which we so fre- quently find diffusing itself over the surface of a contusion, when the finer and more limpid parts of the effused fluid have been carried off, and the colouring matter of the serum that still remains behind is hereby become more concentrated : as we shall have to notice more at large when treating of this affection under the name of Aurigo constituting the fifth species of the genus epichrosis.I Treatment A dose of castor-oil, or any other active purgative, will generally be sufficient to remove the obstruction, which in almost every in- stance proceeds from meconium more than ordinarily tenacious, and consequently will carry off the disease. But frequently the mouth of the ductus choledochus communis is so completely infarcted with this viscid matter that purgatives are insufficient; and in this case an emetic should be given, and repeated a few days after if necessary : for want of which the discoloration of the surface has sometimes con- tinued for weeks. * See Baume's Description de l'Ictere des nouveaux nSs. &c. Nimes 1788—Cull Synops. Nosol. Gen. xci. 6. note. JeI.S?r' DiSS' dC 0"Sine ICte"' maxim* eJtt8> *«»infaBtes re<*ns natos occupat. t CI. vi. Ord. in. Gfti. x. ol. i. "J DIGESTIVE FUNCTION. [ord. ii. 293 GENUS II. MEL^NA. MELENA. THE COLOUR OP THE EYES AND SKIN YELLOW-GREEN, FULIGINOUS, LEADEN, OR LIVID ; THE DEJECTIONS PALE, OCCASIONALLY DARK- COLOURED ; ANXIETY ; DEPRESSION OF SPIRITS. This is the Melasna, or MeXcctm vovtos of the Greeks ; a name FPEN"n\ given to it by Hippocrates, who has been followed up by the Latin by the writers ; among whom, with a mere translation of the term, it is J*™?^8 and called morbus niger, or the Black disease, whence the name of black jaundice in our own country and on the continent. The colour of the skin under this disease is always dark, but differs (hoIoH of considerably in its shades, and even in its hue, in different indivi- varies. duals.* It sometimes approaches to a green ; whence by Forestus, Razouz,t and other writers, it has been called icteritia or icterus vi- ridis; on which account it has of late been described under the name of Green Jaundice by Dr. Baillie, in a valuable article upon this subject, from which I shall beg leave to enrich the diagnosis be- fore us. This versatility of colour is not to be wondered at; for I have ^"roug already had occasion to observe, that the bile, under different states of other cases. a diseased liver or its appendages, exhibits very different appear- ances. In respect to consistency, it has sometimes been found watery,J viscid, or flaky ; in respect to colour, green,§ muddy, pale- white, || pitchy-black, eruginous,H and versicoloured ; in respect to internal properties, insipid, salt, acid, or acrid and effervescent. De Haen, from Citois,** affirms that it has been discharged green from a tumour between the coats of the jejunum. In the disease before us, ",^ayfdeark however, it is always of a dark, and often of a black or pitchy hue. or black. The stools, as in the preceding species, are generally pale from ob- struction ; and as the absorbed bile is more viscid than in yellow jaundice, it is not so easily dissolved in the blOod or separated from it by the kidneys, whence the urine is sometimes pale, and generally clear. Dr. Cullen seems to have been doubtful how to dispose of the Not noticed genus MELiENA. In his Synopsis, he has omitted it altogether : in bycuiien. his First Lines, he has briefly noticed it, first under haematemesis, and again under diarrhoea, as though melaena were a variety of both these. But not satisfied with this distribution, he afterwards intro- * Lib. sin. Obs. 23. | Tables Nosologiques, p. 129. J Bianchi. Hist. Hep. p. 129. Sebez. Exercit. Med. p. 93. S Augen. Hor. Tom. i. lib. xi. ap. 5. f| Eph. Nat. Cur. Dec. I. Ann. iv. Obs. 194.—Cent. in. ix. App. 9. * Stoll, Rat. Med. Part i. p. 292. ** Rat. Med. x. S2. 294 Gen. II. Melrena. Melena. CL. I.j CCELIACA. [ORD. IL Sometimes accompa- nied with cliocolate- colourod and grum- ous blood. duced it into his " Catalogue of Diseases omitted, but which ought not to have been omitted" in his Nosology. And in truth the very different appearances and qualities of genuine bile, when occasion- ally discharged with the feces, or by the mouth, and the chlorotic or livid discoloration of the skin under the present disease, are suffi- cient to show that it ought to have a distinct generic place allotted to it. With these occasional dejections of viscid and pitchy bile, and sometimes even without them, there is also frequently a discharge Of dark grumous chocolate coloured blood, accompanied with or pre- ceded by a considerable pain in both hypochondria, and clearly evincing a decayed condition of the liver, or spleen, or both, and the rupture of some blood vessel in the one or the other of these organs. These symptoms have been accurately distinguished by Hippo- crates, who in consequence hereof has noticed the two following spe- cies of the disease, which I have copied with little variation into our Nosological Synopsis, as forming the best arrangement, and giving the best view of melaena that I am acquainted with. 1. MEL.ENA CHOLJEA. CRUENTA, BLACK JAUNDICE. GREEN JAUNDICE. BLACK VOMIT. SPECIES I. MELENA CHOL^EA. BLACK JAUNDICE. GREEN JAUNDICE. Gen. II. Spec. I. Pathology. Incorrectly supposed to be a mere aggra vation of yellow iaundice. OCCASIONAL DEJECTIONS OF DARK OR PITCHY BILE, INTERMIXED WITH THE FECES ; OCCASIONAL VOMITINGS OF YELLOWISH-GREEN AND ACID COLLUVIES ; GREAT LANGUOR ; OFTEN VERTIGO ; HYPOCHON- DRIA FREE FROM PAIN, BUT TENDER UPON PRESSURE. The liver is here evidently diseased in its structure, and a morbid deep-coloured bile, fulvous, greenish, or fuliginous, is secerned, in- stead of the natural excretion ; from general hebetude and a want of.the ordinary propulsive power, it lingers in the biliary passages, if it get into them all; the finer part of the fluid is first absorbed, and afterwards the grosser; and what remains becomes still more viscid, more stagnant, and of a deeper hue. " In the ordinary use of the term,'' observes Dr. Marcard of Han- over, " black jaundice means nothing more than yellow jaundice of a more than usually deep die : yet when the real disease exists to which this name ought to be limited, no practitioner, who closely examines the very dark colour of the skin and of the defluxions, and especially the danger that accompanies it, can avoid concluding that it has something peculiar in its nature, and cannot be merely an in- tense degree of yellow jaundice. It is highly probable," he conti- cl. i.] DIGESTIVE FUNCTION. [ord. ii. 29o nues, " that a part of the dark colour may depend upon the hue of Gen. IL the bile itself in a state of morbid secretion; but along with this Mete"; '* there is also a very great structural decay in the biliary organs as well; S.1}01"'8* a decay which gives the chief character to the disease ; prevents so jaundice. frequently all beneficial effects from the best medical treatment; and £ruend"ce# consequently renders the disease so often fatal."* Produced The green jaundice is" sometimes to be found in young persons, decayy°fTno but.far oftener in the middle and more advanced periods of life. In bilia,y men it occurs more frequently than in women, probably on account nescrip- of the greater wear and tear of their constitution, as more exposed tlon" to all weathers and all climates ; and appears to be less connected with intemperance than the yellow jaundice; and less disposed to terminate in abdominal dropsy. The hardness and enlargement of the liver, in many instances, Liver often runs through the entire structure of the organ, but is perhaps more throughout. frequently confined to some particular part. Upon pressing the re- gion of the liver, the patient is commonly sensible of some degree of tenderness, but otherwise he feels no pain whatever ; though he has the same distressing itching of the skin which I have already no- ticed in yellow jaundice ; and sometimes a troublesome sensation of heat in the palms of the hands and soles of the feet. The pulse, as observed by Dr. Baillie, continues " natural both P"1se na,u- with respect to strength and frequency, unless some circumstance may have occurred to irritate the constitution for the time." In the more striking cases, however, that have occurred to myself, the pulse has been peculiarly slow, in some instances not amounting at any time to more than fifty beats in a minute, and occasionally to not Sometimes more than thirty. The stools are generally pale ; but from some beats in a irregular excitement of the liver, they appear sometimes tinged with m,nule' bile of a peculiarly dark and pitchy hue ; a part of which, from its overflow, rushes into the stomach, and is discharged by the mouth. The urine is deeply loaded with the same, and tinges the linen of a dark tawny hue ; it flows freely, and sometimes deposites a pinky sedi- ment. The appetite varies, not only in different persons, but even in the Appetite. same. Some patients eat with a pretty good habitual inclination. In others the stomach is extremely capricious; at one time without any desire for food of any kind, at another only relishing particular kinds ; and perhaps a few days afterwards evincing a general taste for whatever is introduced upon the table. In the preceding species jaundice is not a dangerous disease, ex- J>fnos* cept where the substance of the liver is very generally affected, so as to make an approach to the species before us. In green jaundice the patient rarely recovers. The progress of the disease is always slow, and the patient may labour under it for three, four, five, or even seven years. I have lately lost a patient, who had suffered under it for this last term of time, and was not more than forty-two at his death. He was a captain in the royal navy, of regular habits, who had seen hard service, and been severely tried by a change of cli- mates. * Medicinische Versuche, &c. Leipsic, 8vo. 1779. 296 cl. i.J CCELIACA. [ord. II. Gen. II. Contrary to what occurs in all the modes of yellow jaundice, the £nCa '* morbid hue is here so deeply rooted in the system that it never quits it. choia:a. If the patient recover, it may become a few shades lighter, but it jaundice, never leaves his person altogether, and is always visible in the coun- ^undice tenance. Molbid hue In those instances in which the pulse has been very strikingly the'skin"^ slow> l have commonly found it connected with some affection of even on the head, and particularly apoplectic or epileptic fits; evidently from Sometimes the sluggishness of the circulating powers, and the necessary predis- of°aduCtie/x position to congestion. And I have seen a patient at length carried or epilepsy, off by a paroxysm of the one or the other of these affections, after having for years completely recovered, in every instance, from their previous effects, and sometimes, in the intervals, risen from deep de- pression into hilarity of spirits. Medical As there is much obscurity in this disease, its medical treatment is indecTstve. indecisive. Mercurial preparations, which so often aid us in the first saJtotl8ome- sPecies* are rarely of service in the present. Dr. Baillie thinks he times paiii- has found neutral salts, taken daily as an aperient, of palliative use ; *t0' but of a radical cure he seems altogether to despair. It has appeared to me, that though mercury fails when employed alone, combined with antimonials, it is often highly beneficial; and of all prepara- piummer's tions of this kind, 1 have by far preferred the form of Plummer's pill, timef radi- ori m other words, the submuriate of mercury in union with the pre- caiiy useful cipitated sulphuret of antimony, with a warm stimulant of gum-resin. A'kai'es I have also found unquestionable benefit from a union of alkalies and tonics. bitter tonics; particularly the liquor potassag with infusion of columbo. Aqua regia The aqua regia bath is another tonic well worth trying. I think I have found it serviceable; and I am trying it at this moment, but have not yet employed it on a scale that enables me to speak peremptorily. Tartar- Here also, as in spasmodic jaundice, the counter irritation of the ointment, tartar emetic ointment has occasionally proved highly beneficial, SPECIES II. MELiENA CRUENTA. BLACK VOMIT. OCCASIONAL VOMITINGS AND DEJECTIONS OF GRUMOUS BLOOD, INTER- MIXED WITH DARK COLOURED BILE ; PUNGENT, TENSIVE PAIN IS BOTH HYPOCHONDRIA ; COMPRESSIVE PAIN AT THE PIT OF THE STOMACH AND FAINTING. Spec II* • *N tl"S sPecies the organs subservient to the formation of bile are compii'ca-' m a more debilitated and decayed condition than in the preceding : iSlSSS" and lt may hence be contemplated as a disease compounded of species and meirena ctwtcBa and haematemesis atonica, or passive hemorrhage Hemorrhage from the vessels of the liver, spleen, or both ; sometimes from those of liver or of the stomach. spleeru cl.i.J DIGESTIVE FUNCTION. [ord. ii. 297 Little as we know of the exact part performed in the animal eco- Gen. II. nomy by these organs, we see enough to convince us that the func- Sec- tions ot the liver and of the spleen are, in many respects, one and «uenta. the same ; the blood in both is highly carbonated, as even the natu- vdmit. ral colour sufficiently indicates, and the closest alliance subsists be- ^f,,0"8 tween them. On which account Hippocrates calls the spleen the these left, and Aristotle the bastard liver. Sir Everard Home, as we have "many already had occasion to observe, regards the spleen as the medium ™sP*cts of communication between the stomach and the liver ; and has gone far towards establishing, that part of the liquids received into the stomach are conveyed by it (though through vessels not yet dis- covered) directly into the circulation of the liver. It is a singular Bioedofthe property of the blood of the spleen, that, like the catamenial dis- spleen does charge, it does not coagulate. "ate.0088"" Dr. Home took a like view of this disease : and affirmed it to ™£a*|_ be produced, not by a mere effusion of bile of a dark colour, as in plained by black or yellow jaundice, but by an effusion of blood also, which, Dr- Home• however, he imagined to proceed from the meseraic veins. He re- lates three cases in which the disease appeared to be carried off by a critical discharge ; the first by a diarrhoea, and the other two by ;m efflux of sweat and thick urine. Intemperance, but especially habitual dram-drinking, is the com- Symptoms. mon cause. Besides the symptoms noticed in the definition, it may be observed that the countenance is chlorotic, and usually full of anxiety; the pulse is quick and feeble, skin hot and dry ; the strength greatly impaired. As a symptom this disease is met with in severe attacks of Found as n dysentery ; but more frequently in severe attacks of yellow fever, y&om in and especially that variety or stage of it which by some writers has fever. been distinguished, though perhaps unnecessarily, by the name of Bulam fever, as will be hereafter noticed. In this case the black matter is often formed in a few hours, and at once thrown in great abundance from the stomach before it has time to be absorbed and enter into the circulation, so as to produce the true atrabilious tinge upon the skin which distinguishes the idiopathic malady. In a case of this disease related by Dr. Marcard of Hanover, the Has some- morbid blood or bile seems to have proceeded from an encysted thrown66" atheroma in the stomach or liver, as the matter discharged was of the forth from consistence of a poultice, but more granular ; quite black, without atoero^a6 inclining to red or yellow, and passing off clear from white paper when rubbed upon it, without leaving a stain. The patient said it had no particular taste ; the quantity thrown forth at a single dis- charge amounted to at least sixteen ounces : and the vomiting was preceded by excruciating pains about the region of the stomach.* In a cases ince described by Dr. JVlartland, in the Edinburgh Jour- Symptoms nal, the whole line of the intestinal canal, in its villous coat, appears, seatfd in on dissection, to have been more or less gangrenous : and half a pintthe intt)St'' of black grumous blood was found in the stomach. The liver was of a pale brown colour, smaller than usual, with a shrivelled fissured surface, without either blood or bile. * Edin. Med. Comment. Vol. it. p. 203. ' Vol. I. -38 298 cl. i.j CCELIACA [OKD. II. Gen. II. Spec. II. Melaena cruenta. Black vomit. Medical treatment. Obstructed passages to be cleared. Fresh flow to be pre- vented. Acids preferable to alkalies, especially vegetable. Mercurials of little avail. Bitter tonics. In so worn out and exhausted a state of the affected organs, or perhaps of the constitution generally, as this disease indicates, little benefit is to be expected from medical treatment. Our first duty, however, is to clear the impeded passages of the grumous matter that obstructs them ; and our next, to prevent as much as possible a fresh flow of it. For the former, gentle means, whether in the shape of purgatives or emetics, or both, will answer best; as we have a shattered fabric to work upon, and violence will only add to its weakness. For the second purpose, the alkalies have very generally been had recourse to, sometimes alone, and sometimes in the form of soap : but I have rarely found them of decided benefit. For these I have often substituted acids, and have preferred the vegetable to the mineral, particularly where the constitution has appeared to be broken down generally ; as the patient is able to take a much larger proportion of the former than of the latter, because of the corrosive quality which the latter possess : and of the vegetable acids, the fermented or acetous have answere'd better than the native. Mer- curials seem to t>e of as little service as in the preceding species ; except where we have reason to expect a fresh accumulation of the morbific material, in which case they may be employed as a pur- gative. But, between the paroxysms, bitter tonics, a3 columbo and simarouba, with such gentle exercise as may be engaged in without fatigue, a light but generous diet, and the use of, the Cheltenham waters, are what should chiefly be inisted upon, as best calculated to postpone the fatal issue, which, after all, can only be postponed. '!<•/•] DIGESTIVE I'TN'CTfOY (ord. il 299 GENUS III. CHOLOLITHUS. GALL-STONE. PAIN ABOUT THE REGION OF THE LIVER CATENATING WITH PAIN AT THE PIT OF THE STOMACH ; THE PULSE UNCHANGED ; SICK- NESS ; DYSPEPSY ; INACTIVITY ; BILIOUS CONCRETION IN THE GALL-BLADDER OR BILE-DUCTS. In the preceding species we have had occasion to observe that Gkn. III. the bile is frequently found peculiarly viscid or tenacious, either from original secretion in this state, or from an absorption of its finer and more attenuate parts in the gall-bladder or appended ducts. In the Gaii-Btones Vinw farm- disease before us, we find certain portions of it indurated, and as- e(j. suming a concrete form, often of a crystallized, sometimes of a lami- nated structure ; and perhaps most commonly of both ; evincing a tendency towards crystallized rays in the centre, with concentric laminae towards the surface.* These concretions were supposed by Fourcroy to consist of a re- chemical sinous matter combined with a peculiar oil, and a certain quantity of albumen, forming three of the constituent principles of bile. All these principles, however, have of late been denied by Berzelius, who has discovered that the bile becomes resinous only in the process of experiment, by supersaturating it with acids, while the material hi- therto regarded as albumen is nothing more than a small portion of mucus furnished from the gall-bladder. In all instances, perhaps, gall-stones are inflammable ; and when dry, blaze like wax in the flame of a candle. And in some instances Dr. Darwin suspects them to dissolve in the matter of the feces, and to pass away invisibly. It is possible, however, that the cases Whether ,\ , . J J. r. „ t • i- f soluble in here alluded to were only examples of spasmodic jaundice ; tor the feces. nothing but the actual appearance of bilious concretions in the feces can fully prove their existence; while the general symptoms may be produced by other causes. Gall-stones differ in specific gravity: Specific some have been found heavier than water ; others a little lighter, graT,ty> bearing the proportion of nine to ten. In colour they are mostly colour. dark brown ; a few are white externally, though still brown within. It is possible that minute biliary concretions may be occasionally formed in the penicilli,or the pores of the liver, perhaps in the ducts; but the gall-bladder is the common seat of origin : and they are here Found in found of every diversified size, from that of a mustard-seed to that J£"g°.UB of a pullet's egg; often, indeed, not only completely blocking up the cavity, but distending the bladder far beyond its natural dimen- * Baillie, Morbid Anatom. Fol. 5, PI. vi.p. 109—113, 300 cl. il] CCELIACA. [ord. il Gen. III. Chololi- thus. Gall-stone. Effects produced on the bile from obstruction of the gall- bladder. Course of sall-stono into the intestines. The ob- struction not always seriously mischiev- ous. Sometimes mischiev- ous in various ways. sions; and the passing such large concretions shows what won- derful efforts nature is capable of making towards freeing herself from a morbid incumbrance ; for the natural size of the ductus communis choledochus scarcely exceeds that of a goose-quill. The change thus occasioned is often very slow ; and consequently ac- companied with less derangement of the general health than we should expect; but as the bitter of the bile is produced in the ca- vity of the gall-bladder, and this cavity is hereby generally oblite- rated, the bile loses a considerable proportion of its bitter taste ; and, possibly from the want of bile in the intestines, the evacuations are very irregular. The gall-stone, thus closely impacted, will some- times remain quiet, and without being detached for many years, with only occasional uneasiness in the hypogastric region. " In some patients," says Dr. Heberden, "> the jaundice will dis- appear in two or three days : in others I have seen it continue near a twelvemonth before the gall-stone could pass into the intestine, or fall back into the bladder : nor will this long obstruction of the na- tural course of the bile have any lasting .ill effects, or hinder the patient from being soon re-instated in perfect health after the removal of the obstruction." And as little real inroad upon the constitution takes place, in many instances, from a continuance of the concretion in the gall-bladder : " for many," observes the same excellent writer, " have been opened after their death, in whom a very large stone, or many small ones, have been found, without their ever having had in their lifetime any complaint which could certainly be imputed to this cause. A gall-stone weighing two drachms was found in the gall-bladder of the late Lord Bute, though he had never complained of the jaundice, nor of any disorder which I could attribute to this cause."! The irritation of a gall-stone has occasionally excited inflamma- tion, and, where the gall-stone has existed in the liver, a large ab- scess ; and the inflammation in the latter case assuming the adhesive form, the abscess has opened externally, and the calculus been dis- charged in this direction, of which we have a curious example re- lated by Mr. Blagden in the Medical Transactions.! The calculus, on examination, weighed nearly an ounce and a quarter, and was of" an oblong shape. The patient, who was a lady of sixty-six years of age, gradually recovered. From the absence or presence of pain, the rest or transit of the gall-bladder, which give rise to a considerable diversity ol symptoms, as well as mode of treatment, the genus is divisible into the two fol- lowing species:— 1. CHOLOLITHUS QUIESCENS. ?• "■ MEANS. QUIESCENT GALL-STONES. PASSING GALL-STONES. * Heberden, Med. Trans. Vol. n. p. 1S7. Medirsd Transactions, Vol. n. p. 154. t Vol. it. Art. xvi. DIGESTIVE FUNCTION. [oed. ii. 301 SPECIES I. CHOLOLITHUS QUIESCENS. QUIESCENT GALL-STONE. PAIN ABOUT THE LIVER, AND AT THE PIT OP THE STOMACH, OBTUSE AND OCCASIONAL ; THE BILE LESS BITTER THAN USUAL ; THE DE- JECTIONS IRREGULAR. In the quiescent species, the gall-stone remains usually at rest in Gen. III. the gall-bladder or the liver ; and, whatever be its size, the growth ,„ fh^8c' takes place, and the containing organs dilate so gradually as to pro- species, duce little or no inconvenience. In Dr. Baillie's plates there is an fmie'incon- example of a concretion of the size of a pullet's egg, which filled up ^Jjjj""^ the whole of the fundus. Yet so perfect was the adaptation of gradual nature to the case, that the bladder not only became sufficiently fhe'^aH°f enlarged at its base to hold the concretion, but was also sufficiently ^°ne- enlarged immediately above it to form a new reservoir, and con- adaptation tain very nearly, the usual quantity which the gall-bladder is capable of natur e> of holding in its healthy state. At times, however, even in thr* quiescent form of the disease, we Pain and meet with some degree of pain ; occasionally, perhaps, produced by at times. a sudden deposite of fresh concrescent matter ; occasionally by ab- rupt starts of some propulsive power which it is difficult to explain ; and occasionally by some peculiar and temporary irritation in the coats of the surrounding organ, by which the bowels are apt to be considerably affected. In this species, however, little medical treatment is necessary : for Jfj^'^t we have only to correct the commotion of the alvine canal when thus excited, or to quicken its motive power when sluggish ; and to have recourse to anodyne fomentations and narcotics internally, if there should at any time be severe pain. And by palliatives of this kind many a patient, as I have already observed, has been enabled to possess a comfortable enjoyment of life to old age, whose gall- bladder has, after death, been found loaded with concretions which, there has been good reason to conclude, has been gradually accumu- lating for thirty or forty years. 302 cl. i.J CCELIACA. SPECIES II. CHOLOLITHUS MEANS. PASSING OF GALL-STONES. PAIN AT THE PIT OF THE STOMACH ACUTE, EXTENDING TO THE BACK : FREQUENT VOMITINGS : DEJECTIONS WHITE ; AND AT LENGTH LOADED WITH ONE OR MORE BILIOUS CONCRETIONS. Gen. III. It is not a little singular that, during the great anguish sustained pPiEC' *!' m *he transit of a gall-stone, the pulse is rarely or never quickened. Quickened " Insomuch," observes Dr. Heberden, "that this natural state of spe^es, tne pulse, joined with the vehement pain about the pit of the sto- whateyer mach, affords the most certain diagnostic of this illness. I have thePsaton-° seen," says he, " a man of patience and courage rolling upon the mach. floor, and crying out through the violence of this pain, which I was hardly able to lull into a tolerable state with nine grains of opium given within twenty-four hours, to which he had never been accus- tomed : and yet his pulse was all the time as perfectly quiet and natural as it could have been in the sweetest sleep of perfect health."* Sometimes Together with the pain at the pit of the stomach, which is acute right 'hypo6 m almost every instance, there is sometimes a pain also in the re- chondrium gion 0f the liver ; and not unfrequently it commences here. For tor. this it is not difficult to account. Membranous canals, with a very few exceptions, are most sensible at their extremities ; and an irri- tation excited in either extremity acts by sympathy upon the other. A stricture in the prostate gland produces pain while making water, in the glans penis : and notwithstanding the comparative insensi- bility of the rectum, which forms one of the exceptions to which I have just referred, faintness at the stomach is almost always accom- panied with a relaxation of the sphincter ani, so that the stools issued involuntarily. Now in passing a gall-stone the pain is greatest on its first entrance into any one of the ducts, or on its reaching the extre- mity of the ductus communis just before it is disgorged into the duodenum, in consequence of the greater sensibility of these parts. In the former instance, its direct seat is in the origin of the canal, near the liver ; in the latter, in its termination towards the pit of the stomach : but as the one extremity acts by sympathy on the other, both these organs must be affected in a greater or less degree ; and as the duodenum and stomach possess a finer sensibility than the liver, we perceive readily why the pain is more pungent in the former than in the latter region. When the concretion has fairly entered the ductus communis, the pain remits, but generally returns with sudden violence on its reaching the duodenal point: and we hence see the reason of that additional attack of severe agonv which a pa- Med. Trans, et supra. 01- J-J DIGESTIVE FUNCTION. [okd. u. 303 tient often sustains after having flattered himself that the disease was Gen- in- completely subdued. The calculus, when voided, has sometimes ch"Siit£i been found to measure nearly two inches in its long diameter, and mea"3- upwards of three inches and a quarter in its widest circumference.* gaffines. In the medical treatment of this complaint, all that we have in Treatment. our power to accomplish is to ease, and, as far as possible, to accelerate the course of the gall-stone. Formerly, when the gall- bladder was suspected to be completely gorged, its walls thickened from long continued irritation, the concretions too large to be forced forward, and the pain permanent and severe, attempts were made to remove them by a section into the cyst. Blochj gives a singu- lar case of this kind, in which not fewer than sixty-two distinct cal- culi were taken away with success. But in general the operation Section into has not answered, or has been followed by a formation of other {J^^1 crops of concretions ; so that Morgagni and many later writers^ of generally eminence have strongly reprobated the use of the knife, and it is answeretl" rarely or never had recourse to in our own day. In reality there n0jus, seems to be no just cause for its use. At the time that the gall- cause for stone is in the bladder, to whatever extent it enlarges, the progress ti0en?pera of enlargement is slow, and the capacity of the gall-bladder will, in most cases, without much irritation, and sometimes with very little inconvenience, expand to meet its growth : while the moment it has quitted the cyst, and has entered into the duct, it is in vain to attempt to follow it up to any particular spot. Our best and wisest exertions, therefore, must be of a palliative Palliatives kind, with a view of easing and quickening the passage of the gall- ™b°*| advis" stone. We have no direct means, however, of doing the last: and all we can hope to accomplish, is that of rendering a little collateral assistance to the expulsive efforts which are made by nature herself. The duct becomes dilated by the circumambient pressure of the concretion as it gradually passes forward, urged on by the same action that propels the bile in a state of health. Vomiting, there- Vomiting fore, by compressing the whole abdominal viscera, and, particularly, 5?cwfb\rser the full and distended gall-bladder and biliary vessels, may afford one mean of pushing forward the concretion : but a gentle force, and consequently gentle vomits, will promise fairer than those which act violently. Dr. Darwin affirms that in two instances he saw from thirty to fifty gall-stones voided after taking only an oil vomit. If the patient be of tolerable vigour, and inflammation be apprehended, Venesec- bleeding should precede the exhibition of emetics. Cathartics, by cathartics. exciting the action of the intestines, and directly stimulating the mouth of the common bile-ducts, contribute, also, to excite action through its entire range, and' thus farther favour the expulsion of the concretion. And as we often find its passage evidently opposed by spasmodic constriction, opium, given very freely and repeated Opium. every hour or two, and relaxing the skin by fomentations or the ?°™aUl~ warm-bath, will in such cases be of essential service. Horse-exercise »«*■««- * Brayne, Medico-Chir. Trans. Vol. xii. Art. xxi. t Medic. Bemerkungen. No. v. „.. ^ ...... ^,. X De Sed. et. Caus. Morb. Ep. xxxvn. Art. 52.—Sharp's Critical hnqniry, C h yj.—Le Dran, Consultations sur la plupart de Maladies, &c. 304 cl. i.J CCEL1ACA. [ok». 11. Gen. III. Spec. II. Chololithus means- Passing of gall-stones Miliary solvents. Oil of turpentine how fur a solvent. Disease not often fatal. cannot always be made use of: but where it can be submitted to, it is one of the best auxiliaries we can recommend. We know of no solvent of biliary concretions worth attending to. The essential oil of turpentine was at one time regarded as a very powerful medicine of this kind ; and, as such, was strongly recom- mended and very generally employed by Van Swieten,* Bloch,| Durande,| and many other celebrated characters, sometimes alone, but more generally combined with alcohol, or the sulphuric or nitric ether. More recent practice, however, has not justified its posses- sion of this virtue ; and, if it were ever serviceable, it must have been as an antispasmodic rather than as a solvent. Durande, in- deed, seems to have acted upon this view; for his formula con- sisted of three parts of sulphuric ether to one of the oil. Yet where there is danger of inflammation, such a medicine must he always too stimulant; and Dr. Percival has good grounds for remarking that its internal use is productive of mischief.§ It is not often that this disease proves fatal, or even essentially injures the constitution, except where there is an habitual predisposition to the generation of gall-stones, and the frame is worn out by a chronic succession of irritation and pain. GENUS IV. PARABYSMA. VISCERAL TURGESCENCE. KNOTTY OR UNEQUAL INTUMESCENCE OF THE ABDOMEN FROM AS INDURATED ENLARGEMENT OF ONE OR MORE OF THE VISCERA CON- TRIBUTORY TO THE DIGESTIVE FUNCTION ; DERANGEMENT OF THE GENERAL HEALTH. character of the genus Gen. IV.^ This genus is intended to comprise a natural and extensive divi- sion of diseases, consisting in an infarcted protuberance of one or more of the coiiatitious organs of digestion; commonly produced by a deficient action in the absorbent vessels of the part affected. The name under which the disease has been described by Hippo- crates is megalosplanchnus (iuyrX*yx»» on membranous tubercles that " foule de petits tubercules blanchatres PfrPab^ma qui est si frequent sur ces membranes ;"* and has said that we must hepaticum. look to another quarter than that of phlegmasia? for their origin : al- cenwfof the though he seems manifestly to err in regarding tubercles of this kind D^rJiedby as solely capable of originating from serous membranes, and never Kichat, existing in the subjacent substance of an organ except towards the Smiting",n last stages of the complaint in which they are propagated by the eel- '"b«cies iii. i • - i • • m . to ser°ua lular texture ; being m his estimation u une aflection, propre a ces tissues membranes ; comme les eruptions, miliares le sont a la surface cu- alone* tanee, comme les aphtes le sont aux surfaces muqueuses." The nature of many of the morbid growths belonging to the present genus will abundantly show that tubercles of all kinds may take their rise ^'*®tg™™ from the interior as well as from the surface of organs ; as their his- as well as tory will also, that they may originate without any sense of heat or o^gansT pain, without any augmentation of the pulse, or any other sign ofand without inflammatory action. A certain but low degree of such action may ofmflam- indeed accelerate their growth, and augment their number, as one mcat{°J,y. kind of exciting cause ; but congestion from weak action is a cause though their far more frequent; and accidental irritation not much less so. The be°acceiers£ subject, however, is still a source of controversy in France ; the opi- J^Jj? a nion of M. Bichat that inflammation is not a necessary source of tu- degree of it. bercles in any case, being powerfully supported by MM. Bayle and Laennec, and still more lately by M. Andral; while their origin from inflammation alone is as warmly contended for by M. Broussais and his numerous adherents. This disease originates from different causes, and is marked by symptoms and effects of very different kinds. The diversity of the symptoms, however, is not always sufficient to point out the real nature of the swelling, which, in many instances, can only be determined by a post-obit examination. Yet the following varieties may be noticed as frequently distinguishable during life :— ec Coactum. From simple parenchyma- Atonic turgescence. tous coacervation. a Scirrhosum. Accompanied with a hard Scirrhous turgescence. and scirrhous feeling. y Chololithicum. Accompanied with an oc- Gall-stone turgescence. casional discharge of bi- lious concretions. ^ Helminthicum. Accompanied with an oc- Vermicular turgee- casional discharge of cence. worms or larves. The first of these very generally paves a way to one or other of the « p- hepa- three ensuing; and is found most frequently in feeble children who se- actum.00" crete little bile, and have the cells of the liver clogged with mucus from '^^ an atony of the absorbents. It is also found very frequently in in- lound^ temperate eaters, and in foreigners who reside in hot climates; an children"in. * Anatomic Generate, Tom. iv. p. 517. 310 *cl. i.] CCELIACA. [ord. ii. Gen. IV. equal degree of atony, at times amounting to a paralysis, being pro- aSpEhepati- duced in the liver from the exhausting stimulus of the rays of the sun, cum co- and an excessive use of spirituous potations. AtoTctur- In a scrophulous habit, a liver, thus enlarged and infarcted, is apt fmemnerate to become scirrhous in children, if not early attended to, as it is also livers, and in the gormandizers jnst alluded to, who have long habituated them- comerl into selves to the luxuries of the table. . Sometimes the scirrhus is con- hot en- fined to a part of its margin ; sometimes it appears partially on its f) p hepa surface; sometimes it runs through one or the other, or both its sdrrhosum lobes: and sometimes also, the portion that becomes scirrhous evinces Scirrhous a tuberculate structure, and consists of clusters of simple tuber- o/the hver8 cles before the scirrhosity takes place. chiefly in '* *s not always, however, that a scirrhous or even a tubercular scrophulous structure of the liver occasions its enlargement. In many instances, inintemper- indeed, it does so ; but Dr. Baillie has given examples, illustrated VarieTi8' ^y plates, in which the liver has hereby shrunk into a size considerably seat and below its natural proportion.* This disease may be generally de- Bometimes tected by an accurate examination of the hypochondrium with the contracted hand. BcirrhouJ a Almost all the affections of the liver appertaining to the division ypctheea- Derore usi aPPear to owe their origin to atony or hebetude in the ticum cho- organ : and hence the common rise of that variety of turgescence GaiVstone' which is accompanied with bilious calculi. These are sometimes turgescence diffused like granules over the substance of the liver, or among the Calculi ' biliary pores; they are sometimes confined to, and load one or more different morbid cysts existing in the liver ; and are sometimes naked, con- parts, crete, and crystallized; of which I have referred to various examples different6' in the volume of Nosology. These are occasionally to be found in forms. tne dejection. $ p hepati In the variety distinguished by the existence of grubs and worms, minihicum the fluke is, perhaps, sometimes to be found even in the human liver. t^rg?sicular Soever and Clarke, as already observed, assert this, and Darwin con- cence. firms their assertion. That they are found in almost all other animals, Bometimes is admitted by every naturalist ; although Dr. Harrison, of Horn- hTman"the cast^e'bas late'v ventured to deny that they are to be traced in sheep liver. in the well-known disease called the rot. But the vermicles chiefly hym. n. Ep. xxxix. N. 21. 2.5. Vol. I— 41 622 cl. i.j CCEL1ACA. [OHO. Li- Gen. IV. the length of the palm of the hand, was greatly indurated and dis- jf pfinti" tended, with a fleshy, fibrous, and peculiarly thickened tumour, which tiuaie gar- contracted the diameter of the gut,* and, if the boy had lived much C?" longer, would in all probability have adhered, like the last, to the tons turges- surrounding parietes. cenceofthe or intestines. From the violence of the symptoms, and the little prospect we Pathology. have qp auaying. them, this disease is almost hopeless. It com- mences with a considerable irritability of the part of the intestinal canal that is affected, and the effusion, growth of new matter, dis- tension, and, where it takes place, adhesion, add daily to the irrita- ble state, augment the pain, and keep up the tendency to vomit and reject whatever is introduced into the stomach. indications There are two indications to be followed up, and but two medi- of cure. c-neg t^at og-er ug any cjiance 0f succesg while holding the indica- tions in view. Our first object should be to allay the irritability, and consequently the pain and sickness, which after a free loss of blood ofTiume" ty cuPPin£i can oruy be attempted by opium, given in large and re- often neces- peated doses, if necessary to the amount of ten, twelve, or even thTfim fifteen grains a-day if the patient be an adult Ten and twelve grains intention, a-day, for three weeks without intermission, I have myself prescribed with great comfort to the patient, and without stupor or even sleep, the night being passed in a kind of refreshing reverie, without a loss of consciousness at any time. The symptoms we thus endeavour to combat, not only bring on sure destruction by the exhaustion they produce, but very considerably promote the enlargement of the tumour, and the extent of the adhesions. If we can succeed in keeping these in subjection for a week or two, it is possible that the constitution may be broken in to submit to the new action produced by the change of structure, and the irritability may at length sub- side. Mercury We should at the same time endeavour to counteract the morbid formi^fo"1 change of structure, and particularly to arrest its progress; which the second, constitutes our second indication ; and this can only be done by mercurial preparations. Small doses of calomel should, for this purpose, be combined with the opium, while mercurial ointment should at the same time be applied, night and morning, to the seat of pain, and persevered in to ptyalism : for the case is urgent, and not a moment is to be lost. The warm bath may perhaps afford a temporary relief; but no permanent good is to be expected from it. The bowels, however, may often be conveniently refreshed and evacuated by emollient, but at the same time laxative, injections. For the rest, the treatment may be conducted as already laid down under the first species. : Fantoni, Oba. Med. Select. Obs. it 'i. i.] DIGESTIVE FUNCTION. [ord. ti. 328 SPECIES VI. PARABYSMA OMENTALE. TURGESCENCE OF THE OMENTUM. TUMOUR INDURATED AND DIFFUSED : FREQUENTLY SPREADING OVER THE WHOLE OF THE ABDOMINAL REGION : DYSPNCEA : EMACIATION. This species is especially characterized by its extent, and the want Gen- **- of a definite outline, by which it is particularly distinguished from indefiried ' the preceding.. It is usually of a complicated texture ; infarcted, ^e5°mpU" scirrhous, tuberculate, and cartilaginous. It has been found of Sometimes various shapes and magnitudes, from a weight of five pounds to that ^fou" g*"°'" of twenty, twenty-five, thirty, and in one instance fifty-six pounds. In the last case, the patient, a female, appeared to be labouring under Dlustrated- an ascites, so generally was the abdomen enlarged. She sank, gradually worn out by atrophy and pains of various kinds : and on examining the abdomen, the tumour, occupying the entire cavity of the belly, instantly presented itself to view, enclosed in a pretty thick and stout membrane, chiefly adipose, partly scirrhous and glandular, with a cavity in its interior filled with a sordid and fetid sanies. Laterally and below, it adhered to the surrounding organs only slightly ; but was so firmly fixed to the fundus of the stomach and parts adjoining that it could not be separated without laceration.* In some instances the hardness has been almost stony ;t in others Sometimes osseus ;J sometimes loaded with many thousand glandules ;§ and in oiseous* several of these accompanied with excruciating pains. || Whatever benefit may be expected from medicine is to be col- Tr«»tment- lected from the remarks already offered on the preceding species. * Greg. Horst. Prob. x. Dec. vi. f Panarol. Pentec. in. Obs. 10. t Mongin, Hist, de 1'Acad, des Sciences, 1732. § Setrer. Ephem. Germ. 11 Htixh. Phil. Trans. Vol. vu. 324 cl. 1.1 C(ELF AC A [ORD. II. SPECIES VII. PARABYSMA COMPLICATUM. COMPLICATED TURGESCENCE. THE BELLY HARD, ELEVATED, AND DISTENDED AS THOUGH PREGNANT, AND OFTEN SUPPOSED TO BE SO ; YET MOKE OR LESS KNOTTY AND UNEQUAL : RESPIRATION SELDOM IMPEDED : FOR THE MOST PART, ACUTE PAIN, NAUSEA, OBSTINATE VOMITING AND THIRST. Gen. IV. Several of the -preceding species are complicated as to the nature PEC' " of the tumour with which the respective organ is affected; the Tumour present is complicated, as being compounded of various viscera compound- r . r . I ° r ed of which are affected simultaneously. And hence, the symptoms must vfscem. often differ in different individuals, according to the immediate seat The liver of the disease and the nature of the tumour. The liver is, in always perhaps all cases, more or less concerned, sometimes in connexion concerned. wj^n the spleen, sometimes with the mesentery ; sometimes with the stomach or intestines ; and sometimes with all together. Hil- danus found the liver so enlarged as to pass beyond the false ribs of the left side, with the spleen equally enlarged,* and fixed to the adjoining lobe of-the former organ. Huldenreich, in a woman of forty-five years of age, found the liver scirrhous, weighing fourteen pounds, with a fleshy excrescence in the mesentery, of the size of a fna'tinc" of child's head. This case was also further complicated with jaundice.! compiica- Bartholhle mentions a woman of elegant form, in the flower of her tion. &ge^ backed with another modification of this disease, which at length destroyed her : when all the intestines, liver, spleen, and every adjoining viscus, were found intermixed, and buried in fat; the liver being at the same time enlarged and scirrhous, and filling both hypochondria ; the stomach thickened and cartilaginous.! VmBafon Dr' Baron has given various examples of the same, both from aron. earlier wrjters an(j from ms own practicei of which the following is one of the most illustrative ; the patient was a girl of about eighteen, and had laboured under the malady for several months before it proved fatal. " On opening the belly it was found that the whole of its contents adhered to each other, and to the cavity in such a manner as to form apparently one solid mass. None of the viscera could be distinguished, till the thickened layers of the peritomeum were torn from their adhesions. It was impossible to do this from the intestines, for there the thickening and adhesions had proceeded so far as to render any attempt at unfolding them impracticable. 1 he mesentery and its glands were in a very diseased state ; the latter were about the size of almonds, and had much of tho same * Cent. n. Obs. 45. t Miscell. Nat. Cur. Ann. vi. Tn. I Lent, ii, Obs. 6. cl. i.j DIGESTIVE FUNCTION. [ord. ii. 325 appearance when cut into. On separating the peritonaeum from its Gen. IX. adhesions to the diaphragm, the liver was found of a much larger pa^bysma" size than natural; it was of a bright copper colour, and, like the tu>mtplica" intestines, it had lost its proper texture. The fingers pierced it in CompUca- every direction without resistance, and it appeared like a part in a ceednce.rges" state of incipient putrefaction. On cutting through the right lobe, a lumbricus was observed in one of the biliary tubes."* Various morbid changes, as adhesions, thickenings, tubercles, fg?^daty granulated masses, ulceration of the bronchial glands, and purulent in other discharge, were also observed in the thorax : for all the species of orsans' parabysma, when at length accompanied with inflammatory action, are peculiarly apt to spread not only from organ to organ, but from cavity to cavity ; and more so from the abdomen to the chest, than from the chest to the abdomen. Other cases of a striking character are referred to in the author's Nosological Synopsis, which might be easily augmented if necessary ; but the present are sufficient to give a general view of the nature, gigantic features, and mischievous effects of this monstrous race of diseases: diseases which we can rarely hope to conquer, unless J^* Jf we have an opportunity of strangling them in their infancy ; though though we may sometimes give a check to their rapid strides, palliate their to"betimea painful progress, and postpone their fatal triumph. palliated. * On Tuberculated Accretions, &c. p. 25, 8vo. 1819. \ 1 I CLASS II. CLASS II. PNEUMATICA. DISEASES OF THE RESPIRATORY FUNCTION. ORDER I. PHONICA, AFFECTING THE VOCAL AVENUES. II. PNEUMATICA, AFFECTING THE LUNGS, THEIR MEMBRANES OR MOTIVE POWER. CLASS II PHYSIOLOGICAL PROEM. Before we enter on the diseases which disturb the function ol Respiration, and constitute our second Class, it may be found advan- tageous to follow up the plan laid down with respect to the First Class ; and take a brief survey of the general nature of this func- tion, and of the organs which form its instruments. The respiratory function is maintained by a current of air, alter- repose* nately thrown into and thrown out of the chest, and is subservient res. ir^tory to two important purposes : that of furnishing us with speech, or the gnect(£n* means of vocally communicating and interchanging our ideas ; and that of carrying off from the blood a gas recrementory and delete- Removal of rious to life, and possibly of introducing in its stead one or more "o^gt™6"" gases indispensable to animal existence. It is these two purposes H*nce l™° that lay a foundation for the two Orders into which the Class before diseases. us is divided ; the first entitled Phonica, comprising the diseases affecting the vocal avenues ; and the second Pneumonica, compri- sing those affecting the lungs, their membranes or MOTrvE power. 1. At the root of the tongue, lies a minute semilunar bone, which *• v°cai from its resemblance to the Greek letter v or u-psilon, is called the avenueB" hyoid or u-like bone; and immediately from this bone arises a long, Hyoid- cartilaginous tube, which extends to the lungs, and conveys the air backward and forward, in the manner, and for the purposes already mentioned. This tube is denominated the trachea or wind-pipe ; and the upper part of it, or that immediately connected with the hyoid bone, the larynx; and it is this larynx or upper part, that Larynx. alone constitutes the s at of the voice. The tube of the larynx, short as it is, consists of five cartilages; its cartiia- the largest, and apparently, though not really, lowermost of which 8es' produces that acute projection, or knot in the anterior part of the neck, and especially in the neck of males, of which every one must be sensible, and which was formerly denominated pomum Adami, as though it had sprung up in con sequence of Adam's having eaten the forbidden fruit. This is not a complete ring, but is open be- hind, the open space being filled up, in order to make a complete ring, with two other cartilages ofa smaller size and power ; and which, together, form the glottis, as it is called, or immediate aperture out of Glottis. the mouth into the larynx. Of these three cartilages, the first is named scutiform, or shield-shaped ; the other two, arytenoid, or funnel- shaped. A fourth cartilage lies immediately over this aperture, and closes it in the act of swallowing, so as to direct the food to the Vor I,.—4? 330 cl. n.] PHYSIOLOGICAL PROEM Capable of being perfectly closed in birds and amphibials Voice. Speech. I. Vocal esophagus. From its position it is called epiglottis. These foar eF" • cartilages are supported by a fifth, which constitutes their basis, ie narrow before, and broad behind, and has some resemblance to a seal-ring: on which account it is named cricoid, or annular, by the anatomists. The larynx is contracted and dilated in a variety of ways by the antagonist powers of different muscles, and the elasti- city of its cartilaginous coats ; and is covered internally with a very sensible, vascular, and mucous membrane, which is a continuation of the membrane of the mouth. Form and -phe form of the glottis, composed, as we have stated, of three the glottis, distinct cartilages, resembles that of a small box, with a minute aperture or rima. In adults this aperture is about ten or eleven lines in length, and two in breadth at its greatest diameter. It is, however, increased or diminished by the action of the arytenoid and cricoid cartilages : and in birds, and amphibials, is capable of being so completely closed as to prevent the smallest drop of water from penetrating it, except with the will. In this way frogs confine the air in the lungs, and live without inspiration for a considerable time. The organ of the voice, then, is the larynx, its muscles and other appendages ; and the voice itself is the sound of the air propelled through, and striking against the sides of the glottis of aperture into its powers, the mouth. The shrillness or roughness of the voice depends on the internal diameter of the glottis, its elasticity, mobility, and lubricity, and the force with which the air is protruded. Speech is the modi- fication of the voice into distinct articulations in the cavity of the glottis itself, or in that of the mouth or of the nostrils. There is a difficulty, however, in determining by what means the sonorou" in air is rendered sonorous in the glottis, and various explanations have Hypothesis been offered uPon the subject. The oldest is that of Galen, who of Galen: supposed the calibre of the glottis to be alternately expanded and and Dodart. contracted ; an idea revived in modern times by Dodart, who at the same time compares its action to that of a flute.* A second Hypothesis explanation is that of M. Ferrein, who supposes the variations of '"' sound to depend upon variations of tension and relaxation in the liga- ments of the glottis : and in this view such ligaments become vibrating chords, and the entire apparatus approaches the nature of a violin.t A third explanation is that of M. Eicherand, who unites the two preceding conjectures, and supposes that the glottis is a wind and a chord instrument at the same time. To these explanations we may s\ebratZen" add that of Kratzenstein, who regards the glottis in conjunction with the whole length of the larynx as a kind of drum ;} and that of M. Blumenbach, who views the former in the light of an iEolian harp. All which are ingenious sports of the imagination, but con- tribute little to the advancement of physiological science.§ Those animals only that possess lungs, possess a larynx ; and hence none but the three first classes in the Linnean system, consisting of mammals, birds, and amphibials. Even among these, however, some * Memoires de l'Academie, &c. 1700. t H. 1741. | Tentamen de Nature el Charactere Sonorum Literarum Vocalinm. 4to. 1781. 5 Instit sect. ix. x. subsect. 155. Air how rendered of Richer- and: of Blumen bach. Animals only that possess lungs a larynx. PHYSIOLOGICAL PROEM. [cl. n. 331 genera or species are entirely dumb, as the myrmecophaga, or ant- L Voc^ eater ; the manis, or pangolin ; and the cetaceous tribes ; the Yet of these tortoise, lizards, and serpents ; while others lose their voice in n°XraUy particular regions ; as the dog is said to do in some parts of Ame- d"mb:. rica, and quails, and frogs in various districts of Siberia.* their voice It is from the greater or less degree of perfection with which the Ja/JjSg, larynx is formed in the classes of animals that possess it, that the Perfection voice is rendered more or less perfect; and it is by an introduction ° l ev01Ce■ of superadded membranes, or muscles, into its general structure, or a variation in the shape, position, or elasticity of those that are most Whencethe ■ .1. ■ i iir- peculiar common to it, tUat quadrupeds and other animals are capable ot sounds of making those peculiar sounds by which their different kinds are re- ^TBe"f _spectively characterized ; and are able to neigh, bray, bark, or roar ; animals. to pur, as the cat and tiger kind ; to bleat, as the sheep ; or to croak, as the frog ; which last, however, has a sac or bag, of a singular character, in the throat or cheek, directly communicating with the larynx, on which their croaking principally depends. The larynx of the bird class is of a very peculiar kind, and ad- La[Yn* mirably adapted to that sweet and varied music with which we are exquisitely so often delighted in the woodlands. In reality, the whole extent cunous- of the trachea in birds may be regarded as one vocal apparatus ; for the larynx is divided into two sections, or may rather, perhaps, be considered as two distinct organs : the more complicated, or that in which the parts are more numerous and elaborate, being placed at the bottom of the trachea, where it diverges into two branches or bronchia?, one for each of the lungs : and the simpler, or that in which the parts are fewer, and consist of those not included in the former, occupying its usual situation, at the upper end of the tra- chea ; which, however, is still without an epiglottis ; both food and water being, as we have already observed, rendered incapable of penetrating the aperture of the glottis, by another contrivance. The Forms a lungs, trachea, and larynx of "birds therefore, may be regarded as ]^,u™pe forming a complete natural bag-pipe ; in which the lungs constitute the pouch and supply the wind ; the trachea itself, the pipe ; the inferior glottis, the reed or mouth-piece which protrudes the simple sound ; and the superior glottis, the finger-holes which modify the simple sound into an infinite variety of distinct notes, and at the same time give them utterance. Here, however, as among quadrupeds, we meet with a consider- ^j va»«* able diversity in the structure of the vocal apparatus, and especially d"fferent in the length and diameter of the tube or trachea, not only in the genera and different species, but often in the different sexes of the same spe- cies, more particularly among aquatic birds. Thus the trachea is straight in the tame or dumb swan anas Olor) of both sexes; Anas oior. whilst in the male musical swan (anas Cygnus), but not in the Anas female, it winds into a large convolution, contained in the hollow ygnu of the sternum. In the spoon-bill (platalea Leucorodia), as also in Spoon-bill. the mot-mot pheasant (phasianus Mot-mot), and some others, simi- Mot-mot lar windings of the trachea occur, not enclosed in the sternum. Pheasant- * Blumenb. Corap. Anat. Ch. xv. § 193.-Camper. Phil. Trans. Vol. ixix. 1779. p. 139. 332 CL. II. PHYSIOLOGICAL PROEM. I. Vocal avenues. Duck Merganser Singing- birdn. Hence ex- traordinary powers in many kinds Thrush. Nightin- gale Tuneful manakin- Imitatiug birds Bull-finch. Parrot and crow kinds. Nightii;- 2 ale. Mocking- bird, its wonderful powers. Seat of the imitatire vaice. The males of the duck and merganser {anus and mergus) havr. at their inferior larynx, a bony addition to the cavity which contri- butes to strengthen their voice. Among singing-birds, Mr. Hunter, who, at the request of Mr. Pennant, dissected the larynx of many distinct kinds, observes that the loudest songsters have the strongest muscles, and that the sky- lark has the strongest of the whole ; whose clear and vigorous note is often heard when he can no longer be followed in his ascent by the most penetrating eye. He observes also that, among this division of birds, the muscles of the male, following the same rule, are stronger than those of its respective female, whose voice is always less powerful. In birds that have no natural voice he perceived no difference of muscular power in the larynx of either^ sex. From this most extensive and complicated machinery in the vocal organ of birds, we find numerous species possessing powers of a very extraordinary kind. In many of them, as the thrush and the nightingale, the natural song is exquisitely varied, and through an astonishing length of scale. In the pipra musica, or tuneful mana- kin, the song is not only intrinsically sweet, but forms a complete octave; one note succeeding another, in ascending and measured interval, through the whole range of its diapason. There are vari- ous kinds that are capable of imitating tiie music of human art, and amuse us by acquiring national and popular tunes; as the bull-finch, the linnet, and even the robin, when reared in a state of separation from all other birds; whilst some, again, are capable of imitating human speech, as the parrot, the jay, and jack-daw, and, indeed, most of the psittacus and corvus genera; a fact which proves the possession of a powerful and retentive memory, as well as of a precise and delicate ear. A linnet, according to Mr. Pen- nant, was once taught the same at Kensington ; and even the night- ingale is said to have talents for speaking equal to those for sing- ing. But where is the man whose bosom burns with a single spark of the love of nature, who could for a moment consent that this sweet songster of the groves should barter away the touching wild- ness of its native notes for any thing that art has to bestow ? Yet perhaps there is no species among the class of birds that is more entitled to notice in a physiological survey, on account of its voice, than the turdus Polyglottus, or mocking-bird. This is a sub-division of the thrush-kind ; its own natural note is delightfully musical and solemn ; but, beyond this, it possesses an instinctive talent of imitating the note of every other kind of singing-bird, and even the voice of every bird of prey, so exactly as to deceive the very kinds it attempts to mock. It is moreover playful enough to find amusement in the deception ; and takes a pleasure in decoy- ing smaller birds near it by mimicking their notes, when it frightens them almost to death, or drives them away with all speed, by pouring upon them the screams of such birds of prey as they most dread. Now it is clear that the imitative, like the natural, voice has its seat in the cartilages and other moveable powers that form the PHYSIOLOGICAL PROEM. [cl. u. 333 larynx; for the great body of the trachea only gives measure to the L Vocal d_i j ■, . •" . . . avenues. , and renders it more or less copious in proportion to its volume. It is not therefore to be wondered at that a similar sort imitative of imitative power should be sometimes cultivated with success man? in the human larynx ; and that we should occasionally meet with persons who, from long and dextrous practice, are able to copy the notes of almost all the singing-birds of the woods ; or the sounds of other animals; and even to personate the different voices of orators and other public speakers. One of the most extraordinary instances of this last kind consists Ventriio- in the art of what is called ventriloquism, of which no very qU19' plausible explanation has hitherto been offered to the world. The Description. practitioner of this occult art is well known to have a power of modifying his voice in such a manner as to imitate the voices of different persons conversing at some distance from each other, and in very different tones. And hence the first impression which this How a this conjecture, to observe that it does not ac- "or™ count for the perfect quiescence of the mouth and cheeks of the performer while employing his feigned voices ; and that an adept in the art like M. Fitzjames, who exhibited a few years ago in our own country, or M. Alexandre of the present day, is totally indif- ferent to the room in which he practises, and will readily allow an- other person to choose a room for him. Of M. Fitzjames, M. Richerand has given a particular account from personal examination. He observes, that he always made a strong inspiration before he commenced his performance, and could support his various voices till he required a fresh supply of air ; thus evidently proving that the inhaled air was expired, though not through the lips, but, as appears from another case observed by M. Richerand, at least partly through the nostrils. Yet the means by which the ventriloquist is enabled to modify his j£P,Bauna-M_ articulations into the semblance of distinct voices, still remains to tions of the be explained ; and I shall hence beg leave to throw out a sugges- author- tion upon the subject. From various concurrent facts, ventriloquism Ventriio- 334 cl. ix.] PHYSIOLOGICAL PROEM. i. Vocal appears to be an imitative art, founded on a close attention to the 5uismean almost infinite variety of tones, articulations, and inflexions which the an'1*1*6 glottis is capable of producing in its own region alone, when long Consisting and dextrously practised upon; and a skilful modification of these vocal produced in sounds, thus limited to the glottis, into mimic speech, passed for the the glottis most parti an(j whenever necessary, through the cavity of the nostrils Varied instead of through the mouth. It is possible, however, though no jrTtheP3 opportunity has hitherto occurred of proving the fact by dissection, structure or that those who learn this art with facility, and carry it to perfection, its muscles possess some peculiarity in the structure of the glottis, and particu- lagesrtl iarty m respect to its muscles or cartilages. Glottis the In singing, every one knows that the glottis is the only organ made employed" use of except where the tones are not merely uttered but articulated. 'nd"n the1 '* *s tne on^ o^11 employed, as already observed, in the mock mock arti- articulations of parrots, and other imitative birds ; it is the only of'bi'rds organ of natural cries, constituting the language of all animals Natural possessing a voice; and hence Lord Monboddo has ingeniously a'nirnaif8 conjectured that it is the chief organ of articulate language in its ^c°uredC°by rudest and most barbarous style. " As all natural cries," says he, Monboddo " even though modulated.by music, are from the throat and larynx, or beenUie knot of the throat, with little or no operation of the organs of the mouth, chief organ ^ js natural to suppose that the first languages were, for the greater cuiate part, spoken from the throat; and that what consonants were used manUinga °f *° varv ine criesi were mostly guttural, and that the organs of the mouth rude state, would at first be but very little employed."* To which 1 may add, that notwithstanding, in the ordinary use of speech, the tongue takes an auxiliary part among mankind, yet the numerous and well authenticated examples on record, and to which we shall have oc- casion to advert more minutely hereafter, of persons who have re- tained a full and perfect command of speech, after the tongue has been Glottis destroyed or extirpated, proves, incontrovertibly, that the glottis alone supp yfng is capable of supplying, in this respect, the place of the tongue, upon place"6"6 S Particular occasions, and where perhaps peculiar pains are taken to call forth the full extent of its latent powers. This ex- This explanation, which some hundreds of persons in this me- fcneed tropolis may remember to have been advanced by the author, in a authov PUDnc lecture on the subject delivered in the year 1811, has since fourteen been embraced in France, though without adopting the hint that years ago. the full perfection of the art may possibly depend upon some slight addition to the muscular organism of the glottis, in those who aie thus Asjmihir highly endowed with it. And hence M. Magendie asserts that adva^Ted0" ventriloquism consists in nothing more than a delicate attention to Maglndif' the different effects or modifications of sounds or speech, thrown at with only different distances and through different modes of conveyance, and an 'varmtio'n. exact imitation of them in a larynx of common formation and powers. " Les fondemens sur lesquels repose cet art sont faciles a saisir. Nous avons instinctivement reconnu, par l'experience, que les sons s'alterent par plusieurs causes ; par exemple, qu'ils s'affoiblissent. deviennent moins distincts, et changent de timbre a mesure qu'ils * Oriar. and Prog, of Lang. v. j. b. iii. ch. 4. PHYSIOLOGICAL PROEM. [cl. ii. 335 sfeloignent de nous. Un homme est descendu au fond d'un puits, l Vocal U" i • . \ i, . , . avenues. veut parier aux personnes qui sont a 1 ouverture : sa voix n arnvera a leur oreille qu'avec des modifications dependantes de la distance, de la forme du canal qu'elle a parcourue. Si done une personne remarque bien ces modifications, et s'exerce a les reproduire, il pro- duira des illusions d'acoustique, dont on ne pourra plus se defendre, qu'on ne peut pas voir les objects plus gros lorsqu'on les regarde a travers un verre grossissant ; l'erreur sera complete s'il emploie d'ailleurs les prestiges convenables pour detourner 1'attention. " Plus 1'artiste aura de talens, plus les illusions seront nombreu- ses : mais il faut se garder de croire qu'un ventriloque produise les sons vocaux, et articule autrement qu'une autre personne. Sa voix se forme a la maniere ordinaire. Sous un certain rapport, on peut dire que cet art est a l'oreille ce que la peinture est pour les yeux."* But this last view of an ordinary articulation and formation of Single the voice, is at variance with that perfect quiescence of the muscles pointedout. of the cheeks and lips which the more skilful ventriloquists evince, and which can only be accounted for by a formation of articulations, and not merely a modification of sounds, in the larynx. II. The lungs, whose vessels receive the air from the trachea, n. Motive and in which the blood undergoes the important process of ventila- structure of tion, are well known as a pair of large, light, elastic, and spongy thelungs- organs, suspended by the tracheal tubes and large blood-vessels in the cavity of the chest, and in size adapted to the two sacs of the pleura which they completely fill when inflated. They are surrounded by an exquisitely fine duplicature of this delicate membrane, which lines the entire cavity of the thorax, and separate^ the lungs from each other by a process or septum ; which, from its run- ning between the two, is called mediastinum. The substance of the lungs is lobular; the larger lobes dividing into smaller ; and the subdivision being continued through an almost infinite series, till the ultimate lobujes terminate in very minute vesicles ; which, after birth, Air vesicles. though not antecedently, are filled with air, conveyed by an innume- rable host of exquisitely slender ramifications fiom the two grand branches into which the trachea at first forks off, so as to form a main division for each of the lungs, and which are denominated bronchia?, as their subdivisions are bronchial vessels. The vesicles Bronchi*. or air-cells are invested and held in connexion by the mucous web common to all animal organs, which, at the same time that it unites them and forms their boundaries, opens a communication between the one and the other, and is itself freely supplied with exquisitely fine blood-vessels, that are ramifications from tne pulmonary artery, and continue to divide and sub-divide, til! they at length forma beau- tiful net-work upon the sides of the air-cells, and ultimately become invisible from their attenuation; by which means every particle of blood is exposed, in its turn, to the full benefit, whatever this may consist in, of the gases of the atmosphere contained in the air cells which they thus surround. The moving powers of the lungs consist in the bones, cartilages, Df,v^ug powers. * Precis Elementaire de Physiologic, Tom. ii. p. 235. 336 cl. il] PHYSIOLOGICAL PROEM and muscles by which they are encircled. The bones are the ribs and sternum, which, in their form, insertion, and general freedom of play (for even the sternum itself seems to yield a little), exhibit ;i perfection of art that the most careless among us cannot, but admire.' though the wisest could not have contrived : Deus, Deus, ille, Menalca ! state of Antecedently to birth, the whole of this machinery, with the antecedent blood-vessels may be contemplated as at rest, and the lungs in a state to birth. Qf collapse, in whose interstices there is a perfect vacuum. From the moment the infant becomes exposed to the atmosphere, the air which presses forcibly on every side, presses also upon the upper part of the trachea through the channels of the mouth and the nos- inspiration trils ; the motive powers of expansion, and which are afterwards dueed'/" those of expiration, are immediately stimulated into action ; the ribs rise by the agency of the intercostal muscles, and the chest becomes elevated : the diaphragm, whose broad and muscular septum divides the thorax from the abdomen, sinks, from instinctive sympathy, towards the viscera beneath, and the chest becomes deepened ; and into the dilated vacuum, hereby produced, the external air rushes forcibly by the trachea, and, by inflating the lu.igs to the full stretch of their elasticity, compresses all the surrounding organs. Yet as the force with which the air operates is very considerable, perhaps as much as three hundred times, less than that of the heart when sti- mulated to contract, the blood, instead of being hereby impeded in its course through the pulmonary vessels, flows far more freely, and dilates these vessels by its plenitude, as they are already necessarily elongated by the expansion of the lungs ; and the heart in this manner becomes liberated from a load which, if it were to remain in its cavity, would oppress it and put a stop to its action. And hence we behold at once, the important connexion that exists between the sanguiferous and the respiratory systems, and how much the sound- ness of the one must depend upon that of the other. Such, then, are the chief motive powers concerned in the act of ifowraro0-n insPirati°n! and tne means by which they effect their purpose. The duced. process of expiration, or that of throwing the air back again after it has accomplished its intention, is not of more difficult comprehen- sion. All the muscles of the body become exhausted and fatigued by their own action, and show an evident tendency to return to an opposite state, or that of rest; some indeed in a shorter, and others in a longer period of time ; but all of them soonest, when, inde- pendently of their own exertion, they are also opposed by a set of counteracting muscles, whose resistance they must subdue before they can accomplish their purpose. Antagonism Now thig ig precisely the gtate of the moving powers Qf tne lungSi Twer!in m the twc alternate actions of inspiration and expiration. For inspiration while the muscles we have just adverted to are stimulated to expand and expi.a- the chest, tnere are others that by a reverse energy are perpetually striving to contract its diameter. Almost all the abdominal muscles ^nd to produce this effect, and particularly the oblique, straight. anH II. Motive powers. PHYSIOLOGICAL PROKM. [cl. ii. 337 transverse. Many of these are inserted into the ribs ; .and, as the "Motive latter become elevated, endeavour to draw them back into their an- p0WeW" terior situations, to which also the ribs themselves have an inherent inclination to return, from their natural elasticity. Other muscles, urged into action by the descent of the diaphragm, immediately contract their fibres, diminish the convexity of the abdomen, and hereby force the abdominal viscera upwards and backwards against the diaphragm that thus intrudes upon them, and drive it into its former position : whilst all the blood-vessels, and even the air-cells of the lungs, possessing an elastic power, have a natural tendency ,,to return to their smaller diameters; and hence expiration is per- formed with even more facility than inspiration, and is consequently the last action of dying persons. The powers I have thus far noticed are those which usually act Function without the interposition of the will, although the will possesses some eTSiyh" control over most of them. But whenever this faculty of the mind wi'houtthe ii n • mterposi- co-operates and throws its influence into the balance on either side, tion of the other powers are sometimes called into action, and the energy of Yet'on some of these is occasionally suspended. Thus, in the case of a emergencies fractured rib, or of pleurisy, the power of the will keeps the ribs controisand quiescent, and the power of expansion is thrown almost entirely aStjon'of upon the diaphragm: while, on the contrary, when, in run- *« moving ning, a freer supply of air becomes necessary, and the heart palpi- respfration; tates from the rapidity with which the blood is thrown into it, the thorax is urged by the stimulus of the will to a quicker respiration, and the muscles that are inserted into the clavicles and scapulae are often called upon for their conjoint assistance. And where the mind has, from an early period of life, been in the habit of exercising such a control, it is wonderful to contemplate the quantity of air which the lungs may be brought to enclose, and the length of inter- val tlirough which the life may be preserved without a fresh supply : of which savage nations furnish us with striking examples, in the act of diving and remaining under water. Diemerbroek relates the case of a pearl-driver, who, under his own eye, remained half an hour at a time under water, while pursuing his hunt for pearl muscles.* The will also makes use of the muscles of respiration for a va- and some- riety of other purposes ; sometimes for that of freeing the aerial J^91^ passages themselves, or other cavities connected with them, from t00ther *■ & . , , . . 111 • 1 • • purposes; some material that irritates or loads them, as in coughing, sneezing, and hiccup ; all which actions are sonorous from the violence with which the air is protruded, and the last of which is often exercised, even without the consent of the will, from spasm alone. And some- times the will employs these powers as mere expressions of mental feeling at the moment, as in laughing, sighing, or weeping: the?siniaugi, first of which consists of a mere succession of short and abrupt ^^5' expirations; and the last two, of deep inspirations, succeeded by ing. deep expirations ; broken, in the case of weeping, into a quick series of sonorous snatches; and often accompanied, in sighing, with deep and long drawn intonations, which we call groans. III. But the most important part of the general economy of rcspi- hi. Effec » . t •■_ »ca of respire * Artatora. Lib. H. p. 464, Vol. I.—-1" 33S «-. «•] PHYSIOLOGICAL PROEM. itt Re«pi- ration consists in the change which takes place in the blood in eon* tioTon the sequence of its being acted upon by the inspired air. blood. \y-e see the blood conveyed to the lungs of a deep purple hue, onhebiood faint and exhausted by being drained in a considerable degree of its lel^nes'the vital power ; or immature and unassimilated to the nature of the sys- lungs68 tem it is about to support, in consequence of its being received fresh character from the trunk of the lacteals. We find it returned from the lungs afterwards, spirited with newness of life, perfect in its elaboration, more readily disposed to coagulate, and the dead purple hue transformed into a bright scarlet. What has the blood hereby lost ? How has this won- derful change been accomplished ? * Thembject These are questions which have occupied the attention of physio- fo?merd » logists in almost all ages, and were as eagerly studied in the Greek vveliwin8 schools as in our own day. To the present hour, however, they have SnlsT descended in a mantle of Cimmerian darkness ; and though the re- searches of a more accurate chemistry have disclosed volumes of facts heretofore unknown, and the ingenuity of able theorists have laid hold of them, and applied them to an explanation of this curious subject in a great variety of hypotheses, I am afraid we are still but ■till in almost as much at sea as ever; and that there is no inquiry in the an unsatis- wjj0ie range of physiology in a more unsatisfactory state than that state. concerning the ventilation of the blood in the lungs. Average of According to a course of well-conducted experiments, instituted '•Ma minute man7 years ago by Sir Humphry (then Mr.) Davy, it appears that according 'the general sum of a man's natural inspirations are about twenty-six to Davy. or twenty-seven in a minute ; and that thirteen cubic inches of air,. are in every inhalation, taken in, and about twelve and three quarters Contents of alternately thrown out. The atmospheric or inspired air was found inspired air; tQ contaiu? in the thirteen cubic inches, nine and a half inches of ni- trogene, three and four tenths of oxygene, and one tenth of an inch of expired ofcarbonic acid: the twelve inches and three quarters of returned a,r' air gave nine and three tenths of nitrogene, two and two tenths of oxygene, and one and two tenths of carbonic acid. Result. From these experiments, therefore, there should seem to be a re- tention in the system of a large portion of the inspired oxygene, and a small portion of the inspired nitrogene; and a discharge from the system of a very considerable portion of carbonic acid gas. Modena And as the colour of the blood is well known to be changed in its biUoeodf how passage through the lungs, from a deep modena to a bright scarlet produced hue, M. Lavoisier, following up, with additional facts, an earlier set toLavoi? of experiments of Dr. Crawford, endeavoured to show, that, while the modena hue is produced by the carbone with which the blood is loaded when it first reaches the lungs, its scarlet results from its hue'how wsm£ th*3 surplus of carbone, and acquiring oxygene in its stead; produced, during which process a very large quantity of caloric, or heat, in an elementary form, is supposed, also, to be disengaged from the air thrown into the air-cells of the lungs, and to pass into the adjoining minute blood-vessels in combination with the oxygene. Doubu at The experiments of Sir Humphry Davy were afterwards repeated uon Tan", by Messrs. Pepys and Allen; but these acute analysts could not dis- inhaiedthe C0VCT ^ ^ Part °fthe inhaled nitrogene was retained; since the wro-ene. same exact proportion appeared from their trials to be thrown back 9ier. PHYSIOLOGICAL PROEM. [cl. ii. 339 m every instance of expiration, as had been previously received in J^Mpi" every instance of inspiration. And there have since been doubts, Ooubts on the part of Sir Humphry Davy himself, respecting the supposed exinerlce of caloric ; not merely in regard to its separation from the atmospheric jj?1,0^" * air, but as to its substantive existence at all, either there or elsewhere; substance: heat being, in his later view of the subject, nothing more than a rapid, vibratory, or repulsive action of the corpuscles of a body that exhibits this phenomenon : thus reviving the doctrine of Aristotle, *uan re^o and the Peripatetics, which was so ably controverted by the Epicu- eontroversy reans ; who, foretasting the spirit of the Lavoisierian system, stre- peripatetics nuously contended that it was a substance sui generis.* While, to and the close the whole, Mr. Ellis has gone through another extensive range noubto*"8" of inquiry, and instituted or collected another numerous set of expe- ***£*" riments, to prove that even the oxygene of the inspired air does not of the enter into the blood-vessels of the lungs, but becomes itself converted, J,"Bygen0 in the air-cells of these organs, into the carbonate acid gas of the ex- '"to'h8 pired air, by uniting with the carbone of the blood, which he sup- h0w ' poses, as a recrement, to be secreted in the form of a vapour into J^"^^ the air-cells, by the exhalants of the lungs.j He admits, however, J0^' the existence of caloric, as an elementary principle ; conceives it to uVsnb?" be disengaged in very large abundance from the inspired air, during ^tl^e of its union with the secreted carbonic halitus ; and ascribes the reco- caloric;and vered scarlet hue of the blood to its combination with this invisible Swariet fluid ; as he does also whatever effects are produced by the exercise hM of the of the respiratory function, not merely in animals, but in plants. Of the facts and arguments in favour of Mr. Ellis's hypothesis, J*jfBnd which he extends to plants as well as to animals, the two following arguments seem to be the chief. Firstly, the seeds of plants in germination, and ™f5f plants themselves in growth, throw forth carbone, in the formofaque- hypothesis. ous vapour, or, in other words, dissolved in water, even where no oxygene is present. J And, secondly, such ejected fluid, wherever life exists, is the work of secretion. In consequence of which, he ventures to affirm that it is a secretion of this kind which is conti- nually taking place on the surface of the lungs, and of the skin, in animals, both which he thinks concur in a common action ; and in support of this opinion he refers to various insects and worms, with- out stigmata or stemmata, which appear to breathe by the pores of the skin alone.. According to Mr. Ellis, we have no proof of carbonic acid, or of No^roof any aeriform fluid existing naturally in theblood,§ and consequently aeriform have no reason to expect that any can be thrown out: while, if oxy- 5SluQth* gene enter from the air-cells into the system, it must be by absorption, or chemical affinity. If by absorption, it would, in animals, take the regular course of the thoracic duct, and the blood in the right ven- tricle of the heart would first exhibit a scarlet hue : while in the germination of vegetables, their seeds give no evidence of possessing a structure fitted to absorb and expel aeriform fluids; nor of any such fluids at any time existing in them.ll To the operation of chemical affinity he conceives an actual contact between the air and * See the Author's Translation of Lucrcttas.—Note on Book H. v. 74S. t Inquiry into the Changes induced on Atmospheric Air. 8vo. 1807. ' Inquiry, &c. Sect. 20, p. 28. § Id. Sect. 98, p. 122. || Id. Sec. 16, p. IP. 340 cl. n.] PHYSIOLOGICAL PROEM. ur. Respi- the blood to be requisite ; but in the lungs we have an intervention rRtlon' of the coats of the cells, and of the blood-vessels. And if these be presumed so thin that, when moist, they will allow the air, or its oxygene gas, to pervade them, the gas would rather pass into the interstices of the cellular substance, than into the pulmonary vessels, and thus create an emphysema. But the whole of such permeation, he holds to be gratuitous, and contrary to experiment.* The dimi- nution in the bulk of respired air, he thinks, may be accounted for by an union of the carbone of the blood with the oxygene in the air- cells, and the formation of aqueous vapour by the disengagement of the caloric from the oxygene of the atmospheric air.f Reply > To these objections, however, it may be replied, that if caloric can objection, penetrate animal membranes, and unite, by chemical affinity, with the blood in the blood-vessels, so, for any thing we know to the contrary, may oxygene. Mr, Porrett has shown that the voltaic fluid, when operating upon water, is capable of carrying even water itself through the bladder, and raising it into a heap against the force of gravitation.J A like combination may take place between the voltaic or some similar fluid and the oxygene and a part of the nitrogene gases in the air-cells of the lungs ; and a similar permea- tion may follow directly through the membranes of the blood-vessels; and the carbone of the system may, in consequence, pass off by the same channel instead of being secreted ; and in the form of carbonic acid, instead of in that of carbonic vapour. objections Next, we have no proof that carbone will dissolve in water, and of w»cr produce such vapour : and hence, at present, this idea is gratuitous. principles. Again, air appears, in various cases, to have been actually dis- engaged, and is, perhaps, perpetually disengaging from the blood. Mr. J. Hunter declares he has discovered it in an abscess, in which it could neither have been derived from without, nor from putrefaction :§ and he hence adopted the opinion that air is often secreted by animal organs, or separated from the juices conveyed to them. And this opinion has not only been abundantly confirmed, but even Fact»n extended to the vegetable world since his time: for Mr. Bauer show that appears to have shown that an elastic gas is constantly shooting eiistd°e* f°rth m sma^ bufibles from the roots of plants into the slimy papula? naturally, by which they are surrounded ; and that it is hence the slimy animal" and matter becomes elongated and is rendered vascular, or converted JueilesaWe into hair or down; And Mr- Brande has established, by experiments, Experi- that carbonic acid does exist, and that too in a considerable quantity, Bauer.°f m tne blood of animals, while circulating through both arteries and memsri0f veins ' and that il is so lar.£eIy poured forth from blood placed, Brande. while warm, under the receiver of an air pump, as to give the appearance of effervescence; a fact familiar to Mr. Boyle nearly two centuries ago. The venous and arterial blood, according to Mr. Brande's experiments, seems to contain an equal proportion of this gas; and he calculated that not less than two cubic inches were * Inquiry, &c. Sect. 101, p. 125. J ™ Sect' ,8V'9?' SreS.V.!.07' P- 1S2> and comPare with Sect. 11, n. 13. J Thomson's Annals of Philos. No. xliii. pp. 75, 76. 5 Animal Ecpnomy, p. 207. PHYSIOLOGICAL PROEM. [cl. ir. 341 extricated from every ounce of blood thus experimented upon. And Jj^J8*1" hence Sir Everard Home, following up the discoveries of Mr. Bauer, co^ectote ingeniously conjectures that it is by the escape of bubbles of this JJ™;15, gas from the serum of blood, in cases of effusion and coagulation, that new vessels are formed; as also granulations in pus, as a like gas appears to be separable from this latter fluid.* The observations of Mr. Ellis are, therefore, by no means suffi- Hence ob- cient to subvert the Lavoisierian hypothesis of respiration. And of'Ellis not some late experiments, both of M. Gay Lusac and of M. Magendie, J^™|^. seem to support those already adverted to of Sir Humphry Davy, riments of since they concur in proving that in the act of respiration there is a ^adyMa-W little more carbonic acid gas than oxygene consumed. gendie in Since the first edition of this work was printed, the objections the Lavoi- hereoffered to Mr. Ellis's conclusion, and the support thus attempted hyp0athe8is. to be given to M. Lavoisier's hypothesis, have been amply and Later very plausibly supported by a new set of experiments, conducted accurate6 with the utmost accuracy, and upon a far more extensive scale than J^^^j* ever, by Dr. Edwards of Paris, who is fairly entitled to be regarded as inconfirma- one of the clearest and ablest physiologists of the present day. The J,°enw" j,^ results were chiefly obtained by exposing to an atmosphere of offered. hydrogene gas such animals as can live longest in an atmosphere deprived of its oxygene, as frogs and other batrachian tribes among the cold-blooded, and the young (and hence kUtens were selected) among the warm-blooded ; though the experiments were varied by employing birds and fishes as well. The results differed considera- bly in degree according to the kind of animal made use of, and even in respect to the same animal according to the season, or the tem- perature of the atmosphere : but the general conclusion is, in few words, as follows:—All the oxygene which disappears during the inspiration of atmospheric air is absorbed by the blood : carbonic acid is exhaled ; nitrogene gas is also exhaled, and it is likewise absorbed. The carbonic acid is sometimes equivalent to the oxy- gene which disappears, but sometimes also it is less ; and the nitro- gene gas exhaled is sometimes inferior, sometimes equal, and some- times superior, to the quantity absorbed.! The quantity of air inhaled in a single act of inspiration is found Quantity of to vary in persons of different sized ches(s ; but the aggregate inhaled paries in" in a given period does not essentially differ ; since those who inhale ^g™1 most at a time make the feweBt inspirations in a minute. I have in a single said that Sir Humphry Davy calculated the average number of {Jiff "ot'0"' respirations in a minute at twenty-six or twenty-seven, and that the much jn an measure of air inspired or expired was estimated at about thirteen period. cubic inches each time. This breathing has since been supposed too rapid for a common standard ; and the measure of air received and returned too low ; but as the former error compensates the latter, the • amount of air does not essentially deviate from the general allowance for a minute. Andit is by this explanation alone, that we can in any ^nd1.h*nce way reconcile the different results which have been given by different results "of"' different analyses are * Phil. Trans, for 1818. p. 180. reconciled. t De l'Influence des Agens Physiques sur la Vie, &c. Paris, 8vo. 1824. 342 cl. ii] PHYSIOLOGICAL PROEM. in. Respi- eXperimenters upon this subject. Dr. Godwin calculated the inspired air at twelve cubic inches, and the expired at fourteen, being a difference produced by expansion from the heat of the lungs :* which does not essentially vary from the above estimate of Sir Humphry Davy : and he calculated the residuary air in the lungs, immediately after expiration, at one hundred and nine cubic inches, which upon inspiration was increased to one hundred and twenty-three. But Borelli states the inspired air at from fifteen to twenty cubic inches ;t while Jurin, Haller, and Menzies give that which is expired at not less than forty4 About In good health, perfect quiet, with an open chest, few persons, inspirations perhaps, are found to breathe more frequently than about twenty inqnietTnd tmies in a minute ; and the quantity inhaled and exhaled, at a tern- sound perature of fifty-five of Fahrenheit, is estimated at from twenty-six From 26 to to thirty-two cubic inches each time ; which, however, by the heat mchesbic OI*tne lungs, and saturated with moisture, become forty or forty-one each time, cubic inches in the chest itself. Taking, then, twenty cubic orn4i?Ddth2 inches as the ordinary quantity of external air inhaled and exhaled chest when about twenty times in a minute, it will follow that a full grown per- wittfheat son respires twenty-four thousand cubic inches in an hour ; or five an4, hundred and seventy-six thousand cubic inches in the course of a moisture. • . day ; a total equal to about thirty-nine hogsheads. emitted0 ^ne qu:l,lti*y °f carbone thrown out of the system of the lungs, from the when estimated in the gross, may afford matter of no less astonish- tomore'1"1 ment. For taking the gravity of the carbonic acid gas, as calculated than twelve by Lavoisier, a person in health must emit from his lungs something charcoal more than is equal to twelve ounces of solid carbone or charcoal twenty every twenty-four hours. four hours. The primary cause of the red colour of the blood is a chemical cauwTof rather than a physiological question : and belongs to the sanguiferous "otoufof rather than to the respiratory function ; yet upon this point, also, the blood physiologists are by no means agreed, some ascribing it to the con- settied. version of the iron, which forms a constituent principle of the blood, Hypothesis into a red oxyde ; and others, and particularly Sir Humphry Davy, French to the affinity which the calorific rays of light have for oxygene Hypothesis generally, and hence for the oxygene of the animal system ; against of )>avy. the surface of which it is perpetually impinging, and into which it is perpetually carried in combination with the inspire*£air ; separating it incessantly from its union with the carbone of the animal frame, v and transforming the carbone thus decomposed and simplified, into in'*othtlM a ^arlc pi&ment- Birt there are difficulties that hang about both these as these, and indeed, every other hypothesis that has yet been started, eveiy other concerning even the primary cause of the red colour of the blood, as conjecture. we shall have occasion to notice more at large hereafter, which • leave the subject still open to inquiry. JionXne" ^etl wnatever may be the primary cause of the red colour of the other cause blood, we find that, in respiration, there is some other cause super- wKdded added, and which, as observed above, heightens the colour the blood changes the deep red of the * Connexion of Life with Respiration, pp. 27. 37. t De Motu Animal, p. 126. J De Respirat. p. 32. PHYSIOLOGICAL PROEM: ']cl. ii. 343 possesses at the time of its reaching the lungs, and converts it from IU Resi»- a deep purple, or modena, into a rich scarlet. This M. Lavoisier, leiwinto as we have already hinted, supposed to be produced by that supply Ur„™rlct of oxygene which he conceived it was the express object of respira- arteries; tion to communicate to the blood ; and in support of this view, a variety of experiments were appealed to, which seemed to show that the colour of the blood becomes brighter whenever exposed to the action of oxygene. Yet till all the objections of Mr. Ellis are satis- which has factorily removed, and those of Dr. Edwards are further confirmed, "Sc^00 that oxygene in a free state is actually introduced from the air-cells ™%ncii of the lungs into the adjoining minute blood-vessels, we can place e*P am little dependence upon this explanation, however plausible and in- viting. But, may not the deepened colour of the blood be produced by Tj>c deep the carbone with which it becomes gradually loaded in the course of whither its circulation, and which, by the consent of all parties, is separated grodhlg0ed from it in the process of respiration ; and, consequently, may it not carbone oi recover its brightness by the mere loss of this dingy pigment, whe- ahnV>th°e0d' ther oxygene enter at the same time into the blood-vessels or not 1 «oariet, by If the primary colouring material of the blood be the iron which it matenci?8 contains, as first suggested by MM. Parmentier and Deyeux, and the j^l"™^ carbon be a recrementory, and adventitious material, this reply the primary might be satisfactory ; but if, as suppobed by Sir Humphry Davy, matte™! the carbone of the blood be itself the pigment that colours it from J|jebr,°ndof the first, the explanation will content but very few. Yet this last suggested hypothesis is as open to attack as any of the rest: for to say nothing ^and6"* of the difficulty of conceiving how the carbone of the animal fluids peyeux. can give a deep die to the blood, while it gives no die whatever to g0 if the any of the fluids besides, it is sufficient to observe that an abstrac- ^0jm^ tion of a part of this die may, indeed, form a lighter hue of the same matter be kind, but not a different hue. The hypothesis has yet to account for jhseei°faab,ono that yellow or orange tint which must be added to the red of the suggested venous blood before it can become changed into the red of the arte- ThisconI rial; for as a simple dilution of venous blood will not furnish this tint, JoeMeucrt®o®!.S0 so neither will a simple abstraction of the only colouring material able. which is hereby supposed. It may, perhaps, be said that though oxygene do not get admis- J^-Jj^ sion, caloric does; and this too very freely, and becomes itself the the cause of cause of this change of colour. And, in truth, this is the expluna- ^t^^m? tion offered by Mr Ellis and various other physiologists ; who con- tend that the function of respiration consists, firstly, in freeing the blood from its load of carbone, and, secondly, in introducing a very large portion of the matter of heat in its stead j thus far advocating the hypothesis of Dr. Crawford. And as a proof that caloric, as a substance, is separated from the inspired air, they appeal to the quan- tity of vapour that is formed in the vesicles of the lungs simul- ™jj &* taneously with the formation of the carbonic acid, and which they laboratory ascribe to this cause ; regarding the lungs as the great laboratory in cum^faUon which the matter of heat or caloric is accumulated, and rendered fit of heat. for the use of the system. But this, again, is to take for granted what yet remains an unset- *%$"* 344 CL. II.] PHYSIOLOGICAL PROEM. IU. Respi- ration. The last function has been alloted to other organs. Advantage immediate- ly derjved from the change of colour in the lungs not fully known. Hence no set of ex- periments has led to any esta- blished doctrine upon the subject. tied question ; namely, whether caloric be a substance or a mer0 quality of body. Independently of which, admitting the substantive existence of caloric, and that some organ or other is specially em- ployed in its evolution and introduction in a free state into the sys- tem, it is by no means established that this organ is the lungs ; for Dr. Currie, in an ingenious paper published some years ago in the Philosophical Transactions, attempted to show, by various experi- ments, that this is chiefly affected by the action of the stomach. And Mr. Brodie has long since brought other experiments that seem to refer it to the action of the brain.* Perhaps, however, all these and various other organs may co-operate to the same effect. Much, therefore, still remains to be ascertained upon this inter- esting subject. Even the recovery of the bright hue itself to the blood, by whatever means accomplished, and which by most phy- siologists is regarded as a fact of the utmost importance in the pro- cess of respiration, is contemplated by Mr. John Hunter as of scarcely any importance whatever, except as a proof that the blood has undergone the action of ventilation ; an action which he con- ceives, from its being as necessary to white-blooded animals as to red-blooded, produces a far greater effect on the coagulating lymph than on the red particles.! And hence, though we have an abun- dance of facts and experiments upon the subject before us, and an abundance of speculation in respect to them, the " commercium mentis et rerum," as Lord Bacon has elegantly expressed it, has not hitherto led to any established doctrine, however creditable it has been to the industry and ingenuity of those who have engaged in it* * Phil. Trans. 1812. p. 378. t On Blood, pp. 204—206, and following. CLASS II. PNEUMATICA, ORDER I. PHONICA. AFFECTING THE VOCAL AVENUES. The term Phonica (q'NIKA) is sufficiently explained in the de- Class r. finition. The order of diseases which it is intended to comprehend, RDER'1, are seldom dangerous or acutely painful; and are rather character- ized by trenching upon the grace or utility of the voice, than under- mining the general health. It embraces the following GENERA. I. CORYZA. running at the NOSE. II. POLYPUS. POLYPUS. III. RHONCHUS. RATTLING IN THE THROAT. IV. APHONIA. SPEECHLESSNESS. V. nYSPHONIA. DISSONANT VOICE. VI. PELLISMUS. DISSONANT SPEECH. GENUS I. CORYZA. RUNNING AT THE NOSE. DEFLUXION FROM THE NOSTRILS OBSTRUCTING THEIR CHANNEL. IN the commentary to the nosological text, I have ventured to ^!. point out what seems to be the real origin of the term coryza, con- thegenerib cerning which the Greek lexicographers are at a loss; and have t«*. shown it to be a genuine and very extensive as well as very ancient Vol. L—44 346 cl. il] PNEUMATICA. [ord. i. Gen. I. Coryza. Running at the nose. How used by Hippo- crates: by the later Greek physicians: by modern writers. The last sense con- fused and indefinite- Should import an idiopathic affection. Oriental term, common under some modification or other, to the Hebrew, Arabic, Chaldee, and Syriac dialects, from one of which it was doubtless imported into the Greek tongue. By Hippocrates it was used in a very extensive sense, so as to signify defluxion of any kind, whether from the head, nostrils, fauces, or chest. The later Greek physicians restrained coryza to a defluxion from the head and nostrils, and applied the term catastagmus to a defluxion from the fau- ces and thorax. Among modern writers, at least since the time of Cul- len, coryza is used synonymously with catarrh, and is consequently regarded as a febrile affection. But this is rather to confound mor- bid affections than to simplify them. Coryza, running, defluxion or distillation from the nose, may indeed occur as a symptom in catarrh, as it may also in various other complaints, as the measles and some species of ophthalmy ; but it may also occur, and as a simple and idiopathic affection does occur, without febrile action of any kind. In which cases, indeed, it is of little importance, and not often wor- thy of medical interposition : yet, in a general system of morbid affections, it ought no more to be passed by unnoticed than a hedge or bog-plant in a system of botany. Simple defluxion from the nostrils may proceed from two very different states of body, or of local power in the organs affected; which furnish us with two distinct species of affection, characterized by sufficiently marked and discrepant symptoms :— 1. CORYZA ENTONICA. 2. CORYZA ATONICA. ENTONIC CORYZA. ATONIC CORYZA. SPECIES I. CORYZA ENTONICA. ENTONIC CORYZA. Gem. I. Spec. I. Secernent action increased: absorbent diminished. Symptoms vary from difference of stimulants. THE DEFLUXION PELLUCID, MUCOUS, OR ROPY ; WITH A SENSE OF IRRITATION OR INFARCTION. In this species there will always be found an increased action of the secernent emunctories of the nostrils, while the absorbents re- main little disturbed in their function ; and as a morbid diminution of active power is ordinarily expressed by the terms atony and atonic, so entony and entonic are in the present work employed to express the opposite, or a morbid state of activity. According to the differ- ence of the stimuli, or accidental causes by which the present affection is produced, there will be some difference in the symptoms : for these causes may be sternutatories ; the irritation of continuous sym- pathy, as m crying or weeping ; a damp chill, or some other change produced suddenly in the temperature, or perhaps temperament, of the atmosphere. And it is still more generally, and often with great abruptness, brought on by a transfer of action, or sort of reverse cl. n.] RESPIRATORY FUNCTION. [ord. i. 34? sympathy with some remote organ. Thus, there are many persons, <***> *■ who, as Dr. Darwin observes,* by sleeping at night with their arms (?™£ h or shoulders accidentally uncovered, become cold and torpid in the entonica. cutaneous vessels of these organs, and have their nostrils instantly coTyTa? affected with increased action, filled with mucus, and so thickened in the mucous membrane as to render them almost incapable of breathing. An ozcena or nasal ulcer will also frequently produce a like effect: in which case the'increased defluxion will be intermixed with a pu- rulent or ichorous matter, sometimes throwing forth an offensive smell: all which may be arranged in a tabular form under the fol- lowing varieties: et Sternutatoria. From sternutatories : accompanied with sneezing. (& Lachrymosa. From weeping or crying: the lachrymal Snivelling. secretion being increased by mental emotion. y Catarrhalis. From sudden chill or moisture in the tem- Snuffling. perature or temperament of the atmos- phere. ^ Ozcenosa. The defluxion more or less purulent; or ichorous and fetid. (ieneral The last is a case of surgical rather than of medical treatment, remark. and is often connected with a caries of some part of the ethmoid, or ™*?£ ng even the sphcenoid bone, and frequently with a lodgment of pus in f^8modifi- the frontal sinus or antrum maxillare ; in both which cases the in- cations. flammation is at times accompanied with excruciating pain. The first is peculiarly common to grazing animals, and especially to sheep, from the irritation of minute insects, and especially those of the gad-fly, whose eggs have been deposited in the upper part of the nostrils by the impregnated female. From the dryness of the mucous membrane of the nostrils in India, the common coryza is peculiarly common under the name of naukera. The natives cure it in its onset by topical bleeding : for which pur- pose they prick the inflamed membrane with a sharp-edged grass, which answers the purpose of a lancet, and soon relieves the pain by the flow of blood which ensues.! A warm atmosphere easily, and in a short time, takes off the va- riety produced by a sudden application of cold, or a sudden change in the temperament of the atmosphere, and which makes an approach towards a catarrh, though without any sense of heaviness or oppres- sion in the head, or harshness in the fauces. From the obstruction of the nostrils, however, there is usually a nasal voice and a deficiency or loss of smell; and, where the discharge is acrid, an excoriation of the mucous or Schneiderian membrane. When it is the result ot a reverse sympathy with the arms or other limbs, rendered chilly at night by being uncovered, it is easily and almost instantly removed * Zoonom. Cl. i. Ord. i. ii. 7. . t Miscellaneous Obseryations on certain Indigenous Customs, &c. in India, oy Daniel Johnson. Esq. 348 cl.k.'] PNEUMATICA. [ord. i. Gen. I. Dy covering the chilly organs with additional bed-clothes, and thus COTyza" restoring the balance of heat and cutaneous secretion. entonica. \n a singular idiosyncrasy, reported in the Ephemera of Natural cory°za.c Curiosities, the odour of roses, without amounting to a sternutatory, iinffubwi^ Proved a stimulus sufficient to excite a coryza whenever applied.* ties of cause It is well remarked by Galen that there are various foods that pro- and effect. ^nce a jji^g effect ;| and Bonet, in one instance, found it occasioned by a globular tumour surrounded by a fluid in the ventricles of the brain,J probably from an excitement of the olfactory nerves which take their rise in the corpora striata, situated in this quarter of the cerebrum, SPECIES II. CORYZA ATONICA. ATONIC CORYZA. THE DEFLUXION LIMPID, AND WITHOUT ACRIMONY OR SENSE OF IRRI- TATION. Gen. I. The chief causes are exposure to a keen frosty air ; the natural Spec. II. paresis of old age ; and a long and immoderate use of strong aroma- tics, volatile alkali, or snuff: affording the three following varieties: a Algida. From exposure to a keen frosty air. & Senilis. From old age. y Superacta. From habitual indulgence in snuff, or nasal stimulants. Dinunished In all these, there is a diminished action in both the secernent and bothsecer- absorbent vessels of the nostrils, but chiefly in the latter, which almost absotbents untf°rmty yiem" soonest from causes we shall hereafter have to ex- plain. And hence, while the secernents, from a degree of torpitude more or less approaching to the nature of paralysis, are only capable of separating a thin limpid water, instead of a viscid mucus, the ab- sorbents are too inert to carry off even this ; which in consequence, 2rS?tat accumulates' and driPs fi"om tne nostrils. A warm atmosphere, or variety, the vapour of warm water snuffed up the nostrils, affords an easy re- medy for the first variety of this species, which far more frequently gufshed" occurs' and Perhaps only occurs, in a dry, sharp, frosty air, than in from the an atmosphere rendered chilly from damp ; damp being, as already KcK* noticed' r.ather a cause of the preceding species. In the former case, the severity of the cold overcomes all power of re-action ; and hence, notwithstanding there is a defluxion, because whatever is secreted is not carried off* by the correspondent absorbents, the discharge is checked in its quantity, at the same time that it is rendered more * Dec. ii. Ann. v. Obs. 22. t Fragment, ex Aphor. Rabi Movses, P. 36 ' Sepnlchr. Lib. i. Sect. xvii. Obs. 10. CL. II.] RESPIRATORY FUNCTION. [ORD. i, 349 limpid. In the atter case, the tone of the excretories rises superior Gen. I. to the chill to which they are exposed, and the re-action ascends to *™' L something of a morbid excess. A warm room, and particularly the «S excitement of a gentle perspiration, will cure both ; but the first is c^yt' also often cured by brisk walking, or any other vigorous exercise proportioned to the sharpness of the frost: for as the system becomes roused generally, the nasal excretories become oused also, and tri- umph over the cold with a re-active power, which is at the same time communicated to the correspondent absorbents, when the defluxion immediately ceases. The two last varieties are beyond the reach of medical aid. The Two last coryza, or snuffing of old age, is precisely analogous to its ptyalism S„7 or drivelling. In the one, the atony is seated in the excretories of remed"f- the salivary glands; in the other, in those of the mucous membrane of the nostrils. There is in both a want of elasticity, which keeps the mouths of each set of vessels in a state of permanent relaxation, and consequently of permanent defluxion. Among the habitual irri- tants that lead to the same effect, snuffs are the worst; for the to- bacco of which they consist operates with the mischief of a narcotic as well as of a stimulant; and hence the copious and foul distilla- tion with which the nostrils of aged snuff-takers are constantly de- formed. GENUS II. POLYPUS. POL.YPUS. FLESHY, ELONGATED EXCRESCENCE, SHOOTING FROM ONE OR MORE SLENDER ROOTS IN THE CHANNEL OP THE NOSTRILS ; RUNNING IN DIFFERENT DIRECTIONS, AND AFFECTING THE SPEECH. This is the polypus properly so called, and the disease to which Gen. II. the term is applied by Celsus, and continued to be applied till after term used the days of Heister, who uses it in the same restricted sense. More in *e pre- lately, however, the term polypus has been employed in a much formerly5? looser signification, and made to import concretions and excres- }jm'teidei"n cences appearing in various channels or cavities of the body, of very later times. different origins and textures, as those of the heart, which are perhaps always grumous blood, or concrete gluten ; those of the uterus and bladder, which are caruncles or sarcophytes, with a slender base, or peduncle ; and those of the trachea in croup, which are also con- crete gluten; whence the croup is by such writers denominated angina Polypus or polyposa. It is better with the old authors, who have been followed by y^'1^. Vogel. and still more lately by Mr. B. Bell, to restrain polypus as a be the ^ " distinction. 350 cl.ilJ PNEUMATICA. [<*»• *■ Gen. II. distinct generic term to peduncular excrescences in the nostrils; Polypus. and tQ distinguish Dy the phrase polypous tumours, caruncles or shoots, such adscititious productions as may have a resemblance to them in other organs. Polypus, in this limited and proper sense, comprises two species. from the very different texture under which it is found. 1. POLYPUS ELASTICUS. COMPRESSIBLE POLYPUS. 2. ______ CORIACEUS. CARTILAGINOUS POLYPUS. SPECIES I. POLYPUS ELASTICUS. COMPRESSIBLE POLYPUS. SOFT, COMPRESSIBLE, UNACHING, CHIEFLY PALE-RED ; APPARENTLY ORIGINATING FROM DISTENTION, OR RELAXATION OF THE SCHNEI- DERIAN MEMBRANE. [Gen. II. This species is very apt to be affected by the state of the atmos- Spec. I. phere; being often retracted and shrivelled in dry weather, and theeatmos-y enormously enlarged and elongated in thick hazy weather. There j^g is little pain during any stage of its progress, however troublesome painful. it may be to deglutition or the voice. If attended to when small or eaeiiy e in an incipient state, it may often be prevented from growing large fnSan'ned DV ine use °^ astringent applications ; as a strong solution Of alum, incipient a decoction of oak-bark, or the application of vinegar or brandy. But where the excrescence becomes inconvenient from its bulk, it Afterwards ought to be instantly extirpated ; concerning which, however, we should be , 6„ , .,' *i extirpated, shall speak more at large presently. SPECIES II. POLYPUS CORIACEUS. CARTILAGINOUS POLYPUS. FIRM, CARTILAGINOUS, OFTEN PAINFUL, CHIEFLY DEEP-RED ; APPA- RENTLY ORIGINATING FROM, OR CONNECTED WITH, A CARIES OF THE ETHMOID BONE. Spec. II. This species is not only painful, but, from being firm and deep- Painfui seated, very troublesome in removal. It is not always indeed that early '"ago.il can be extirpated entire, or that it is advisable to extirpate it when extracted Poss*b*e- When extracted imperfectly, it is very apt to regenerate. npuo e' and has sometimes become canccrou?. -•'senera'o CL. II.] RESPIRATORY FUNCTION. [ord. i. 351 It is too generally believed, however, that polypi in all instances Gen. II. may and ought to be extracted ; and that if the shoot can be laid hold PS0lEpcu;IL of by the forceps, and we are not afraid of any hemorrhage, nothing coriaceue. is to be dreaded from the operation. Mr. Pott was of a different °£ einous opinion ; he had observed many cases, which, though neither scir- gj,1^"8" rhous nor cancerous, were very unfit for any chirurgical process, nouo be Some circumstances, he remarks, may forbid the attempt from the KJSSiy. impossibility of its being successful; others, from its being more circum- fikely to increase and exasperate the disease than to cure it. He SSiy dissuades from the opeiation in almost every instance of the second ^J^uon or coriaceous species ; in all those cases in which the polypus begins according with considerable pain in the forehead and upper part of the nose,t0 Potu or is preceded by these symptoms ; and which, as soon as it can De seen is either highly red or of a dark colour ; which is never alter- nately smaller and larger, but rather progressively increasing : in which the common actions of coughing, sneezing, or blowing the nose, give pain, or produce a very disagreeable sensation in the nostril and forehead; in all cases of polypi, which, when within reach, are painful to the touch, or which, upon being touched slightly, are apt to bleed; those which do not seem to be moveable by the action of blowing the nose, or driving the air through the affected nostril only, when confined to one side; those which are incom- pressibly hard, and, when pressed, occasion pain in the corner of the eye, or in the forehead, and which, if they discharge any thing, shed blood ; those which, by adhesion, occupy a very considerable space, ' and seem to consist of a thickening or an enlargement of the mem- brane covering the septum narium ; those from which there is a discharge of an ulcerous, offensive, discoloured fluid; and those round the lower part of which, within the nose, a probe cannot easily and freely be passed to some height. In all cases thus charac- terized, Mr. Pott was of opinion that no trial should be made by the forceps ; and he advised further, that no attempt to remove them should be made by any other means with which he had the good fortune to be acquainted. But where these characters do not occur, and in general where circum-i the polypus answers to the first species in elasticity and colour, he favourable recommends its removal, and by the forceps rather than by escha- J^JJ^f rotics, ligature, or any other means ; and thinks it may be extracted the excres with great safety .* " cence• * Chirurgical Observations relative to the Cataract, Polypus of the Nose, &c. 8vo. London, 1774. 352 .*l. n.'l PNEUMATICA. [ohp. r. GENUS III. RHONCHUS. RATTLING IN THE THROAT. HARSH, SONOROUS BREATHING FROM STAGNATION OF MUCUS IN THE VOCAL CANAL. How far ' There are two species of morbid affection which may be arranged idiopathic, under this genus, each of which has been raised to the rank of a distinct genus by Vogel and several other nosologists ; while by Cul- len, and those who have followed him, they have been entirely struck out of the catalogue of morbid affections, as either unworthy of notice or merely symptomatic of some other complaint. To a generic distinction they are scarcely entitled ; but a slight acquaintance with the habits and morbid actions of the system, is sufficient to afford instances in which both sorts are idiopathic. Many persons' have a thick or wheezy respiration, produced by corpulency, or by changes of the atmosphere from hot to cold, or from dry to moist, without any other diseased affection. Many persons snore habitually during sleep ; and most persons have a an(1 tendency to do so as they grow old. Under such circumstances, entitled to the affections before us are strictly idiopathic. They are not often notice.. indeed accompanied with much inconvenience ; but as deviations from a perfect state of health, they have a full claim to their re- spective places in a general system of nosology. Confervas in bo- tany, and infusory worms in natural history, are as confessedly objects of scientific arrangement and study, as the oak and the elephant. The two species then appertaining to the present genus, are the following:— 1. RHONCHUS STERTOR. SNORING. 2.--------CERCHNUS. WHEEZING. M. Laennec has increased the subdivisions of rhonchus, or, as he calls it, rale, to four ; and as modified by a variety of primary diseases of the chest, they may easily be extended to this number; but then they become mere sypmtoms, and not idiopathic affections. "For want," says he, uof a more strictly generic term I take the word in a more extended signification than is commonly applied to it, and understand by rale all the noises prpduced by the passage of the air, in the act of respiration, through whatever fluids it may be found in the bronchia; or pulmonary texture." The four modifica- tions of rale or rattling he hereby obtains are arranged by him as follows : 1 " Rale humide, ou crepitation. 2. R;ile muqueux, ou gargouillement. 3. R^le sec sonore, ou ronflement. 4. Rale sibilant sec, ou siflement.,,* Subdivi- sions of Laennec. * De l'Ascultation Mediate, ou Traite du Diagnostique des Maladies des Poumons et du Creur, &c. Par R. T. H. Laennec, &c. % Toms. Paris, 1819. ™uw» • l. ii.] RESPIRATORY FUNCTION. [or*, t. 353 SPECIES I RHONCHUS STERTOR. SNORING. THE SOUND DEEP AND LOUD ; PRODUCED IN THE LARYNX AND FAUCES. As a symptom, this is common to apoplexy ; but, as I have just Gem. ni. observed, it is found idiopathically in many instances, brought on by General1' advancing age or peculiar to the habit. A syrup made of the leaves remarks. of the erysimum officinale, or hedge-mustard, was for this kind of noisy breathing once popular ; and the pungency of the plant may often prove useful. The common cause is here, as in atonic coryza, deficient action in the absorbents of the larynx and fauces, so that only the finer part of the mucus is inhaled by their mouths, and the tougher and denser part accumulates and obstructs the passage. It is possible also that in some cases, as in the atonic coryza of age, the excretories of these organs may at the same time be per- manently relaxed, so as to admit of a larger defluxion than in health and vigour. And hence local stimulants are particularly applicable, among the best of which may be ranked camphor, and other tere- binthinate medicines, gum ammonia, and the alliacea. SPECIES II. RHONCHUS CERCHNUS. WHEEZING. THE SOUND DENSE AND IMPEDED ; PRODUCED BELOW THE LARYNX. This affection, as a symptom, is common to asthma and dyspnoea ; Gen. III. but I have already observed it is sometimes found as a primary evil, pathoiogy.' or independent of any other complaint. In the introductory disser- tation to the present class, we remarked that a considerable quantity of aqueous vapour is formed in the air-cells of the lungs during the process of respiration ; supposed, by the physiologists who contend for the inhalation of caloric as a distinct substance, to be produced by its separation from the inspired air of the atmosphere, and the union of a part of its oxygene with the hydrogene furnished by the lungs. In a state of health this vapour is very freely exhaled by the mouth, and forms that mist which is seen to issue from every man's lips in frosty weather, and especially when thrown into a dark polish- ed surface, as that of a mirror. But if the bronchial vessels be ob- structed by a more than ordinary increase or accumulation of mucus, Vor. I.—45 354 cl. ii.] PNEUMATICA. [ord. I. Gen. III. it escapes with difficulty ; and, encountering the air that is thrown ihon'chi"" into the lungs, occasions that hissing or wheezing sound which is cerehnu"! always produced by a current of air when it has to force its passage ordinarily through a body of dense vapour. Commonly, therefore, this is a a result of cage 0f atQny, local or general; and, like the last species, will be reueved^by best relieved by those medicines that gently stimulate, and warm, and Saantl give power to the bronchial lymphatics, as the resinous gums, and Sometimes the bulbs of the alliaceous plants. In fat people, and especially from"1' those who are low of stature, short-necked, and oppressed with fat obesity: about the xChesti the obstruction is chiefly the result of infarction and pressure ; for the diaphragm and other muscles not having full play, the lungs are never thoroughly expanded, and the extricated va- and cured p0ur is put into a smaller space, and has a narrower exit. And here Se^teS! the only cure must consist in taking off the obesity by repeated ve- nesections, active purgatives, vigorous exercise, and a low diet. GENUS IV. APHONIA. DUMBNESS. SPEECHLESSNESS. INABILITY OF SPEECH. Gen. IV. We now proceed to a group of diseases that affect not so much Smarts. tne tracnea or general avenue of sound-as the organs of articulation fixed on its upper end, like a capital upon a' pillar, as M. Blumen- bach has elegantly observed, and consequently which impede or vitiate the power of speech. These have been very differently ar- ranged by different writers, and have often been very unnecessarily extended and complicated, especially by Vogel, as may be seen by a reference to the commentary in the author's volume on Nosology. Upon the whole they will be found to distribute themselves most easily and distinctly under the three following generic divisions ; de- fects that depend on an utter inability of speech ; those in which the sound of the voice is imperfect or depraved; and those in which, while the sound of the voice continues unaffected, the articulation is incorrect or vitiated. It is the first of these divisions that constitutes the genus before us. Inability of speech may proceed from three different causes, each of which lays a foundation for several symptoms peculiar to itself and consequently for the three following species :■— 1. APHONIA ELINGUIUM. ELINGUAL DUMBNESS. 2. ------- ATONICA. ATONIC DUMBNESS. 3. ----._ SURDORUM. DEAF DUMBNESS. ol. il] RESPIRATORY FUNCTION. [ord. i. 355 SPECIES I. APHONIA EL1NGUIUM. ELINGUAL DU3IBNESS. SPEECHLESSNESS FROM DESTITUTION OF TONGUE. This may be of two sorts; each of which lays a foundation for Gen. IV. very different results. SrEC< L « Congenita. The defect coeval with the birth. 0 Oblassa. The defect produced by accident, punishment, or disease. The glottis is the chief organ employed in dividing the voice into vw*T of distinct or simple tones or notes ; as the tongue chiefly divides it, compared either singly, or by a co-operation with other organs, into distinct ^to^uef articulations, so as to form proper language, which is hence com- monly regarded as nothing more than a modification of the powers of the lingua, as the tongue is called in Latin ; and hence tongue and language are often used synonymously. It is obvious, therefore, Hence those that, in all common cases, the man who is deprived of his tongue, Jongue, for whether by congenital defect, by mechanical force, or by disease, thetndostb must at the same time be deprived of the power of speech and become dumb. I say in all common cases ; for a privation of the tongue is not Yet not always accompanied with dumbness. It is not necessarily so in all sin^the cases of congenital destitution, and still less in all cases of priva- s1"^ or tion that occur after speech has been acquired. In the Physiological organs Proem to the present Class we had occasion to remark that the glot- luppiy™" tis alone, in some instances, either from a greater pliancy and volubi- pi»«»; lity of the muscles proper to it, or from the possession of some su- peradded muscle or membrane, seems to have a power of forming distinct articulations without the assistance of the tongue ; and I hence endeavoured to account for that singular talent which we deno- minate ventriloquism. But there is a more singular talent still, that as in ven- sometimes occurs in the history of the human voice, and which is and^u"1' probably resolvable into the same cause ; for we have examples, sup- ™0^ ported by indisputable authentication, of persons, who having lost the persons entire organ of the tongue, and a few of them of the uvula also, have t0™*e still retained a power of speaking, and even of expressing themselves h^bee.^ with a clear and accurate enunciation. Such examples, indeed, are not very common; but they seem to have occurred in all ages, and especially when it was the barbarous custom among the Turks, Goths, and other half-civilized nations, to cut out the tongues of the unhappy wretches whom the chance of war had thrown into their hands as prisoners. There are some persons who profess to disbelieve all the stories of ^un(a this kind that have descended to us, for the mere reason that they have jgj^ 356 cl. ii.] PNEUMATICA. !>». i. Gen. IV. never witnessed any thing of the same kind in their own age or coun- a honi'a1' try- But such PersonS would have also j°ined the king of Siam in disbelieving the Dutch ambassador's assertion that the rivers in his own country became so hard and solid during the winter, that men and women could walk and skate upon them. The accounts are too numerous, and, in many instances, too well supported, to be treated with skepticism ; and all that is left to our judgment and ingenuity is not to deny the evidence, but to account, as we shall presently proceed to do, for the fact. Hundreds of cases might be quoted upon this subject; but the following may be sufficient, though others are referred to in the no- sological system, which may be examined at the reader's leisure. Those now selected are taken from recent times, and from authorities that may indeed be disbelieved, but cannot be disputed. In the third volume of the Ephemerides Germanicae, we have the his- tory of a boy, who, at eight years of age, lost the whole organ of the tongue, in consequence of a sphacelus proceeding from the small- pox, and who was able to talk after its separation. The boy was exhibited publicly, but a trick was generally suspected : in con- sequence of which the boy and his friends were summoned to appear in court before the members of the celebrated university of Saumur. In the presence of this learned body he underwent a strict examina- tion as to the loss he had sustained, and the lingual powers he still possessed. The report was found correct; and the university, in consequence, gave their official attestation to the fact, in order, as it expressly asserts in its record, that its reality might not be called in question in succeeding times. In the Memoires-de l'Academie des Sciences for the year 1718, is an account of a girl who was born without a tongue, but had nevertheless learned to speak, and talked as easily and distinctly as if she had enjoyed the full benefit of that organ. The case is given by a Physician of character, who had accurately and repeatedly exa- mined the girl's organs of speech, and was desirous that others should examine them also. About seventy years ago our own country furnished us with another elinguium. Elingual dumbness. when well supported by evi- dence. Illustrated from recent examples- Case _ examined by the university of Saumur. Case of congenital destitution of tongue recorded by the Academie des Scien- ces. byroureown equally striking example of the same power, and which forms the country, subject of various papers in the Philosophical Transactions, drawn up chiefly by Dr. Parsons at the time, and printed in the volumes that were published between the years 1742 and 1747. It is the his- tory of a young woman of the name of Margaret Cutting, of Wick- ham-market, near Ipswich, in Suffolk ; who, when only four years old, lost the whole of her tongue, together with the uvula, from what is said to have been a cancerous affection; but still retained the powers artTcufation of speech, taste, and deglutition, without any imperfection whatever : perfectly; articulating, indeed, as fluently and with as much correctness as other as also a persons ; and articulating, too, those peculiar syllables which ordina- smging. rily require the express aid of the tip of the tongue for exact enuncia- tion. She also sung to admiration, and still articulated her words while singing ; and could form no conception of the use of a tongue in other people. Neither were her teeth in any respect able to supply the place of the deficient organs: for these also were but few, and rose Tongue lost at four years old, together with uvula cl. ii.] RESPIRATORY FUNCTION. [ord. i. 357 scarcely higher than the surface of the gums, in consequence of the Gen. IV, . injury to the sockets from the disease that had destroyed the tongue. ygJnik1* The case, thus introduced before the Royal Society, was attested eiipguium. by the minister of the parish, a medical practitioner of repute, and dmXeL another respectable person. From its singularity, however, the Nation Society evinced a commendable tardiness of belief. They requested * another report upon the subject, and from another set of witnesses, whom they themselves named for the purpose, and for whose guidance they drew up a line of categorical examination. This second report soon reached the Society, and minutely coincided with the first: and, to set the question completely at rest, the young woman was shortly afterwards brought to London, and satisfied'the ^°>aI So" T> 1 ci • ^ • i cie,y eye- rtoyal feociety in her own person. wiuesses. To explain this unexpected power, we should not only turn our atten- Articula- tion to what is actually and in our own day accomplished by ventrilo- whatmeans quists; but should recollect that the tongue is only a single organ em- j^compiish- ployed in the articulation of sounds, and that the fauces, nostrils, lips, and teeth, bear, at least, an equal part, while the glottis, which forms all the vocal or vowel sounds, is the chief organ of the whole. In reality, Enumera- out of the twenty-four articulate sounds which fill up our common articulate alphabet, the only two in which the tongue takes a distinct lead are ^s*08- the I and r, though it is auxiliary to several others ; but the guttural, or palatine, as g, h, k, q ; the nasal, as m andn ; the labial, as b,p, Their f, v,w, most of the dental, as c, d, z, together with all the vowels, powers! which hold so large a space in our vocabularies, are but little indebted to its assistance. It is singular that so delicately sensible an organ as the tongue Tongue should receive the severest injuries, and submit to very violent opera- violence0 tions, with less serious mischief than almost any other organ of the ^j*h'£sfs same size in the body. And it is on this account that the cruel and than most barbarous manner in which the tongue was extirpated by the ferocious ors»ns- tribes that overran Europe from the east formerly, was rarely pro- ductive of fatal consequences. Sir Everard Home published, many years ago, a paper upon this subject, containing various cases of sections of the tongue to a less or greater depth in consequence of diseased action. The operation was, in every instance, performed Ktostrated by the ligature. He does not state what effect was in any instance tons of sir produced on the speech, and we are hence led to conjecture that B Home" nothing in this respect occurred of material importance : but he draws the following conclusions: The internal structure of the tongue isfioSa'Sence less irritable than almost any other organized part of the body. Its derived. nerves appear to be more easily compressed and deprived of their power of communicating sensation than nerves in general; and any injury done to them is not productive of diseased action in the trunk of the injured nerve. The tongue appears to have a power of throw- ing off its sloughs in a shorter time than any other part. 358 cl. il] PNEUMATICA. | ORD. f. SPECIES II. APHONIA ATONICA. ATONIC DUMBNESS. Gen. IV. Spec. II. Chiefly confined to the vosal a A. atonica ©blaesa. Dumbness from injury to the vocal nerves. When from a division of the recurrent nerves, mostly incurable. First noticed by Galen and ascribed to its real cause. How accounted for antece- dently. Origin of the term carotids. Proofs offered by Galen. SPEECHLESSNESS FROM ATONY OF THE VOCAL ORGANS, This atony is chiefly if not altogether confined to the nerves of the vocal organs, which may be injured by violence, or exhausted by mental or other commotion, independently of the occurrence of the disease occasionally as a symptom of paralysis, quinsy, or catarrh : thus furnishing us with two distinct varieties: x Oblsesa. From lesion of the nerves of the tongue or glottis. (5 Soluta. From sudden or overwhelming commotion, or shock of any kind. The instances of speechlessness produced by an injury to the lingual nerves are not common. But a division of the recurrent nerves which are offsets from the par vagum, and distributed over the larynx and glottis, produces a speechlessness that is rarely, if ever, recovered from : for here the muscles belonging to the arytenoid cartilages being rendered atonic or paralytic, can never be brought into a due degree of constriction, the glottis remains permanently open, and the diameter of the larynx suffers no variety of con- traction or dilatation. Galen seems to be the first anatomist who noticed this effect, or rather ascribed it to its real cause ; for it was known before his time, that, by making ligatures on the blood vessels of the trachea, the noisiest animal is immediately struck dumb and made quiescent. It was supposed that the state of the blood-vessels themselves, and not of the nerves included with them in the ligature, was the cause of this effect; that the blood became intercepted in its passage from the heart, and that the animal became mute be- cause rendered comatose : and hence the name of carotids, or so- porific vessels (from xxgos, sopor), was given to the arteries whose ligature was supposed to produce this very singular result. Galen, however, demonstrated very satisfactorily that the dumbness is, in this case, entirely owing to the pressure of the ligature on the accompanying nerves ; and he afterwards produced to his opponents two cases of boys, who in a greater or less degree had lost their voice in consequence of the recurrent nerves being cut by surgeons unac- quainted with anatomy, in extracting strumous tumours from the neck. In the one case, only one of these nerves was divided, and the voice was merely much weakened, or about half destroyed ; in the other, both were divided, and the voice was lost altogether. A whizzing senseless noise, indeed, remains in most instances, as Vezalius has correctly observed ; but there is no vocal sound articulate or inarti- culate. cl. n.] RESPIRATORY FUNCTION. [ord. i. 359 Where the speechlessness has followed upon an injury to some Gen- IV. branches of the lingual nerves, we have numerous examples of re- Spec* IL covery. In one instance, the dumbness ceased suddenly after tfie patient had been speechless for not less than ten years.* In other instances dumbness is produced suddenly, from a total PA- Aton»- exhaustion of nervous power in the vocal organs without any organic Dunbneas's lesion whatever. A sudden and overwhelming emotion of the mind fron ,„ p ' . o nenous irom terror, anger, or any other passion, has frequently had this exiausticn. effect in irritable habits. So has a violent fit of hysterics ;| or any other vehement shock which j instantaneously exhausts the nerves of their sensorial power and the muscular fibres of their irritability : as a stroke of lightning, or a severe and unexpected blow on the sto- mach, will sometimes exhaust the entire system of its vital energy, and make life immediately cease. A sudden chill, as from drinking cold water during a violent heat, or the shock of a sudden fall, has frequently produced it, of which numerous instances are recorded in the Ephemerides of Natural Curiosities. Speechlessness of this kind fri?inl?T has sometimes arisen from deleterious exhalations; from eating mushrooms ; and in one instance, recorded in Hufeland's Annals, by repeatedly rubbing the wound made by a poisonous insect with saliva, and as often putting the finger to the mouth to obtain a supply of fresh fluid.§ In like manner, Bonet informs us that the same effect has followed from putting into the mouth and swallowing a piece of money cankered with the rust of verdi- grise.H Where medical aid is required, our dependence must be on tonics, ClTative local or general, and topical stimulants. Blisters and masticatories Teatment. have chiefly been made use of, and frequently with good effect; as has the vesication of a hair-brush contrived for the purpose. The dumbness has sometimes yielded to emetics, at others to electricity ;1T and in a few cases to a severe cough ;** and occasionally the same, or a like violence which occasioned the disease, has removed it, and S)metime3 the cause has become the cure ; as is reported of Athys, the son of Sesameby Croesus. In like manner, we have examples of its having yielded ™>lence abruptly to a fit of anger or terror, in one instance to a fit of laugh- diced it. ter,tt in another to a blow on the head.|J * Sammlung. 1721, ii. 406. 503.—Bresl. | Van der Hont. Verhandelingen van net geneeskond Genortsek. X Biichner, Miscell. 1728.—Bartholin. Art, Hafn. I. (lbs. 101. Schurig. Chilologia, p. 205. § See also Dupau in Journ. de Medicine, Sept. 1789. || Bonet Sepulchr. Lib. I. § 22. IT Krazenstein, Pr. Hist, restitutae Loqueloe par Electrirasionem. Hafn. 1753. ** Iperen. Abh. aus. holl. Schriften. B. i. p. 356. Morgagni, De Sed. et Cms. Morb. Ep. Ixiii. Art. 15. tt Iperen. ut supr. Martini, n. Duzend Beobachtuugen. It Ephera. Nat. Cur. Dec. in. An. v. Obs. 236. 360 cl. il] PNEUMATICA. [ORD. I. SPECIES III. APHONIA SURDORUM. DEAF-DUMBNESS. SPEECHLESSNESS FROM DEAFNESS CONGENITAL OR PRODUCED DURING INFANCY. Gen. IV. The ears are as necessary to speech, or articulate sounds, as the The ea^L' tongue or even the glottis ; for if such sounds be not heard, and necessaiyto distinctly discriminated, they can never be imitated. Persons who theevocti become deaf after a thorough acquisition of speech, do not become Whanth< dumb ror t^e very reason that articulation has already formed a deaf ar« habit, and can easily be preserved by practice. But if deafness be dumb.W,yS congenital, or take place antecedently to such habit, articulation Necessaiiy can never be acquired afterwards, unless by some rare good fortune where tie the ears should acquire hearing; and the unfortunate individual can coneenTuf on^.v receiye ana< interchange ideas by the eye; through which me- Such may dium, however, he may be taught written, though not oral lan- commul- gua£e j arjd tiius still, happily for himself, have his mind almost as «»lion ol richly stored, though not his ideas as readily communicated, as eye and through the outlet of speech. Persons thus organically defective knowfedre are denominated sourds-muets, or sordi-muti, on the continent, and of ian- sometimes deaf-dumb among ourselves. This is an interesting subject, and not unconnected with patho- logical science, since it opens to us the only remedy that can be resorted to where the defect before us, or that of deafness prior to articulation, is the subject of discussion. It is interesting also to us from the very considerable proportion of human beings which in all countries, and, apparently, in all ages, have been sufferers ^"deaf-0* fr°m tms melancn°ty affection; a proportion that has been ingeni- dumb to ously calculated from a comparison of various tables deduced from ot ers" the extent of the disease in different parts of the world, as amount- foibwsin mg to 1 m -441 individuals.* And it is peculiarly lamentable to succession observe that when the defect has once made an entrance into, a famiiy,Bam< family, whether from the influence it produces on the nervous sys- >vhrenjonc| tem of the mother, or from any other less obvious cause, it is pecu- liarly apt to become common to those children which are born afterwards: insomuch that we often meet with a third, or a half, and in a few instances, where the first-born has been thus affected, with every individual of the progeny, suffering from the same dis- mirdand. tres?ing .eviL " The late investigation in Ireland discovered families in which there were two, three, four, or more thus circum- stanced. In one family there were five children all deaf and dumb, in another seven, in another ten ; and in that of a poor militia * Quarterly Journal of Foreign Med. Vol. i. p. 319. cl. h.] RESPIRATORY FUNCTION. [ord. i. 361 officer on half pay, there were nine born deaf and dumb in succes- gen. IV. sion."* Yet it is consoling to reflect that the instances are very Ijhoni?1" rare indeed in which the same defect has been propagated to a sue- surdorum. ceeding generation, when the deaf-dumb have married, and even dumbness. when both the husband and wife have been thus afflicted. ^"^ated To pursue the calamity, however, into the various plans which to a suc- Ihe benevolence and ingenuity of the human mind have invented generation. to supply the defect of speech, from the times of Ammanus of Amsterdam, and Wallis of our own country, to the wonderful degree of perfection attained under the Abbe" Sicard, in the Royal Institution at Paris, would carry us far beyond the limits to which the present work must be confined. And I shall therefore only General observe that the grand principle laid down under almost all the advened to various plans and systems that have been devised, in order to obtain '".'the1101" the proposed remedy, and supply the want of speech, is that of de8af-dumB. commencing with picture characters, and( making these the key to alphabetical and arbitrary signs : and in this manner it is that the eye is rendered subservient to the purposes of the ear. When the deaf-dumb scholar is made to understand that the picture of a knife or of a ship is to be regarded as the representative of such objects or ideas, there is no great difficulty in teaching him that the arbitrary letters of which these words are composed, and which for this pur- pose are always written or should be written underneath these pictures, are intended to stand for the same purpose as the pictures themselves, and to import the same objects or their ideas, whenever they are met with in a certain arrangement: and so of other pictures and other combinations of letters which are equivalent to them. And hence, such combinations of letters, when the learners are accustomed to them, will as effectually become the signs or repre- sentatives of the objects they are intended to express, as the pictures which preceded their use. The power that appertains to each Speaking separate letter is a lesson to be learnt long afterwards; and still deaf-dumb longer afterwards an idea, for it can never be any thing more, of Jearned the vocal or articulate effects produced by different movements of afterwards: the lips, cheeks, and throat, which that letter is designed to ex- press.! An accurate and habitual attention, however, will teach how. the scholar this ; and he will, in a considerable degree, be able to acquite' make out what is spoken by the motion of the lips and other vocal organs alone ; and, if he possesses a facility of copying these, he may be taught, still farther, how to measure and modulate them, so as to produce the articulations they are intended to convey, and to speak with tolerable accuracy without hearing himself: while a fellow-scholar labouring under the same defect, and having made How con an equal progress in the same kind of education, will understand canbe°n his meaning, or the vocal terms he conveys, by the mere movement ^ween"6'1 of the vocal organs alone. I have myself borne a part in such deaf-dumb persons. * Quarterly Journal of Foreign Med. Vol. i. p. 321. t See the Abbe De l'Epee's Institution des Sourds et Muets par le vole des signes methodiques, &c. Paris, 1776. As also the Abbe Sicard's " Theorie des signes ou Introduction a 1'etude des ton- gues ; ou le sens des mots an lien d'etre defini est mis en actioDx" Ton*, n. fjyo. 1808;, V0Tj. I.—46 362 CL. II.] PNEUMATICA. [ord. I. Gen. IV. Spec. HI. Aphonia surdorum. Deal- dumbness. Singular case of habitual conversa- tion between persons totally deaf. French schools- Extent of knowledge and genius often evinced. Illustrated in M Gard. conversations at that excellent institution of this metropolis, the Asylum for Deaf and Dumb Children, and have seen scholars con- versing in this manner without hearing a single syllable on either side, but at the same time with a perfect understanding of each other's meaning. Mr. Waller relates a singular case of this kind, in a man and his sister, who lived together to an advanced age, neither of them having the least sense of hearing, but who understood each other, as well as other persons, by the motion of the lips alone ; sup- porting themselves by daily labour. They became deaf, how- ever, when children, after they had learned to speak, and hence in moving their lips, they continued to articulate though not very distinctly.* I have said that the mode of commencing instruction in almost all the schools of the kind before us, is by pictures or other imita- tive signs, and that a knowledge of alphabetical characters does not take place till long afterwards. The limitation is introduced because in a few of the French schools in the present day, and particularly that at Bourdeaux, under the superintendance of the Abbe Gondelin and M. Gard, this easy and natural order is re- versed, and the tutors have voluntarily loaded themselves with a very unnecessary difficulty, and their scholars with a useless and incomprehensible burden of many months' duration. For what reason the disciples of the Abbe" Sicard, or of the Abbe de l'Epee, should thus intricately deviate from the plain and simple path of their masters, it is not easy to conceive. The extent of knowledge, and even the expansion of genius which the deaf-dumb have occasionally exhibited, is truly marvel- lous ; of which indeed, M. Gard himself, to whom we have just referred, is a striking example. This gentleman was born with the faculty of hearing, and only lost it in his seventh year of child- hood : so that his mind must have become stored with a multitude of ideas, derived from the inlet of hearing, which he could not have acquired afterwards. It is said that, in consequence of his deafness, he so completely lost the power of speech, as to forget even the commonest words that had been familiar to him. This feature, however, in his history seems to be considerably over- coloured ; yet it is well known that he did not commence any plan of education till he was twenty-seven years old : from which time, such was the vigour of his mind, and the assiduity of his pursuit, that the able and professional critic, to whom I have just referred, affirms, " he is perfectly well informed upon all subjects which are usually studied; well versed in history, literature, politics, and languages. He has been taught Greek and Latin; and has, by himself, acquired the English language, of which he even showed us a grammar written for his own use. On presenting him with a printed report of one of our institutions, he immediately translated a part of it into French."! * Phih Trans. Vol. xxv. 1707, No. 312. p. 2468. + Quart, Journ. of Foreign Med. Vol. i. p. 822. ISP cl. ii.j RESPIRATORY FUNCTION. [obd. i. 363 Yet it is well known that there are several other scholars of the Gen- iv- same school that have excelled even M. Gard; and who, having Apr^'ia11' been born perfectly deaf, have been necessarily dumb from the surdorum. same period; of whom it may be sufficient to mention M. Clerc, dumbness. and M. Massieu. The last was literally taken from the plough, in ^npie*' the department of the Gironde, and was carried by a stranger, who happened accidentally to see him, and took compassion on him, to M. Sicard, at that time stationed at Bourdeaux. By dint of hard study, and a comprehensive capacity, he has also raised himself to the office of assistant instructor to M. Sicard, in the Parisian school, where he teaches the departments of syntax, his- tory, geography, and religion. On one occasion happening to be robbed, he pleaded his own cause in the court of justice : and when, during the French revolution, his revered master was put into prison, he addressed a letter of so much force and feeling to the President of the National Assembly, as to obtain his libe- ration. There are a few instances on record of a recovery from deafness Exampiesof, many years after birth, and of a gradual acquisition of speech in oflpeech" consequence hereof; chiefly produced by some violent but fortu- £"mecovery nate affection of the brain. Thus Lambzweerde relates the case congenital of a fortunate fracture of the scull, through a fall from a consider- deatness' able height, by which a young person, deaf-dumb from birth, was suddenly endowed with hearing, and, in process of time, with speech.* In like manner, Mr. Martin, in one of the early volumes of the Philosophical Transactions, gives an account of a native of Stratherig, near Inverness, of the name of Fraser, who was born deaf and continued dumb till seventeen years of age, when he was attacked with a fever which affected his brain for some time ; on recovering from this, he began to have a sense of hearing, and soon afterwards to understand speech, which he gradually imitated, and at length acquired so as to converse fluently ; though, from commencing at so late a period, he never attained perfect accuracy in articulating many words.t As an artificial mean of cure, puncturing the tympanum has been recommended by M. Delear ;J and in a few instances with ourselves, as well as abroad, it has succeeded. It is hence worth trying, though the success has been very rare. * Append, ad Amoenit. t Vol. xxv. No. 312. p. 2469, X Joara. Complimentaire, Juin 1822. 36d cl. n-1 PNEUMATICA. [»«»• i- GENUS V. DYSPHONIA. DISSONANT VOICE. THE SOUND OF TIIE VOICE IMFERFECT OR DEPRAVED. Gejl v. Voice, as we have already observed, is the sound of the air pro- con'tradis- pelled through, and striking against the sides of the glottis : while iror^'shed speech is the modification of the vbice into distinct articulations, by speech. means of particular muscles in the cavity of the glottis itself, or in that of the mouth or the nostrils, employed as signs of ideas. Hencevoice Hence voice belongs to many animals in common with man: many speech, thus limited as to its object, belongs to man alone, for fhatare there is no other animal that can distinctly articulate and make use destitute of of articulations as signs of what is occurring in the mind: though speec . there are a few animals that may be taught to imitate articulate sounds without having ideas attached to them. The present genus embraces the morbid affections to which the voice is subject; the next, those which appertain to the speech. It includes three species: 1. DYSPOHNIA STJSURRANS. WHISPERING VOICE. 2.--------PUBEKUM. VOICE OF PUBERTY. 3.-------- IMMODULATA. 1MMELODIOUS VOICE. SPECIES I. DYSPHONIA SUSURRANS. WHISPERING VOICE. VOICE WEAK, WHISPERING, AND SCARCELY AUDIBLE. Stkc V\ Many of the ca"ses of atonic dumbness, when operating with a less degree of violence, become causes of the present affection, while a few are peculiar to itself. The following varieties may not unfrequently be noticed: a Oblassa. From lesion of the nerves of the larynx. P Pathematica. From sudden emotion of the mind. X ^omPressoria- From permanent compression of the trachea. fecUy sioned alone by our not having the nasal passages clear; and con- speaking sequently from not being able to speak through them with our usual nh0^BOe,!8h',ll0 facility. This last is often the result of affectation, or a foolish habit not easy to be conquered when once acquired. GENUS VI. PSELLISMUS. DISSONANT SPEECH. THE ARTICULATION IMPERFECT OR DEPRAVED. In the preceding genus, the imperfection or depravity exists, Gen- vi< not in the articulation, but in the sound of the voice ; whence the distinction between that and the present is clear. Psellismus embraces two species : that of stammering, and that of a vicious ENUNCIATION. 1. PSELLISIUUS BAMBALIA. STAMMERING. 2, ____•-----BL&SITAS. ^HSEJNtNClATION. Vol. ).—47 370 ot.. n.] PNEUMATICA. [ord- i. SPECIES I. PSELLISMUS BAMBALIA. STAMMERING. THE FLOW OP THE ARTICULATION DISTURBED BY IRREGULAR IN- TERMISSIONS OR SNATCHES. Gen. VI. This affection may be regarded as a sort of clonic spasm, or St. Spec. I. Vitus's dance confined to the vocal organs, and offers us the two following varieties :— x Hesitans. (3 Titubans. Hesitation. Stuttering. a F. Bam- halia hesitans. Hesitation. Pathology. fi P. Bam- balia titubans. Stuttering. Character. Defect may be often overcome. Hesitation most when the words are most thought of or hunted for: hence many stammerers sing well, In the hesitating variety there is an involuntary and tremulous retardation in articulating peculiar syllables. The organs are gene- rally too mobile and unsteady, and the will has lost its control over them, if it ever possessed any. By reverting to the remarks made on Dysphonia puberum, the physiology of the affection will be easily understood. As bad habits are more readily learnt than good ones, because they are more striking and more strongly arrest the atten- tion, this complaint is often caught by imitation, and especially among children; who for this reason ought never to be intrusted in the company of a stutterer till their speech has become steady and confirmed. In the second variety we have a higher degree of stammering than in the first; accompanied with more impetuosity of effort. It consists in an involuntary and tremulous reduplication of some sylla- bles, alternating with a tremulous hurry of those that follow. " I would thou couldst stammer," says Shakspeare, with a striking illus- tration of this morbid affection, " that thou mightst pour out of thy mouth, as wine comes out of a narrow-mouthed bottle, either too much at once, or none at all." The convulsive action of the muscles of the glottis, and which are communicated to the other organs of speech, whether productive of the present or the preceding variety, may often be overcome by a firm and judicious discipline ; insomuch that some of the most dis- tinguished orators of both ancient and modern times are well known to have been subject to this affection in their youth. In ordinary conversation, or where a man has time to pick out single words, in- stead of speaking whole sentences, the stammerer always hesitates most; and hence always least where his attention is completely en- grossed. On which account there are many stammerers that scarcely utter a word in speaking without betraying themselves, who never- theless, sing and enunciate the words of the song without any hesita- <*• tt.j RESPIRATORY FUNCTION. [ord. i. 371 tion whatever, their whole mind being led away with the tune, and a Gne. VI. strong desire to keep in time and harmony: while there are others /",££ who hesitate as little in reading, the words being immediately before baiia them, and their attention being swallowed up in the subject. One sluuering. of the worst stutterers I have ever known, was one of the best readers ""^j^f" of Milton's Paradise Lost, He was a scholar of considerable attain- toc by It would at least stimulate the speaker to strain his voice to the full rousVater- extent of its power, and thus fit him for public speaking before large faU< bodies of people, where a loud and elevated voice can alone be heard distinctly; which was probably the chief object Demosthenes had in view : for we are expressly told that his voice was weak, as well as his speech tremulous and hesitating. Adults, who have firm- ness and perseverance enough for the purpose, may undertake the task of disciplining themselves ; but children should always be put under the care of a judicious tutor, whose best qualifications will be patience and good-temper. A very few words only should be marked down at a time for trial, and these should be attempted separately : nor should a second lesson be entered upon till the first has been completely mastered, although the effort should demand many weeks or even months. An acquisition of one lesson will always facilitate that of another. SPECIES II. PSELLISMUS BL^ESITAS. MISENUNCIATION- ARTICULATE SOUNDS FREELY BUT INACCURATELY ENUNCIATED. The elementary articulate sounds which the organs of speech* are Gen. VI. capable of enunciating are but few; and hence they are the same in E|ement«ry all languages, which are alone founded upon them ; differently, in- *™f*£w. deed, modified in several of them, and with a difference of number and the 372 cl. n.] PNEUMATICA. L0RjU- *• Gen. VI. instill more : for diversities of language consist, not in different sets pleUis'miL1' of articulations, to which the vocal organs are not competent, but Biaesitas. oniy in their different modes of combination, and the different ideas atirunc" which such combinations indicate. So seven notes comprise the same in ail wh0ie 0f mUsic, an(j by their different arrangements produce that languages. > J , • ■ i iruJI ^.^ chiefly di- variety of harmony which we admire in the works ot lianaei or numb^and Mozart. If we would ascend higher than eight notes, we only corn- amount to mence another series of like proportions. In the same manner, to ab™ut,nt ° quote the words of the author of Hermes," It is only to about twenty- twenty. four p,ain ejementary SOUnds that we owe that variety of articulate voices which have been sufficient to explain the sentiments of so innumerable a multitude, as all the present and past generations of men."* and are The twenty-four plain elementary sounds here referred to, are denoted by «/ r j t_ a*1 the letters those which are denoted by the letters of the greater number ot our Sato.8'" European alphabets. Yet of these, many are rather mere modifica- tions of other sounds than distinct sounds in themselves : insomuch that the ingenious Wachter has endeavoured to reduce the twenty- four to ten primary articulate enunciations, and to show that these alone would be sufficient for the purposes of the most polished lan- The twenty guages ; and consequently, that an alphabet of not more than ten ten. marks or signs might be sufficient to express its entire range.t In making this reduction, he regards all the five vowels as modifications of each other, or rather of one common articulation, the simplest be- longing to the organs of speech, formed with least difficulty, and, on this account, composing a very great part of the languages of \S°ZaB\ re" sava£e nations. In like manner he regards all the gutturals as only Wachter. modifications of another common articulation, as K, c, ch, q, g, h. So b and p have nearly a common sound ; as have d and t ; and ph, v, and w. While l, k, s, m, and n, are distinct articulations, and will not readily blend with any others. me'rat" ™* These, no doubt, might be sufficient for all the purposes of speech: sufficient for we find that ten simple numerals are adequate to all the purposes for anthme. Qf arithmetical calculations, which extend to infinity ; and that able Number of mathematician Tacquet, who has worked the problem for the pur- tionscapa- pose, informs us, that the combinations capable of being produced producbedns b^ tne ordinary series of twenty-four letters, amount to not less than b/twenty- 620,448,401,733,239,439,360,000, without any repetition.:}: So four letters. tnat the rjcnest vocabulary has made but a small inroad into that in- exhaustible mine of wealth which the wisdom of Providence has be- stowed upon the few distinct and primary sounds, be they more or less, which the vocal organs of man are capable of articulating; thus devising a plan which is equally entitled to our admiration for the simplicity of its design and the comprehensiveness of its power. mer?tary,e" * nave observed that some languages have more elementary- sounds dif- sounds than others, and as these are expressed by elementary cha- ber i" di"m* racters or letters, it follows that some languages must also have a "ua-L'fso more extensive alphabet than others. The proper Phoenician alpha- must the letters of * Book m. ch. ii. p. 324. their alpha- j Nat. et Script. Concord, p. 64. Astle, Origin and Progress of Writing, p. 20. Phraicftn. * Arithmeticte Theor. p. 517, edit. Amst. 1704. Astle, ut supr. p. 20. ol. n.] RESPIRATORY FUNCTION. [ord. l. 373 bet, which is, perhaps, the oldest of which we have any distinct Gem. vi. account, seems to have consisted of not more than thirteen letters ffefifsmus" at first; it had afterwards three added to it, making sixteen in the ^*8itas-. whole ; and in this state it seems to have been earliest employed ciation. by many of the adjoining countries, and is distinguished by the name of the Samaritan or ancient Hebrew : for the terms and characters Samaritan- of this last are so nearly those of the Phoenician in its improved form, that it is difficult and altogether unnecessary, to make a dis- tinction. The Chaldeans introduced some change into the shape Chaldean. of the letters, rendered them more elegant, and added six other letters, as the Samaritan alphabet did not seem sufficiently full to express all the articulations of their speech ; and the Jews, during Hebrew. the Babylonish captivity, readily adopted the improvement, and have continued the Chaldaic characters in their writings ever since. And in this manner, with various changes and augmentations, the Phce- ^"^^J. nician alphabet can be traced through every part of ancient and the most modern Europe, every region of Africa where writing of any kind fro^hT^ is current, and the western countries of Asia. Phoenician. Over a very extensive portion of this last continent, however, Some not, we meet with an alphabet that has no common origin or conformity vanaj?an." of principle with any hitherto described. This is the Nagari, or Devanagari, as it is called by way of pre-eminence. It consists of Jta3,fo0nmype1i* not less than fifty letters, of which sixteen are vowels, and thirty- systematio four consonants, all arranged in the order of the alphabet with a "l™?*' systematic precision that is to be found no where else. The vowels take the lead, beginning with those most easily uttered, and termi- nating with those that approach towards a consonant sound. The consonants then follow in five regular series of gutturals, com- pounds, palatines, dentals, and labials ; the whole closing with letters symbolical of sounds that do not exactly enter into any of the preceding series, and which may be regarded as a general appen- dix. This alphabet is asserted by many learned Bramins to be of a higher antiquity than any other ; and there can be no doubt that it has a very just claim to a very remote date. But its very perfec- tion is a sufficient confutation of its having been invented first of all. Something far more rude and incondite must have preceded and 5™£jj°js paved the way for it; and, in the complex characters of which it simpler consists, we seem to have the relics of those emblematic or picture- ™£dheadve symbols, which there can be little doubt were first made use of; ™£™ which are still employed by the Chinese and the uncivilized tribes of America, and seem to have laid a foundation for alphabeti- cal characters in every quarter of the world. With a few trivial variations this correct and elegant alphabet extends from the Per- sian gulf to China ; but it has no pretensions to rival the antiquity of the Phoenician. It is unborrowed, but of later origin. Whatever be the number of simple articulations that enter into Sj£pJ« m- the constitution of a language, or however modified in enunciation, ^noniybo they can only be learned with accuracy in early life, when the vocal J^jXdL organs are most pliable, and the untutored infant is most prone to early life. imitation. And hence, unless care be taken to imprint upon the h<>™^0 organs of speech a just and correct enunciation of the first elements of giving n 374 cl. ii.] PNEUMATICA. [ord. I. Gen. Vi. 0f vvords at this time, it is with great difficulty that the art can be Ps^ifmuP* acquired afterwards. This occurs to us under the best and most Biasitas. favourable circumstances. Foreigners coining into our own coun- ciation.n try after the age of thirty, thoug t urged by an ardent desire to speak ckriorun English, seldom pronounce the language tolerably. An English- infancy man at the same age, can hardly be taught to utter the guttural revere sound which the Welchman gives to the Greek x, or even the thder "rare French sound of the vowel u: and of the stray and solitary savages ly attain the that have been caught in the forests ot Lithuania, and a few other o?"aUves8 regions, there is not perhaps a single instance of their having been able, after the asje of manhood, to articulate any language so as to be understood with facility. Peculiar But we sometimes meet with less favourable circumstances to an to^ac-" acquisition of proper articulate sounds, and this too in a state of quisition of childhood, which is the immediate age of imitation. For, firstly, sounds. we sometimes see children brought up under the care of those who Ifnunciation have a vitious articulation themselves, from whom they will be sure is teacher*, to catch it; and hence those pronunciations and rude dialects that are so frequently found in the remoter and less polished districts of Want of almost every extensive people. Secondly, we occasionally meet thTorgans'" w^tn some natural disability or want of harmonious power in the of articuia- organs of speech themselves ; one or two of them evincing a greater mobility than the rest, and consequently taking the lead of Structural them, and interfering with their office. And thirdly, there is not unfrequently a defect of structure in the organs of articulation, as a want or loss of the fore-teeth, or a fissure in the palate or the lips. Many vocal Many of the articulate sounds moreover in most, perhaps in all, caUedBsim. languages, though called simple, are produced by the joint exertion of pie, require two or more distinct organs: and unless these organs precisely accord rence°ofUr in flexibility and power, and are equally under the command of the more°or- W*M' t*ie sourm" W1^ be imperfectly imitated. The Arabic and the cans Saxon sound, in English expressed by th, is an articulation of this ^English kind, being compounded of a dental and an aspirate or guttural *• sound. From early habit the natives of both countries are able to enunciate it perfectly, and they enunciate it alike. But there is scarcely an individual in any other country, who can ever be taught to sound it accurately, unless he should have an opportunity of try- ing it in early life ; for the motive powers concerned in the sound The Ger- will not move in sufficient unison. For the same reason it is as anVsch. difficult for a foreigner to catch the German ch in the pronoun ich, the sch in schdtzen, or both in schadlich or schmdchtigkeit. But TheseM>pe- even these combined sounds have sometimes shades of distinction are them-s which constitute other sounds, and are expressly intended to do so; variedby6" and in sucn cases tne difficulty of an accurate enunciation is greatly modifica- enhanced. Thus the English th in thing, and in thou, is a different articulation ; and the Arabians, who have both, express them by different marks or letters ; which if expressed by our own letters Yinciailsrhs WDuW PerhaPs be best written dth. And it is on this account that IndCdia8mS where a common language spreads over different countries, as tho !««s. Arabian, or different parts of a country, which formerly made use of a diversity of tongues, as the English, varieties will necessarily take t*. n-3 RESPIRATORY FUNCTION. [ord. i. 375 place in the utterance ; and the dialectic may be more in favour than Gen. VI. even the original or normal enunciation. There are some persona pfefiumni" who prefer the English of Edinburgh to that of London ; and the JfJ^JJ; Arabic of Delhi, Ispahan, and Constantinople has modifications of ciation. sounds as well as of inflections, which, though regarded as barba- risms by a native of Cairo, are contemplated as excellencies by those who make use of them. The organ chiefly employed in the articulation of sounds is the oiyigiontf glottis ; and subordinate to this are the fauces, the nostrils^ the sounds. tongue, the lips, and the teeth. And hence the division of articu- late sounds into vowel or vocal, which are formed by the glottis alone, and are the simplest of all sounds ; guttural, or those which are formed in the Auces more or less acting conjointly with the glottis, of which the fauces are only a continuation, as h, ch, q, g, h; nasal, as m, n, and the compound ng ; lingual, as I and r; labial, as b, p,f, v, w; and dkntal, as c, d, t, z. If we were to be more particular than we have time to be, or than is necessary, it would not be difficult to derive very numerous ex- amples of vitious enunciation, and consequently varieties of the spe- cies of morbid utterance before us, from every one of these divi- sions ; but the following are the chief which occur in our own tongue, and those that are cognate with it:— x Ringens. Vitious pronunciation of the letter R. 0 Lallans. Vitious pronunciation of the letter L. y Emolliens. Vitious substitution of soft for harsher letters. S1 Balbutiens. Vitious multiplication of labials. e Mogilalia. Vitious omission of labials or exchange for other letters. £ Dentiloquens. Vitious employment of dentals. *) Gutturahs. Vitious pronunciation of gutturals. The vitious pronunciation of the letter r is produced by a « * BUm- harsh or aspirated vibration or redoubling of it. Examples of this inele- r^uS.8' gance are common to several of the northern provinces of our own ^£,ana" country, as it is to the ruder provinces of France. Among the Greeks from the letter f (ro) it was denominated rotacismus, and was common to the Eretrienses in the island of Eubcea. It is gene- Ca<»<" rally ascribed to the possession of too large and tardy a tongue. But it is rather produced by pressing the point of the tongue down- ward towards the root of the teeth of the lower jaw, instead of up- wards, with a slight vibration towards the palate. In the second variety of vitious enunciation, the letter I is ren- £ j^]^1- dered unduly liquid, or substituted for an r. As when delusive is t! vitious!' pronounced deKusive, as though the I possessed the power ofgjj"*- the Spanish 11, or the Italian gl; or as when parable is pro- nounced paZable. Alcibiades is said to have laboured under this defect. The Greeks, from the letter A (lamda,) denominated this lamdacismus; the Romans with more severity, lallatio, or lul- laby-speech. This is often the result of affectation; sometimes Cauw. perhaps from not having the tongue sufficiently free, as where there 376 cl. n.] PNEUMATICA. [ord. f. Gen. VI. Spec. II. (i P BUesi tas lallans L vitious. y P. Blssi- tas emol- liens. Soft letters vitious Explana- tion Cause. Compari- son of the most po- lished with the most barbarous tongues. Softness of the Otahei- tan Ian guage. d P. Blassi- tas balbuti- cns. Multiplica- tion of harsh la- bials. Explained. is too gf eat a breadth of the fraenum which ties it to the base of the mouth, or too large and oppressive a flow of saliva. As the arti- culation of r does not enter into some languages, as those of Mexico and China, the I is often substituted for it; hence the Jews of the former country, who, from long disuse, have lost the power of pro- nouncing the r, employ the I in its stead; and for -\wx urxn '"WK in the opening of the first psalm read 'WN BfJCl ,v?ty«. In the next variety, the harsh letters are vitiously dropped for softer ; as in the substitution of anzel for angel; capitZol for capital; (Jat for tha.t. This may be the result of a debilitated articulation in children who have been brought up too daintily ; but it is more usually the result of affectation ; or is founded upon a general principle of softening the rougher or harsher sounds of a language into a smoother and more limpid flow : as is the case with most of the modern dialects of the south of Europe, and particularly those of Italy and Spain, which are well known to be derived from the Latin. Thus in the former we have piano for pZano ; piangere, and still further piagnere, for pZangere, and egli for iZle : and in the latter Zlamar for clamare ; Zlaga for ylaga, and Aermosa for Formosa. It is curious to observe how, in this respect, the most barbarous and the most polished languages agree. It is generally, but erro- neously conceived, that the former are peculiarly harsh and dis- sonant ; for savages, in speaking, as in any other exertion, take no more pains than are absolutely necessary, and hence content them- selves with the soft and simple vowel sounds or those of the glottis, drawled out indeed at too great length ; and when they are driven to the use of consonants, select those that give them least trouble to enunciate. On this account Lord Monboddo is correct in observ- ing that " the words of barbarous languages are long and full of vowels ; not short and full of consonants, as has been imagined."* And the following remark of my excellent and distinguished friend Dr. Perceval of Dublin, in the manuscript commentary with which he favoured me on the volume of Nosology already spoken of in the Preface, is peculiarly in unison with this statement:—" In a para- lytic affection of the organs of articulation, the patient pronounced the word cocoa, toto. The Otaheitans call Cooke, Toote. Their language is beautifully soft and vocal. A sentence reported in Cooke's second voyage is distinguished by the harmonious and expressive collocation of its words : ' Tootaha, taio Toote—mutte Tootaha.'—Tootaha, the friend of Cooke—dead is Tootaha." Man in savage life is fond of ease, and would not move a muscle if he could help it; in the voluptuousness of polished life he loves it equally, and is, if possible, still less disposed to exertion ; and hence this extraordinary accordance in the character of their articulations. In the balbutient variety, we have the labial letters too fre- quently repeated, or enunciated too harshly, or used instead of other letters. The Welsh are proverbially addicted to this inelegance, by confounding the v with the/, and the b with the^>; of which Sir Hugh Evans, in the Merry Wives of Windsor, affords a correct and * Origin and Progress of Language, second edit. Vol. 1.1>. iii. p. 496. w- "•] RESPIRATORY FUNCTION. [ord. i. 377 amusing example. " Fery goot," says he, " I will make a prief of Gen. VI. it m my note-book." So infringe is often used for infringe, and fp^"; loory for ivory. And thus Feda is pronounced Beda, and Fenares tas baibu- Benares, in Bengal, the Bengalee having no such letter or articula- MuTtipii- tion as V. cation of Infants before they cut their teeth are constantly using labials too bfais. freely as the lips press together without resistance ; and hence they oKlS delight in iterating the same labial sound ; and it is from a copy of bv mfaats' such infantile iteration that we derive the names of pa-pa and ma- ma, which they first learn to utter : for the original Hebrew terms, Hence the from which these names have descended to Europe, and indeed to papTand most other parts of the world, savage as well as civilized, are with- Xled*" out any iteration whatever, being simply ab, am, the first importing from the love, and the second sustenance, in Syriac rendered aba or abha, Hebrew. and ama; and the same in Chaldee : whence the Greek terms and their correlatives itx-xtcx or jrawcroe; and uxftftx, (pappa or pappas and mamma,) produced by a mere infantine balbutiation, or substi- tution of p for 6, in the first term, and a reduplication of the conso- nant in each : and hence, too, am-o, and am-or, in Latin. Persons in a state of intoxication, from the tremulous debility of other ex- their lips, often exhibit the same reduplication of the labial sounds ; p3ons"st- and thus make an approach towards one of the varieties of the last b°u"n? species. It is also often to be found in persons whose lips are un- toxication. duly thick and broad, a deformity distinguished vernacularly by the withXoad name of blobber-lipped : to which cause Quintilian, who notices thick lips. this variety of vicious expression, chiefly ascribes it, and hence dis- tinguishes it by the name of plateiasma, probably from Theocritus: Tpvyoves tKicvaiaevvrt T:\arvaoSotaai atravTa.* Cooing, like pigeons, with your blobber-lips: A verse designed to ridicule the Doric dialect, and consequently in- timating that this kind of vitious enunciation was common to a con- siderable part of Achaia. The erroneous articulation constituting the next variety, is of«P- Bisesi- a character precisely opposite to the preceding; and consists in iS ™°sl" omitting the harsher labials altogether, or exchanging them for others ™™y*,£?e that are softer and more easily uttered. biais. Thus mantle is broken down into antle, /ish into wish, and pilfer Eon'ana' into/ilfer. So in the Spanish the Latin/arina becomes Carina, and Examples. /a&a Aaua, and in French the Latin si&ilo, sj^Zer. This blemish is especially common to those who are hare-lipped, or have any other kind of defect in either lip, so that the two will not play in harmony; and more particularly still, if any of their front teeth be wanting. In the dentiloquent variety, the dental sounds, as of c, s, t, z, t, P. Biaisi- are too frequently employed, producing the effect of what is called ^ns!"10" lisping, or, in common language, speaking through the teeth. This, gig!*,,, also, is often an affected blemish, as though it were an elegance, instead of a fault in enunciation. It is produced by having a tongue * Idvl, xr. 8P. Vol. I.—-45 378 cl. ii.] PNEUMATICA. [OKD. I. Gem. VI. Spec. II. £ P. Bla-si tas dentilo- quens Lisping. n P. Klaesi- tas guttu- ralis. Gutturals, or pala- tines, vi- tious. Expidined Examples. Remedial intentions. naturally too long, and hence perpetually thrust against the front teeth from necessity, and from a habit of pressing it in this direction too frequently. The guttural or palatine letters, as g, h, j, c, x, are some- times uttered imperfectly by being introduced where they ought not, or withheld where they should be distinctly enunciated ; and in this consists the last variety it may he necessary to notice. One of the most common examples is in the superfluous use of the aspirate, or h, by means of which exalt and exasperate are pro- nounced exAalt and exAasperate; so collar is called kAollar, and custom kAustom. And not unfrequently among men of unfinished education, the aspirate is just as uniformly omitted where it ought to be employed, as employed where it ought to be omitted ; whence for this sentence, " the upper part of the house is to be let unfur- nished," we have "the Aupper part of the ouse Ais to be let Aun- furnished." And if the palate be fissured, or in any other way im- perfect, " ghost" is pronounced " host," "jolly," " iolly," or " yol- ly," "coffee," " dhoffee," "Xerxes," " Zherzes." Where these defects depend on organic misformation, they will mostly be found without a remedy, though they may be palliated by a laborious discipline. Where they are the result of debility or vicious habit, the remarks with which we closed the preceding spe- cies will be equally applicable here. CLASS II. PNEUMATICA. ORDER II. PXEUMOVICA. AFFECTING THE LUNGS, THEIR MEMBRANES OR MOTIVE POWER. THE RESPIRATION IRREGULAR, IMPEDED, OR PAINFUL. The idiopathic diseases that appertain to this order differ very Class II. widely in their respective degrees of severity and danger ; and upon the whole are but few ; though the number is very considerable in which the lungs and their auxiliary powers are deeply implicated, by sympathy or continuity, in disorders that originate in other organs, and primarily affect other functions. The genera are as follow: I. BEX. COUGH. II. DYSPNCSA. ANHELATION. III. ASTHMA. ASTHMA. IV. EPHIALTES. DAY-MARE. NIGHT-MARE. V. STERNALGIA. SUFFOCATIVE BREAST-PANG. VI. PLEUBALGIA. STITCH. 330 cl. ii.] PNEUMATICA. {ord. ii. GENUS I. BEX. COUGH. SONOROUS AND VIOLENT EXPULSION OP AIR FROM THE LUNGS, Gen. I. This genus of diseases was by the Latins named tussis, a term ^rTeric* tnat has Deen more generally employed by nosologists than any other. name pre- I have ventured, however, to restore the Greek name bex (bhvh) tussis. ° for the sake of uniformity ; so that the generic terms may all be de- rived from a single tongue. Common Cough, defined as above, is well known to accompany, as a symp- tom tomp" torn, a great multiplicity of other affections, some of which are very many other remote from the seat of coughing. Thus it occurs to us in pleurisy, complaints. . --i , •, ■ ■ i •, • i ■ m pneumonitis, hepatitis, pansthmitis, empyema, asthma, catarrh, phthisis, haemoptysis, hysteria, helminthia, and dropsies of various Hence re- species. Hence Dr. Cullen has omitted cough as an idiopathic af- crftena/ fecti°ni and nas onty introduced it as a symptom or synonym of ca- synrptoma- tarrh ; although it belongs at least as much to phthisis, and perhaps uc alone. jQ everv one 0f tj,e diseases just enumerated : but Dr. Cullen's sys- tem did not allow a place for cough as a primary disease ; and in this, as in various other cases, he was obliged to bend to the force of necessity. Yet at Cough, undoubtedly, occurs in its most frequent appearance as a idiopathic^ symptom of some other complaint; but it is at times as truly idio- pathic as any complaint whatever, and ought to be treated of as Seat wd such. Under this form its seat is in the chest; and the parts prin- e" ec" cipally affected are the trachea, bronchiae, the membranes, and sub- Lungs inert stance of the lungs. In the act of coughing, the lungs, like the injj0"8 " stomach in vomiting, continue inert; and the active or convulsive part by which the lungs are emptied, is performed by the muscles of respiration. " It is not necessary," observes Mr. John Hunter, " that the sto- mach should act violently to produce the evacuation of its contents ; nor is it even necessary that it should act at all: for the lungs them- selves do not act in the least when any extraneous matter is to be mach in°" thrown UP : and coughing is to the lungs what vomiting is to the vomiting, stomach. The muscles of respiration are t e active parts in emp- Actedupon tying the lungs, and can act naturally and preternaturally. The musciesof action of vomiting is performed entirely by the diaphragm and ab- respu-atton. dominal muscles ; and we know by the same action that the con- tents of the rectum can be expelled.''* In the Physiological Proem * Anim. Economy, p. 199. CL. II.] RESPIRATORY FUNCTION. [ord. ii. 381 to the present class, I have endeavoured to establish this remark in Gen. I. respect to the lungs ; and under the species emesia in the preceding Co*„h class, I have noticed experiments of M. Magendie, that confirm Mr. Hunter's opinion in respect to the stomach. Generally speaking, idiopathic cough is not dangerous in itself, or Rarely dan- while running its regular course ; but it has often proved highly dan, .S£XinIt" gerous in its results, by superinducing peripneumony, haemoptysis, «><"«>; but hectic fever, or phthisis. SSSJ3£ The whole of these remarks apply not more to common coughs H°°pu»£ than to pertussis or hooping-cough : which unquestionably, there- peri|h,aPng* fore, ought to be arranged as a species under the present genus. In S?eupnr^Jn, truth, the commencement of both is in most cases so much alike genus. that it is often impossible, and always difficult, to distinguish them : both are, in many cases, accompanied with a slight degree of fever ; the most obvious and assignable cause of both is cold, (I mean where the hooping-cough is original,) and in both the sonorous fits, how much soever they may differ in violence and a few other circum- stances, are produced by a spasmodic action of the same muscles. Thus explained, the genus bex or tussis may be divided into the three following species: 1. bex humida. common or humid cough, 2. ---sicca. dry cough. 3. ----CONVULSIVA. hooping-cough. SPECIES I. BEX HUMIDA. COMMON COUGH. HUMID COUGH. THE COUGH ACCOMPANIED WITH AN EXPECTORATION OF A MUCOUS OR SEROUS FLUID. To this species the Greeks gave the name of anaptysis, and Gen. I anacatharsis ; which last has been copied by Sauvages, and appro- H[ priated to the present purpose. The species affords us four varieties : by the one entonic, or accompanied with an excess of power, and thi atonic, or distinguished by enfeebled action. Spec. I. ow called x Mucosa. Common mucous cough. (3 Anhelans. Chronic cough of old age. y Acrida. Frothy saline cough. ^ Periodica. Nervous cough. In the first variety, the discharge is chiefly mucous, and ex- "jaBm'u"mi' creted freely. The exhalants of the bronchia? are stimulated by an common irritation of some kind or other, frequently by a reverse sympathy, in j!™1,?" 382 cl. n.J PNEUMATICA. [ORD. II. Gen. I. consequence of cold and torpid feet, to act more powerfully than in iB.humidH a state of ordinary health, whence the bronchial vessels become overloaded, and relieve themselves by an expectoration, that takes place freely and without the hoarseness which usually accompanies catarrh, or any other very troublesome disturbance of the respiratory organs. There is another variety, commonly called the chronic cough of old age, in which the cough occurs in long paroxysms, with a viscid and mucous discharge, excreted with difficulty, and laborious breath- ing. Heie the bronchial secretion of mucus is peihaps less copious than in ordinary health ; but the action of the absorbents being as weak and sluggish as that of the excretories, the thinner part of the mucus alone is imbibed and carried off; and hence what remains is in ordinary necessarily small in quantity, peculiarly tenacious, and thrown up noretena- with great labour and repeated efforts. This kind of cough is pe- culiarly common to persons in advanced life; or whose lungs or bronchial vessels are rendered weak and irritable from a neglect of common mucous coughs ; which have at length run into the present variety, and become almost habitual; showing themselves on every change of the atmosphere; and particularly during the inclemency of winter. In the third, ob acrid vakiety, the fluid coughed up is thin, frothy, and saline ; and for the most part excreted with difficulty,! It is evidently, like the last, an atonic affection of the lungs ; though often produced by diseased action in some remote organ with which the lungs associate. It is hence sometimes found in transferred gout, and still more frequently in cases of diseased liver ; especially where the liver has been affected from a habit of ebriety ; and in these cases it is peculiarly troublesome on first rising from bed in the morning. There is, as I suspect, in this form of humid cough, not only great torpor and imbecile action in the mucous membrane of the lungs, but a depraved secretion, small in quantity, and thinner and more acrid in quality than it ought to be. This cough is sometimes peculiarly pertinacious. Dr. Darwin tells us that he has met with it twice in the same person, at a distance of some years, during a fit of gout, so intractable as to resist vene- section, opiates, bark, blisters, mucilages, and all the usual methods. It was, for a time, supposed to be the hooping-cough, from the violence of the spasmodic fits of coughing: it continued two or three embung weeksi the patient never being able to sleep more than a few minutes hooping- at once during the whole time; and never for a moment unless propped up in bed with pillows.* There is another variety of the present species to be met with, which developes a striking tendency to recur at stated periods. The cough, instead of being violent, is here partly restrainable, and the discharge, though thin, is not acrid. It is the nervous cough of Dr. Whytt, who, in his Treatise on Nervous Diseases, has ihosTofT described lt wi*h great accuracy and judgment. It is a frequent attendant upon persons of a nervous or irritable temperament, and mucosa Common humid- cough. The bron- chial ves- sels become over-load- ed. (8 B hunii- da anhe- lans Chronic cough of old age. Bronchial secretion less than oious. Common to advanced life, and those who have neg- lected mu- cous Coughs. y B. humi- da acrida Frothy sa- line cough- Character. A disease of debility. The secre- tion pro- bably de- praved. Peculiarly pertina- cious : and from its violent and spas- modic fits OB humida periodica Nervous cough. nervous and irrita- ble habit. ZooDom. Class iv. ii. 1.9. cl. n.J RESPIRATORY FUNCTION. [ord. ii. 383 hence common to the hysteric, dyspeptic, and choleric. Like the Gen. I. last variety, it is also occasionally found in repelled gout. There JB**amJii seems here, also, to be some depravation in the nature of the secre- periodica. tion dependent on the debility of the secreting organs. And hence cough."8 we sometimes find that the morbjd phlegm forms a nidus, as in sre0c£fbf"n various cases of phthisis, for the eggs of minute insects floating in the depraved. atmosphere, which are conveyed with the inspired air to the bronchial M™fa vessels ; where they are hatched in the secreted fluid, and often be eggs of thrown up in the shape of larves or maggots. In like manner we ' ' sometimes meet with hydatids formed and thrown up in the same way; of which we have a singular example in the Medical Trans- actions, in a lady, thirty-seven years of age, of a delicate constitu- tion, and nervous or hypochondriacal habit. For half a year she expectorated more or less of these in the rnidst of thick viscid phlegm, sometimes to the amount of twelve, fifteen, or twenty-four in a day, of various sizes, from that of a pea to that of a pullet's egg. From the difference of causes and symptoms which these varieties evince, a very different mode of treatment is evidently required. The first variety, produced by excess of action in the mucous Treatment membrane of the lungs, and mostly by sympathy with a remote organ, cough™1"1 as in the case of cold and torpid feet, will be best relieved by dia- j>»pi»ore- phoretics and the warmer sedatives ; and especially Dover's powder, which will restore to the system its harmonious balance of power. The warm bath, or bathing the feet in warm water ; warm and co- Warm pious apozems, and oily or mucilaginous demulcents, are also pecu- Dem'ui- liarly adapted to this species of cough. At the same time the bowels cents. should be kept open by any gentle laxative, as the neutral salts, or the confections of cassia or senna. On the continent it has lately been a very popular practice to Tartar- employ tartar-emetic in preference to ipecacuan, whether alone or iarge „nd combined, as in Dover's powder, with opium. It has been given in J^™"1 all complaints of the chest attended with defluxion, and in all pos- sible proportions. In some instances so diluted with water as to form a part of the common beverage, and in others so concentrated as to rival our boldest wholesale preseribers of calomel. This is especially the practice of the supporters of the contra-stimulant Italian school. Thus Rasori has given a gradual increase of tartar- emetic, to the amount of two drachms a day ; and, according to his account, without producing vomiting, except in the first instance. He adds, that when the patient gets better, the emetic property again comes into operation, and the remedy is left off. M. Peschier of Geneva has imitated this innovation. He declares bleeding to be useless, and that he cures all fluxions of the chest with tartar-emetic alone, which he gives in doses of fourteen grains in the day, without producing vomiting. And in like manner Dr. Duffin has lately in- formed us that he swallowed from twenty to twenty-five grains of tartarised antimony by mistake, but without suffering from any remarkable symptom. From all which we may learn, I fear, that. in the present day the powers of experiment are more widely afloat than the powers of judgment and sobriety. In the disease before us we have also reason to expect benefit 384 cl. ii.] PNEUMATICA. [ord. II. Gen. I. Spec. I. Bex hu mi- da Treatment of humid cough. Expecto- rants. Proper meaning of the term. Principle on which they act. Probably a specific determina tion to the lungs. Cullen's hypothesis objected to Expecto- rants probably possess a peculiar stimulus. In mucous cough the milder to be pre- ferred. Treatment of B. humi- tla mucosa. Whether the inula of modern medicine he that of the Romans in their con- diments. from many of the expectorants, properly so called : those medicines which rather promote the separation of the viscid phlegm with which the bronchiae are loaded, than simply inviscate or dilute it, though these are also treated of as expectorants by many writers. The list of the proper expectorants employed formerly was very voluminous ; in the present day they are comparatively but few, and the proscription has, perhaps, been carried too far. The principle upon which they act is, in some degree, doubtful. The simplest way of accounting for it is by means of a specific determination to the lungs. For as we have pretty clear proofs of medicines operating specifically upon other organs, as that of mercury upon the sali- vary glands, and cinchona upon the irritable fibre, there is no reason why we should not expect a like operation upon the viscera of the chest. Dr. Cullen is quite at a loss upon this subject, from not admitting of specific medicines, or a specific action upon any organ. As a general rule, he supposes expectorants to operate on the bronchiae merely by a diaphoretic power, or that of increasing the flow of the superficial exhalants at large, and consequently of the exhalants of the lungs, by which the mucus present in the follicles may be poured out in a less viscid form, and hence in a state to be more easily thrown up by the trachea. But this is a very unsatisfactory view of the question. For, first, admitting there are medicines that act directly upon the exhalants of the skin, a specific power is hereby immediately conceded to one set of organs ; and if such a power exist in respect to one set, there is no reason why it may not in respect to fifty. Next, we see evi- dent proofs of an expectorant power in many medicines, as in gum- ammoniac, where we have no proof whatever of increased exha- lation from the surface of the body. And, further, the general explanation gives us no clue to the different operations of particular expectorants. It is possible that in all these there is a peculiar stimulus ; but whether this depends upon any sensible quality they possess, we cannot easily determine : for though many of them are more pungent to the taste than others, their degree of expectorant power does not in every instance keep pace with their degree of pungency. In the variety, however, of a common mucous cough from cold, it is obvious that, where expectorants are employed, they should be of a mild rather than of an acrimonious nature, as we have already an excess of action to encounter. And hence honey, the rob or jelly of the sub-acid fruits, as currants or raspberries, liquorice- root, and perhaps hyssop, butterbur, and inula, may be used with advantage, though the virtues of the last two or three are but doubt- ful, notwithstanding the high repute in which they were held formerly. The officinal inula of our own day, however, does not appear to be that of the Latins ; for among them its farina is repre- sented as having been particularly sapid ; so much so indeed, as to have formed a favourite ingredient in the most celebrated sauces of their public feasts. Horace speaks of it in one place as pos- sessing a bitter taste ; for he thus makes an epicure boast of having invented the sauce :— cl. u.J RESPIRATORY FUNCTION. [ord. u. 385 —inulas ego primus amakas Gen. I. Monstravi incoquere.* Spec. I. Treatment And in another he describes it as acrid, or stimulating ; for it is °[B- hu*"\- ..,.,.. ,, ' &>' da mucosa. probably m this sense that the term acidas should be understood:— —acidas mavult inulas. f While Lucretius makes it rather a mild general stimulant or art* matic:— qusc titillare magis sensus, quam Icedere possint, Faecula jam quo de genere, est, inul^que sapores. J But let the quality of the Roman inula be what it may, we do not seem to possess the plant in the almost tasteless and inert root em- ployed under this name in our own day. In the second variety, or chronic cough of old age, where the Trentment mucous discharge is peculiarly viscid, much smaller in quantity, and mida "" excreted with great difficulty and laborious breathing, and the gene- a"heians, ral symptoms evince great torpor of the extreme vessels of the lungs, the warmer and more pungent expectorants can alone be of any Wa™ m*1 service, as the alliacea, and stimulant gum-resins, especially ammo- pecuTrant^' niac, benzoin, styrax, and, perhaps, all the turpentine modifica- e"jjj?®"g-ns. tions. Tar-water was at one time a famous remedy ; but has long fallen Tan into great disesteem. From its warm terebinthinate impregnation, and the approach it makes to camphor and the gum-resins just enu- merated, it may doubtless prove serviceable in many cases. It is for the same reason that the vapour of tar exhaled from a tin pan with an oil or spirit-lamp beneath, as recommended by Sir Alexander Crichton in phthisis, is, in the present cough, frequently employed with advantage. The acidum abietis, another old preparation of Actfum the same kind, seems, however, to be the most deserving of trial of all the terebinthinate forms, and has sunk into disrepute without reason : it is the peculiar acid liquor, yielded along with the essen- tial oil, in distillation of the fresh branches or fruit of the pinus silvestris and p. alba of Linneus. It is too acrid to be drunk alone, and is usually diluted with water : and combines in itself some portion of the terebinthinate oil with an acid very nearly resem- bling the acetous. . The same tribe of medicines will generally be found useful in the T^ent third variety, or that in which the cough is followed by a thin frothy Saacrid™1' and saline excretion: for here we meet with as much local atony ;•*«* and torpor of the excretories as in the preceding. We may here vary from also with advantage employ several of the narcotic bitters, and c%?™; especially the hop, in the form of pills or tincture ; and occasionally Narcotic the narcotics themselves, as opium, or hyoscyamus, or the extract and ^c of the common potato, solanum tuberosum,™ recommended by »«"*»• Dr. Latham.§ But where the cough is dependent upon morbid when^ affection of some remote organ, and the lungs are only influenced ^he * Sat. Lib. ii. Tiii. 51. t Sat. Lib. ii. ii 44. % De R«r. Nat. ». 430. ^SS&fl § Med. Trans. Vol. vl Art- fi. Vol. I.—40 386 cl. il] PNEUMATICA. [okd. 11. Gen. I. by sympathy, it is obvious that our chief attention should be direct- T^tmJt ed to the primary disease. I was lately called in to a young gentle- ofB. humi-man who was severely afflicted with a cough of the present kind, which allowed him no rest, and induced an apprehension of serious illustrated, mischief in the lungs and considerable danger. On minutely examin- ing the case, I found him labouring under a chronic hepatitis, which, in the more prominent symptoms of pulmonic disorder, had been overlooked. I directed my attention to the former disease alone, with the exception of giving opiates pretty freely as a palliative. The liver had all the external and internal tokens of inflammatory action ; and from one or two most violent fits of shivering and horripilation, which made the teeth chatter, Ihave no doubt that suppuration took place to a certain extent. From this time the inflammatory symp- toms ceased, and the cough was heard of no more ; yet the tender- ness and defined tumour in the right hypochondrium remained for weeks before they entirely disappeared. Trfiatment In the nervous or periodic cough, narcotics should be employed mida "" very cautiously, and only where the irritation is perpetual or other- periodica. wjse unconquerable; demulcents will also be of no service. rarely to be Though the warmer expectorants may be useful, our chief depen- D™muicent8 dence must be on general tonics, as the columbo, cusparia, and of no use. cinchona, with which may be combined several of the metallic advisable, oxydes, especially those of bismuth and zinc. When the flowers of tableam?* zmc were m the height of their popularity, they were supposed to metallic, be an unfailing remedy ; and Dr. Percival, of Manchester, has given once'too numerous examples of their complete success. By having been too tofhiittieOW mSnty advocated, this medicine has now fallen into an undue degree esteemed, of disesteem. Camphor and volatile alkali will often prove pallia- tives for the cough, and may be occasionally had resort to ; but moderate exercise and change of air should uniformly make a part of the tonic plan wherever the patient's means will allow, Prussic In this modification of cough, more than in any other, we have reason also to expect benefit from a cautious employment of the Prussic acid, which has the peculiar power of diminishing the general sensibility, without affecting the functions of respiration or circula- tion. Of all the cases published by MM. Magendie and Brera, in proof of its beneficial qualities, there are none in any degree so de- cisive as in chronic and nervous coughs.* Six drops of the acid prepared according to Scheele's method, may be given in a wine- glass of infusion of cusparia every four hours. * Recherches Physiologiques et Cliniques sur l'emploi de l'Acide Prussique on Hydro-cyanique dans le Traitement des Maladies de Poitrine, &c. Par F. Magendie. se.. 8vo. Pans 1819. «*• n.] RESPIRATORY FUNCTION. (iord. ir, 387 SPECIES II. BEX SICCA. DRY COUGH. COUGH UNACCOMPANIED WITH EXPECTORATION. The symptom in the definition sufficiently shows that the seat of Gen. I. the disease is here, either in a remote organ or in the parenchyma, seafot the or general substance of the lungs ; rather than in the mucous mem- disease. brane of the bronchia?. The disease is commonly, indeed, produced Causes. by some irritable substance generated within the lungs, as in the case of a scirrhous or calcareous affection of these organs ; or con- veyed into them from without, as is common to glass-cutters, hewers of free-stone or sand-stone, workers of metals, and similar mechanics, in consequence of the finer particles of the materials on which they operate being occasionally inhaled with the inspired air, and after- wards worming their way through the delicate tunics of the air-cells. The dry cough is also at times to be traced to a remote irritation, 0ft?n as that of worms or an inflammatory action in the intestines, liver, a remote or other abdominal organs : in most cases of which it is probable "ntatl0n- that the lungs themselves are entirely passive, and do nothing more than yield to the propulsive action of the diaphragm, and its auxiliary muscles, to which the remote stimulus seems to confine its sympa- thetic power. The minute and invisible eggs of various insects floating in the b3o™fni™t|B atmosphere, are also sometimes swallowed in like manner, and in a eggs inhaled few instances hatched into larves, which have been thrown up by Wlth lhe air' coughing.* Minute pieces of bone,t and the kernels of cherries f/^jj^ and other fruits, have, moreover, occasionally slipped into the tra- that have chea accidentally ; and, after exciting great irritation and a hard dry f™^ cough for a considerable period of time, have ultimately been thrown mistake. up.J A bean, in this manner dropped into the trachea, was rejected on the fifth day in a violent fit of coughing.§ It is more extraor- Singular^ dinary that materials introduced into or engendered in wounds in su9bcstances° the thorax, should at times be found to work their way into the ^^ bronchial vessels, and in like manner be thrown up by coughing, by the Yet in this way have been discharged surgical tents that have slipped mout ' beyond the lips of the wound ;|| and the splinter of a fractured rib.H The varieties chiefly worthy of notice are the three following :— * Bartholin. Act. Hafn. iv. Obs. 46. t Schwencke, in Verhandlingen van Haarlem, vm. ii. p. 203.—Percival, Philos. Essays, i. p. 272. 1 Eph. Nat. Cur. passim. & Beaussier de la Bonchardiere, Joura.de Med. xlv. p. 267. R Tulpius, Lib. ii. c. 15.—Fabric. Hildanus, Cent, i- Obs. 46. Cent. vj. Obs. H. T Hildan. ex Pigray. Ep. 51. 388 cl.ii.] PNEUMATICA. [ord.il Gen. I. Spec. II. Bex sicca. Pry cough. x Ingenerata. From ingenerate irritants. p Extranea. From extraneous irritants. y Verminosa. From remote worms or vermicules. From irritation produced locally, as a scrofulous, scirrhous, or calcu- lous affection of the lungs. From irritating materials inhaled from without, as in various opera- tions on glass, metals, sand-stone, and marble.* From some remote irritation, chief- ly that of worms burrowing in the intestines, liver, or other ab- dominal organ. General remarks and treatment. When produced by worms. Scrofulous state of the lungs. Calcareous deposite. Acid inha- lations. Qsthectic diathesis. Treatment. Diluents drunk -froelv. Of these, the last is only to be removed by removing the primary disease. It is most common to children and has the associ te signs of a tumid belly, and pale emaciated countenance. For the medical treatment we must therefore refer to the genus helminthia, in the preceding class. When the irritation proceeds from a scrofulous or calculous affection of the lungs themselves, our attention must be directed to the peculiar diathesis on which the disease is dependent. In the former case small doses of the milder mercurial preparations, com- bined with the usual narcotics of the lurid and umbellate orders, as conium GSnanthe (dropwort), hyoscyamus, and solanum, may afford local relief by their narcotic and alterative power: while the ge- neral state of the system should be subjected to the regulations which will be found laid down under the diseases struma and marasmus Phthisis, in the ensuing class. The deposite of calcareous matter in the substance or air-cells of the lungs may be the result of a morbid affection confined to the lungs themselves ; for we often find them loaded with a deposite of this kind, while all the other viscera are in a state of health ; or it may proceed from a calcareous diathesis, of which we shall have to treat more at large under the genus osthexia, in Class VI. Order I. of the Nosological Arrangement. In the former case acid inhalations, or fumigating the chamber with the vapour of tar, which always con- tains a portion of acid, after the manner proposed under the preceding species, will afford a prospect, not merely of temporary relief by their tendency to dissolve the calcareous deposite, but probably of more permanent benefit by changing the nature of the morbid action, and giving tone to the debilitated excernents. Where the formation of calcareous matter appears to depend upon an osthectic diathesis, or a constitution prone to generate lime, what- ever may tend to increase the action of the superficial exhalants will be most likely to prove beneficial; for we cannot increase the ac- tion of these generally, without increasing that of the secernents of the lungs, and consequently throwing off the secerned fluid in its most attenuate form. And hence diluting apozems drunk freely will be serviceable ; and particularly a very free beverage of jerated aiemerbroek. Anat. lib. in. Cap. 13—Rawmazsirii. &c. Morb. ArtifActim. cl. ii.] RESPIRATORY FUNCTION. [ord. ii. 389 mineral waters ; which, while they dilute, will tend to invigorate the Gen. I. system generally, and produce a beneficial change upon the habit. Bex sicca." Where calculi are disposed to form in the kidneys or bladder, Dr. Treatment! Russell has recommended a very liberal use of sea-water ; De Haen Seawater of lime-water, of which he tells us that in one case not less than fif- ^"JJy teen hundred pints were drunk with very essential advantage. Many Limewater. foreign physicians advise the continental mineral springs, as those of Pyrmont, Carolina, and Baregas: while other pathologists have found large quantities of pure water, hot or cold, prove as good a Simple hot n- . , • 11 i • , . .. water. palliative or remedy : in all which we trace out one common prin- ciple, which is that of dilution, and we can trace out nothing else. A warm climate, which proves a perpetual diaphoretic, and urges per- a warm petually to the surface, will also in all probability be found servicea- c ima e" ble ; and, above all things, pure air and as brisk exercise as the pa- Brisk exer- tient can bear without fatigue, so as to strengthen the system, and at the same time keep the skin soft and moist. Mechanics engaged in working on metals, glass, free-stone, or Acr>d par-^ any other material, minute particles of which are apt to fly about and led by me- impregnate the atmosphere, and pass by inhalation into the lungs, chamcs: should be peculiarly careful to keep their mouths and nostrils cover- hence cau- ed with a handkerchief. And if the lungs be hereby loaded and sary in their irritated with sharp spicule, and a distressing and chronic cough be ^aiungsT5 excited, all similar labour must be abstained from ; the diet be pe- culiarly light ; emetics be frequently administered ; and, in the in- Emetics. terval, diluting apozems be used copiously, with bland demulcents. And if by these means we can check the irritation for some weeks L™|tBe(}ess or months, the lungs will often, by a growing habit of exposure to (rom habit. its cause, cease to be materially affected by it; and the patient may pass through life without much inconvenience. But if hereby we should not be abie to succeed, inflammation, hemorrhage, or phthisis, will probably be the result. In this variety we have also great reason to expect benefit from f^c^ni the use of mild expectorants and demulcents. demulcents. Of the nature and operation of expectorants I have spoken already : and as there is no complaint in which demulcents can be employed to more advantage, and few in which they will prove so pleasant and tranquillizing, let us digress for one moment to exa- mine into their nature and operation. Demulcents are medicines that obtund the action of acrid or spi- ^rau^nftB cular materials, not by changing their acrimony, but by covering them with a viscid and inirritant fluid. They are of two sorts, mu- -JJ^jfct cilaginous and oily : and of the manner in which they act when ap- plied to the surface of the body, there is no doubt whatever. But by what means they are able to retain their inviscating power when myawnhat\ey passing through the stomach to a remote organ, is far less clear, and act. has been a source of considerable controversy. Where the irrita- tion is in the lungs, as in the case before us, it has been supposed by many writers, and especially by Dr. Cullen, that by swallowing these Hypothesis ubstances leisurely, as we necessarily besmear the fauces and upper part of the glottis, we directly take off all irritation from these organs ; and that the quietism hereby produced in the upper extre- 390 cl. ii.] PNEUMATICA. [ord. ii. Gen. I. niity of the trachea, is propagated by sympathy through the whole h«E^MH' of the bronchial ramifications and the air-cells of the lungs *, and that Dry cough it is in this manner demulcents prove remedial in all pulmonic nn- Treatment. . ,. tations. Unsatisfac- But this is no explanation of their obtunding power in remote tory: quarters, as for instance in the kidneys and bladder, where these or- gans have been stimulated by a blistering plaster : and as Dr. Cul- len is not willing to allow of any specific power in medicines of any kind, nothing has remained to him but to cut the Gordian knot abruptly, and to contend that " the operation of demulcents in covering acrimony in the mass of blood, must be very inconsidera- ble."* and oppo- But this is to uphold an hypothesis by an assertion opposed to the rience.expe experienced train of events, and to which he himself submits on other occasions ; for Dr. Cullen has no hesitation in recommending the use of demulcents, when we follow him into his practice, almost as Whether freely as any other physician whatever. I pretend not to determine toef/visco whether they act in every instance when employed internally by their sity or by a sensible quality of viscosity, or by some insensible specific power ; power,°not but that by some means or other they are capable of allaying irrita- known. jjon m organs remote from the stomach, is a fact so generally known that it would be a waste of words to bring examples of it. And notwithstanding the difficulty of conceiving how a few drachms of bland oil or a few ounces of gum arabic can be intermixed with many pounds of serosity, and still retain their sensible quality of inviscating sedatives, it is by no means more difficult to conceive this than that moderate doses of sulphuric acid introduced into the stomach should pass copiously by the skin in its acid state, as Dr. Cullen allows it to do, and cure the itch; or that the muriate of soda, employed as an ingredient in the manufacture of glass, should, in the melting of this material, impregnate the atmosphere of the glass-house, be in- haled by the lungs of the workmen, and, passing with the matter of perspiration through the pores of the skin, once more concrete in crystals on their foreheads. Expressed As several of the vegetable oils are obtained from narcotic cotlcpiantE. plants, it is well worth inquiring, though a different question, whe- ther in any of these, there is a combination of any portion of the narcotic principle ; as such oils would in many cases possess a high advantage over the rest. The oils of this description which have been more tried are those obtained from the seeds of the lactuca virosa, and the papaver somniferum : and both these kinds of seeds, while they make pleasant emulsions, are said, by many writers, to communicate a slight degree of narcotic power at the same time ; an assertion, however, which Dr. Cullen does not give credit to, and which seems to be disproved by repeated trains of experiments in France, and especially by those of the society of agriculture in 1773, with respect to the former. But as 1 have not tried them sufficiently to speak with decision on the subject, I merely throw out the hint, that it may be followed up by others, and extended to * Mat. Med. Part ii. cap. xn. p. 412, cl. ii.] RESPIRATORY FUNCTION. [ord. ii. 391 moss. plants not yet examined for this purpose. The seeds of both plants Gek. 1. give forth oil pretty freely : those of the poppy often in the propor- K'cca tion of six or seven ounces of the oil to every two pounds of the ?fy f^sh* Seeds. * Treatment. In hot weather, sultry climates, or long voyages where rancidity "hocoiate. may be apprehended, the best as well as the pleasantest of all the vegetable oils is the expressed oil of the cocoa nut, commonly known by the name of butter of chocolate. It is of a brownish hue when first obtained, but may be whitened by ablution in hot water, and still more so by an alkaline ley, quick-lime, or spirit of wine. It will keep for years without becoming rancid, and may even be left for a month in a copper vessel without undergoing this change. Of the vegetable mucilages, the best fitted for keeping is that Mucilage of obtained from the Iceland moss. If infused in water before it is boiled, it will lose much of its rougher bitterness and colouring material, and its taste will be pleasant. Its viscidity is more than double that of gum arabic ; and emulsions thus formed have been kept fourteen weeks without the slightest marks of putrescency. SPECIES III. BEX CONVULSIVA. HOOPING-COUGH. KIN-COUGH. THE COUGH CONVULSIVE AND SUFFOCATIVE ; ACCOMPANIED WITH A SHRILL REITERATED HOOP ; AND FREQUENTLY WITH VOMITING ; CON- TAGIOUS. The Greeks denominated this disease Bex theriodes {Hhgwhs), Gen. I. which the Latins translated literally Tussis ferina, " wild or un- |fe^' tameable cough," from its violence. The name of Pertussis, by ™me. which it has often been called in later times, is of doubtful origin pertussis!"0 and meaning ; and I have hence followed M. de Sauvages, and ex- changed it for Tussis convulsiva, the specific epithet being far more expressive than that of the Greek writers. Our own name of Hoop- ing-cough is evidently derived from the convulsive clangor which accompanies the fit. The name of Kin-cough, by which it is dis- Kin-cough, tinguished in the north, and which should rather be written Kind- rnearaneof* cough, is derived from the Saxon or German term kind, " a child," as being peculiarly common to this age. This cough is unquestion- ably contagious, though not in a very high degree ; whence Stoll and other writers have fallen into the error of asserting that it is not so at all.* The remote cause of hooping-cough it is often difficult to trace. £fum^e Frequently, indeed, like common or humid cough, it seems to pro- numerour ceed from cold, from some irritability of the stomach,! or some pe- ' Mat. Med. P. u. p. 184. t Allgem. Deutsche Bibl. LVH. p. 434. 392 cl. h.] PNEUMATICA. [ohd. ii. Gen. I. Spec. III. Bex convulsiva. Hooping- cough. Kin-cough. By Linneus supposed to be produced by animal- cules. Mostly from a peculiar Description- Symptoms mitigated by a free discharge of mucus. Seat placed by Ruttor in the alimentary canal. Why dangerous to infants. culiar affection of the lungs.* I have already observed that the dry cough (tussis sicca) has occasionally been produced by larves of insects, whose minute eggs, being inhaled with the air of respiration, have found a convenient nidus in the bronchial vessels ; and hence Linneus, who at one period of his life endeavoured to resolve almost all diseases whatever into an animalcular or insect origin, taught that the hooping-cough was also produced in the same way by an insect of a peculiar kind.j This opinion has not been adopted beyond the precincts of the Linnean school. But we are, nevertheless, very considerably in the dark upon the subject; for there are nu- merous cases of the disease occurring daily, in which it originates from a source that eludes our research altogether. It is most com- mon to children, though sometimes to be met with in adults; is often epidemic, but rarely, if ever, attacks more than once in a man's life. And from all these circumstances there can be little doubt that it proceeds, in most instances, from a miasm of a specific nature and peculiar quality ; which, like those of the influenza or epidemic catarrh, and the measles, has a direct determination to the lungs ; though it is not, like these contagions, essentially linked with fever. The excretion is at first small in quantity, but afterwards more co- pious, though always viscid. The hoop, or sonorous spasm, is often accompanied with a rejection of the contents of the stomach; and the whole system during the paroxysm suffers great violence. The face is turgid and purple from suffusion, and the eye-balls swollen and prominent. The little patient, with a forewarning of the attack, falls on his knees at the time, or clings closely to any thing near him. Yet the violence is instantly forgotten ; and, after deeply pant- ing for breath, he returns with as much eagerness as ever to his play, or other pursuits : while the vomiting, which is commonly a good sign, is succeeded by a craving for fresh food. The disease lasts irregularly from three weeks to as many months. The hooping-cough, when in the height of its career, is usually accompanied with a very copious secretion of mucus, a free dis- charge of which mitigates the general symptoms. From this cir- cumstance Dr. Butter concludes, and with great correctness, that a morbid irritability of the mucous glands is the primary affection, to which the spasms are only secondary.J It is somewhat singular that with this view of the disease he should place its seat, not in the larynx, or any part of the trachea, but in the alimentary canal. It is true that worms or depraved humours in the stomach or bowels may be a predisposing cause of the complaint, but so likewise may dentition, cold, and irritable habit, measles, or acute diseases in gene- ral. It is not always, however, that it is united with any of these; and, where it is, the disease is apt to assume a more dangerous aspect; to be more violent in its progress, and not unfrequently of longer duration in its career. In infants, it is mostly alarming from its tendency to produce convulsions, suffocation, apoplexy, inflamma- * Stoll, Prelect, p. 289. t Diss. Exanth. viva. Vide Amoen. Acad. Vol. v. 82. X Treatise on the Kin-cough., with an Appendix, &c. 8f(> w- "•] RESPIRATORY FUNCTION. [ord. ii. 393 tion of the brain, ruptures, and incurvation of the spine. In adults, it Gen. I. excites pneumonitis more frequently than in children ; and in preg- ®PEC-m- nant women has often led to abortion. A moist skin, warm extremi- co^uisiva. ties, open bowels, plentiful expectoration, and free vomiting, are 5"s' tavourabfe symptoms. Frequent hemorrhage protracts the disease ; Kin-cough. aflf Jt Pfoceed from the lungs, a foundation will often be laid for Pro^osU. phthisis. The violence of the action occasionally excites inflamma- tion in the trachea. Dr. Marcus, among other singular opinions identified that distinguished his career, brought himself at last to believe that w^croup. such inflammation was always present: and having advanced thus far, he next undertook to show that hooping-cough and croup are one and the same disease. He died indeed, while dictating the preface to his treatise on the former aflection, which he hoped would estab- lish this opinion. Straack maintains that the material cause of the disease (causam materialem ejus) is seated in the glands of the fauces and glottis. Perhaps says Dr. Swediaur, the seat of the disease varies at different times, and in different individuals.* If for seat he had said remote cause he would have been nearer the truth. In a few rare instances it assumes a periodic character, and is then Periodic sure to become peculiarly intractable. Dr. Perceval, in his Com- Sought" ments on the Nosology, has favoured me with a singular case of this kind, which occurred daily at a certain hour, attended with a tremor of the whole body: the fit terminating by a shriek rather than a hoop. The complaint was obstinate for several months, and returned at the same season for two years. It yielded to no medicine, and was supposed to depend on some morbid condition of the liver. In treating the disease, our attention ought, in the first place, to Medicai be directed to an expulsion of the morbific matter or miasm, which produces it; if we were better acquainted with its nature and had a direct specific for this purpose. But as we are not thus fortunate, and perhaps never shall be, we must pursue another plan. Dr. Cullen, in laying down his own mode of treatment, indulges Attention in an ingenious, and I believe correct, hypothesis, and divides the two stage's, disease into two stages. The first consists of that part of it during jJ,8ernedcodmu which he supposes the contagion to be present and operative, which Cullen. possibly may include the first three weeks; the second embraces the remainder of its duration. Throughout the former stage, our atten- Process tion should be directed to whatever will moderate the influence of elst s'tagc. the contagious stimulus, retard the return of the convulsive paroxysms, and mitigate their violence. Bleeding, in severe cases, will usually nJ^dfiDS be found necessary for this purpose ; but it should be avoided except proper. in severe cases, as spasmodic affections are often rather increased than diminished by the use of the lancet; and it will generally be found better to employ blisters as a substitute. The most effectual ^metucsf, remedy is emetics ; whose action tends equally to interrupt the re- turn of the paroxysms, and to keep the lungs unloaded, by producing a determination towards the surface. The food must be light, and * Nov. Nosol. Metb. Syst. Vol. i. p. 494. Vol. I — 50 394 cl. u.] PNEUMATICA [orv. v., Gen. I. Sfec. III. Bex convuisiva. Hooping- cough. Kin-cough. Treatment. From purging no benefit. Process under the second Sedatives. Opium and conium. Ledum palustre. Musk and artificial musk. costiveness carefully prevented ; but no benefit seems to be derived from purging. In this manner, upon Dr. Cullen's mode of treatment, we are to guide the patient through that part of the disease which we may ra- tionally suppose to be kept up by the stimulus of contagion. In its latter part, or second stage, in which a morbid habit alone is, in all probability, the irritative power, a different course is demanded. For we have now nothing more to do than to oppose the spasmodic habit by an antispasmodic process. A sudden and violent emotion of the mind, as overwhelming terror, is well known to have had this effect. But such a remedy is not to be recommended ; and hence different tribes of medicines have been resorted to, which may be arranged under the three divisions—of sedatives, for the purpose of taking off the morbid irritability of the affected muscles ; stimulants, for the purpose of local or general revulsion ; and tonics, for that of both local and general re-invigoration. The sedatives chiefly made use of or recommended, have been opium, hyoscyamus, belladonna, conium, ledum palastre, the mos- chate antispasmodics, and lead. Of the first four a general preference has been given to the conium; for though opium has the authority of many distinguished practi- tioners,* it has often been found of no avail, even where it has been given in large and frequent doses ; and, still more generally, has been productive of greater mischief than good, where it has unques- tionably proved of temporary benefit. The conium has hence ac- quired a far higher degree of public favour, for which it is chiefly in- debted to the writings of Dr. Butter : who represents it as having the double virtue of retarding the returns of the convulsive paroxysms, and of mitigating their violence : and on this account he prescribed it through every stage of the disease, and however complicated with other affections. He employed it moreover in every form, whether of powder, extract, plaster, or cataplasm ; but, for internal use, he gave the powder, allotting a grain a-day to infants under six months, and ten grains to adults, with a gradual increase as they persevered. In Dr. ButterVhands it seems to have been of some use, as it has been also occasionally in the hands of other practitioners : but it has so often failed in general employment, as to have sunk into a disrespect below its proper standard in the present day ; and princi- pally, perhaps, because it was too highly extolled in the day of its popularity. The ledum palustre, or marsh cistus, stands chiefly on the authority of Linneus,t who tells us that it is very generally employed in Westrogotha as a sedative in hooping-cough, and accompanied with great success. And the assertion of Linneus is supported by Dr. Wahlin,j and other continental writers ; but it has not been intro- duced into the practice of our own country. Musk has been tried in all proportions and with all possible effects, * Hufeland, N. Annalem, i. p. 367.—Demachy, Manuel de Pharmacie. Paris, 1788. —Ruling, Beobachtung. der Stat. Northeim. p. 107. j Diss. Led. Palustr. in Ameenit. Acad. vm. p. 156. i; FoTRtiittning of Provincial Doeternas Berattelser, p. 180. «t- "•] RESPIRATORY FUNCTION. [ord. ii. 395 both abroad and at home, from six grains to half a drachm at a time; Gen. I. but the effects it is stated to produce are so various, and indeed con- f« c*IIL tradictory in different individuals, as to prevent confidence in its use. convuisiva. The accounts can only be reconciled by supposing that in some co0ugh.ns habits it operates far more beneficially than in others. The artificial Kmellt: musk, a spongy mass, obtained by mixing nitrous acid with oil of amber, appears in every instance to have been as successful as the best and most genuine musk from Thibet; and is hence well entitled to attention from its comparative cheapness. The boldest sedative practice has been the internal employment Lead. of lead. It was first recommended, so far as I know, by Dr. Forbes of Edinburgh,* who used the liquor subacetatis, or Goulard's well- known extract, and speaks highly of its success : and it has been oc- casionally tried by practitioners to the present day; but it has never acquired any standard reputation, and, in my own practice, I have never found it necessary to have recourse to it. Nothing but an extremity of symptoms can justify its use among children. The stimulant plan, if it have not been more successful than the Siimulanfs. sedative, has at least been as powerfully supported. Its intention I have already stated to be that of taking off the propensity to spas- modic action in the trachea, by exciting a general or remote local revulsion. And the medicines chiefly employed for this purpose have been cantharides, ammonia, ether, camphor, the herb paris, cantba- and rhus ¥ernix. M* f When blisters were formerly employed with great freedom in the Hooping- hooping-cough, it was thought to be ascertained that they always Treatment. answered best when they irritated the bladder and occasioned stran- gury. And, on this account, some practitioners have endeavoured to produce the latter effect without the pain of the former, and have for this purpose employed cantharides in tincture, in the proportion of twenty minims to a dose.j Dr. Lettsom combined it with bark and the camphorated tincture of opium. But whether given alone or in combination, I have never found any decided benefit from its use, and cannot contemplate it as a medicine to be recommended. Where the intention is to divert the tendency to convulsive action stimulant by local revellents, it is far better to employ them externally, and tions. particularly on the chest and down the chain of the spine. The most common stimulants for this purpose are garlic, camphor, am- monia, ether, and the essential oils of amber and turpentine, which, in different combinations, have been long used and still preserve their reputation. The practice seems to have been first tried in Poland ; and the oil of amber formed, perhaps, the first embrocation; which, however, was soon afterwards united with the water of am- monia. It is a chief ingredient in several of the empiric medicines still in vogue for this purpose, which are rubbed down the spine several times a-day. I have reason to believe that embrocations of this kind have often Whence j proved highly beneficial; and it is not difficult to account for such an effect:° since the cervical and dorsal nerves are so generally dis- * De Tussi Convuisiva. Edin. 1743. t Forbes, loC cijat. 396 CL. II.J PNEUMATICA. [ORD. II. Gen. I. Spec. III. Bex convuisiva. Hooping- cough. Kin-cough. Treatment. Universal revellents. Daphne mezereum. Rhus vornix. Tonic me- dicines and regimen Cinchona. Mineral tonics. Oxyde of zinc. Nitrate of silver. tributed over the muscles of the chest, the diaphragm, and the sca- pula? : and some of them, as the accessory nerves of Willis, form an integral part of the par vagum, and assist in giving rise to the cardiac and pulmonic plexus. Many stimulants have also been occasionally employed internally for the purpose of producing an excitement generally, and thus of acting as universal revellents, as camphor, ammonia, and various pre- parations of both the sulphuric and nitric ethers. These have often been found useful, and, where narcotics are given, they rather assist than oppose their good effect. In Russia and Finland, the berries of the spurge-laurel, daphne Mezereum, are employed for the same purpose. To the taste these are extremely pungent, and, in the countries where they are used, are said to be a specific : but I do not know that they have been tried in England. The rhus Vernix comes also strongly recommended by many foreign writers of distinguished character, as a stimulant spasmodic of considerable power, and highly useful in the hooping-cough. Dr. Fresnoi, to whom we are chiefly indebted for our acquaintance with it, employed its leaves in the form of an extract. Of this he dissolved four grains in four ounces of syrup, and gave a table spoonful every three hours to a child. He adds that, by the time the whole of this mixture was taken, the cough generally abated, and, in most in- stances, ceased altogether. In this manner, he tells us, he cured forty-two children at Valenciennes in 1786. It is certainly a very active and pungent plant, and, when given in an over-dose, is a severe poison. The vapour, or aroma, that issues from its juice, will often excite inflammation in the eyes when held for a short time over it. After all, perhaps the best antispasmodics are tonic medicines, and a tonic regimen. Dr. Cullen trusts almost exclusively to the cin- chona : " I consider," says he, " the use of this medicine as the most certain means of curing the disease in its second stage ; and when there has been little fever present, and a sufficient quantity of the bark has been given, it has seldom failed of soon putting an end to the disease." Floyer strongly recommends the same medicine ; and it meets with an almost universal approbation among the German physicians: some of whom, however, unite it with sulphur of antimony * and others, as already observed, with the tincture of cantharides.! The best and most convenient form of the bark for children is the sulphate of quinine : and where this disagrees, as it will sometimes do, I have employed the mineral tonics, as the oxyde of zinc, from half a grain to a grain two or three times a day ; or the nitrate of silver, from the twelfth to the eighth part of a grain, repeated in the same manner. The former has, I believe, fallen into a very undeserved degree of disfavour in the present day, and chiefly from its having formerly been * Hannes, brief iiber den Friesel, &c. t Schaeffer. Ortbeschreibttng von Re^enspurg, &c. cl. ii.J RESPIRATORY FUNCTION. [ord. ii. 397 extolled for qualities which it by no means possesses. Dr. Gaubius, sGen'iii"t who was a man of sound judgment, was peculiarly attached to it; Bex not only in the present disease, but in all clonic irregularities of the h™"1^11, muscles : and it was upon his recommendation that it first became cough." popular. Of the solution of arsenic I cannot speak from my own Treatment! knowledge. It has, however, been tried by several respectable practitioners of late, and is said to have proved highly serviceable. Yet the prussic or hydro-cyanic acid, has a still fairer claim to trial, l™l*ic and has unquestionably subdued the spasmodic irritation, and con- sequently relieved the cough in a variety of instances. It is here in- deed, and in nervous cough, that it seems to act with most advan- tage.* I have known it succeed in the utmost degree of danger from general convulsions; the dose for a child of four years old being from a drop to a drop and a half, or even two drops of Scheele's preparation of the acid, every four hours till a decided impression is produced. As an important part of our tonic plan, may be mentioned change ^angeof of air, and especially where the difference of temperament, or even temperature, can be rendered very considerable, as from a low to a high atmosphere, or from the interior of a country to the sea-coast; but cold-bathing, so far as my own experience extends, has proved ^ng. more certainly and rapidly remedial than any other prescription whatever: and particularly where it has never been made use of before, and hence introduces a new action into the system. M. Laennec has occasionally applied his stethoscope to this disease : and thinks he has in some instances obtained a measure of its violence and extent, as he has also done in tonic catarrh. To effect such a result, however, there must be some increase of cavity in the vessels or organs of the thorax, beyond that of ordinary health: and M. Laennec conceives this occurs in both instances: in hooping- cough from a dilatation of the bronchiae occasioned by weakness, brought on by excess of straining: and in chronic-cough, from a debility in all the vessels, both bronchial and sanguiferous. The nature of the stethoscope, and its mode of application, we shall de- scribe when treating of Phthisis,! as a test for which it is chiefly had recourse to. * Recherches Physiologiques et Cliniqnes sur l'Emploi de l'Acide Prussique, &c. par N. Magendie, D.M. Paris, 1819. t Vol. in. Cl. hi. Ord. iv. Gen. m. Spec. iv. 398 cl. il J PNEUMATICA. [ord. k. GENUS II. LARYNGISMUS. LARYNGIC SUFFOCATION. SENSE OF SPASMODIC SUFFOCATION IN THE LARYNX, COMMENCING SUD- DENLY, AND RELAXING, OK INTERMITTING ; COUOH TROUBLESOME ; SCANTY DISCHARGE OF VISCID MUCUS. Gen. II. There is a disease that often attacks the larynx, and especially of coafounded infants and children, which has so near a resemblance to croup, as wi'h crouP to be very generally confounded with it, and which is hence corn- spasmodic monly known by the name of spasmodic croup: but which, notwith- croup- standing the resemblance of many of its symptoms, is essentially dif- ferent from it, and ought to be arranged in a different place. It is for this purpose the present genus has been formed, and the present . name invented, with a termination that sufficiently distinguishes it from laryngitis, or inflammation of the larynx, yet a termination that Distinction has the sanction of the best medical writers in every age.* The dis- two. tmctive characters of bronchlemmitis or croup are, inflammation of the mucous membrane of the trachea and bronchial vessels, and the secretion of a peculiar concrete and membrane-like material that lines the tracheal tubes, and threatens suffocation by obstructing them. In the disease before us, we have neither inflammation nor mem- brane-like secretion ; while the sense of suffocation is produced, not by obstruction, but by spasm. The only known species belonging to this genus is the following. SPECIES. LARYNGISMUS STRIDULUS. STRIDULOUS CONSTRICTION OF THE LARYNX. COMMENCING USUALLY IN THE NIGHT ; VOICE SHRILL AND CROAKING ; COUNTENANCE FLUSHED AND SWOLLEN ; DISTRESSING STRUGGLE FOR BREATH. Gen. II. This species forms the spasmodic asthma of Millar, Parr, and sometimes various other writers. Yet it is not strictly an asthma, though it confounded makes an approach to it; and the name under which it has been with flSthmH : * See Prelim. Diss, to the Author's System of Nosology. "*> u.] RESPIRATORY FUNCTION. [ord. ii. 399 thus described, shows sufficiently that the present is the proper place Gen. II. for its reception. In asthma the constriction commences in the Laf pnE?l chest, and chiefly exerts itself there, though the spasm may extend mu/Ku- to the upper part of the trachea. In spasmodic laryngismus the sedulous constriction commences in the larynx, and is chiefly confined to that '^he'"'0" organ, though it may extend to the chest. In the former, the °arynl. respiration is wheezy, but the voice is not stridulous ; in the latter, the voice is stridulous, but the respiration is rarely wheezy, or rather rarely so in an equal degree ; evidently showing a difference in the seat of the two diseases. And hence I have found it necessary to separate it from asthma, and arrange it under a different head. As already observed, the general symptoms make a nearervet more approach to croup : " The inconvenience," observes Dr. Parr, " is Ambles the greater, since, from the resemblance of the symptoms, remedies croup- have been celebrated as successful in croup, which were never used in the disease ; and the less experienced practitioner, trusting to them, has felt the severest disappointment.''' The suddenness with which this complaint commences its attack, piagnos- forms another mark of distinction between itself and croup, almost fining0"" as pathognomic as the absence of inflammation, and the peculiar ^™s r secretionin the latter. There are instances, indeed, in which genuine distinction croup has also commenced abruptly, but these are very rare ; for Jhe present it has usually the precursive symptoms of a slight cough and hoarse- species and ness for a day, and sometimes two days, as though the patient were cr°up labouring under a catarrh. In croup also, the inflammation, when it has once taken effect, becomes a permanent cause of excitement, and the anxiety and struggle for breath continue with little if any abatement till the inflammation is subdued. In the disease before us, the spasm suddenly subsides in a short time, though it may perhaps return in an hour, or half an hour, or even a few minutes ; and in the interval the patient enjoys perfect ease, though the voice is rendered hoarse from the previous straining. Croup is, moreover, an exclusive disease of children ; stridulous spasm of the larynx is sometimes found in adults.' Those who have been dissatisfied with the name of spasmodic asthma, have, however, treated of it under the name of spasmodic croup, but merely because they have not known how else to distinguish it: for almost every one who has thus noticed it, has acknowledged that it is a different disease, and demands a different plan of cure. The exciting causes are not always clear ; cold and teething are Exciting the most common. It appears most frequently in relaxed and irri- obvious. table habits, where, in truth, we should soonest expect a display of spasmodic action. As there is mostly some degree of cough, and always a secretion of a small portion of viscid mucus, and a croaking voice, there is indeed great reason for supposing some degree of local irritation ; and it is on this account that I have preferred , entering the disease here, to an arrangement of it under the fourth class, consisting of diseases that are purely and idiopathic ally nervous. It is possible, however, that some of these symptoms may be the result of the spasmodic struggle itself. An active and speedy plan of treatment is imperiously demanded. Treatment. 400 cl. il] PNEUMATICA. [OKD. II. Gen. II. Yet an antimonial emetic generally effects a cure as soon as it begins Laryngis- to operate, if employed early: but the diaphoresis which it excites mus suidu should be maintained for some hours, by keeping the child in bed, stTiduious and the use of diluents ; which will be the most effectual means of ofThe01'0" preventing a return of the spasm. The bowels should also be larynx. excited by a purgative of calomel. And if the emetic do not prove Treatment. guffic}ent^ or me stricture should be renewed, laudanum should be exhibited according to the age of the patient, and a blister be applied to the throat. But bleeding, which is indispensable in croup, should here be avoided, as it will only add to the irritability. Those who regard this affection as an asthma, have strongly recommended the fetid antispasmodics, as assafetida, both by the mouth and injections; but I have not found them successful. Generally speaking, after the action of the emetic, the child falls into a deep and quiet sleep, and awakes with few remains of the complaint. Yet if the spasm be not attacked at once, suffocation may soon follow. Those who have once laboured under it are more susceptible of it than before ; and the younger branches of some families seem much more predisposed to it than those of others. GENUS III. DYSPNOEA. ANHELATION. PERMANENT DIFFICULTY OF BREATHING ; WITH A SENSE OF WEIGHT ON THE CHEST. Gen. III. There has been no small perplexity felt by nosologists in arrang- ^ttiingYhe mS tne various diseases which are chiefly characterized by irksome present or distressful breathing. The lungs, like the stomach, maintain a close connexion with most of the functions of the body and the organs which are instrumental to them; while the complaints affecting respiration, that originate in the chest, run so frequently into each other as to require the utmost nicety in drawing the line between what ought to be regarded as genera, and what as species. There are three thoracic disorders that are peculiarly obnoxious to this remark; I mean, those which among recent writers have been described under the names of dyspnoea, orthopnoea, and UoWddb astnma* Celsus, following the Greek physicians, regards them as cfisus. y only modifications of the same malady, merely differing from each other in degree. , " Each," says he, " consists in difficulty of breathing. When this difficulty is moderate and unsuffocative, it is called dyspncEa ; when it is more vehement, so that the breathing is sonorous and cl. il] RESPIRATORY FUNCTION. [ord. ii. 401 wheezing, it constitutes asthma; and when it can only take place J»EN- IH* • • • . i mi_ n i • Uyspnoea. m an erect position, it is denominated orthopncea. 1 he nrst is Anheiation. usually a chronic affection, the latter two, acute."* Galen, on the JJ°w by p • iv Oalen. contrary, treats of these diseases as distinct genera, and discusses them in remote positions. The same diversity of view has occurred in modern times. Sir diversity ° John Floyer and Dr. Bree have reduced the three divisions of Cel- ™£ejj| sus to two, and have used the term asthma as a generic name under times. which to arrange them. These two divisions are continued asthma, ^mUT and convulsive or periodic asthma ;t the former being the nysp- Fioyecand N(ea of the Greek writers and of Celsus, and the latter uniting their Bree' asthma and orthopncea. I call these, divisions rather than species, because Dr. Bree makes four subdivisions of the latter, derived from their supposed causes, and assigns the name of species to them when thus subdivided: though if asthma be employed generically, it would perhaps be more consistent with the rules of classification to name the primary ramifications, species; and the secondary, sub- species or varieties. Almost all the continental writers make each affection a separate ^Insental genus, as does Macbride among those of our own country. Cullen cullen. makes a genus of dyspnoea, as well as of asthma, but merges orthop- ncea in the former ; Dr. Parr and Dr. Young take as little notice of gjJJJ4 orthopncea, and, with Celsus, reduce dyspnoea and asthma, to the rank of species under a genus which they denominate anhelatio or pneusis ; which are a Latin and a Greek synonym ; the former of which is applied by Sauvages to an entire order. Yet Dr. Cullen himself, in his First Lines, is untrue to his Noso- ™j£ to logy ; for having in his earlier work arranged and defined dyspnoea himself. as a distinct genus, in his later he expresses doubts whether, under almost every modification, it is to be regarded otherwise than as a vicarious or symptomatic affection. On which account, probably, Dr. Crichton, though for the most part very scrupulous in adopting Crichton. Dr. Cullen's views, has banished dyspnoea as well as orthopncea from his catalogue, and has only retained asthma of the whole three. Dr. Wilson Philip seems to make little distinction in the use of the terms asthma and dyspnoea, for his habitual asthma, and asthmatic dyspnoea are synonymous for the same disease, and run parallel with the PrTheregis"nevertheless, a distinctive character, which, if steadily Juh«yf®;w adhered to, may easily settle the question, and designate the proper resolvable. place to which each respectively belongs. The difficulty of breath- incr is sometimes permanent, and sometimes recurrent, with consi- derable intervals of perfect ease ; and where it is permanent it is occasionally distinguished by sudden and irregular exacerbations. These characters are clear, and cannot well be mistaken ; and it is upon these pathognomic marks that the arrangement we are now about to pursue has been founded. Dyspnoea distinguishes he cases of permanent difficulty of breathing: asthma, those of the * Medicinse, Lib. iv. iv. 2. # „-. t Inquiry into Disordered Respiration. 5tn fcdit. p. <«»• X On Indigestion, &c. P. 377.384, Edit. iv. Syo. hfini. 1824. Vol. \.—ol 402 cl. n. j PNEUMATICA. [OSD.IL Gen. III. recurrent; and orthopncea, the cases of permanent difficulty of AnMation. breathing with irregular exacerbations. The first two, therefore, form distinct genera; the last is necessarily a peculiar species of dyspnoea, linking it very closely with asthma. Thus bounded and distinguished, dyspnoea, as a genus, offers us the two following species : 1. DYSPNOEA CHRONICA. SHORT BREATH. 2. ——-—- EXACERBANS. EXACERBATING ANHELATION. SPECIES I. DYSPNOEA CHRONICA. SHORT BREATH. THE BREATHING UNIFORMLY SHORT AND HEAVY: MOSTLY ACCOM- PANIED WITH A COUGH. Gen. III. The causes of this complaint exist in the chest locally, or in the Spec. I. habit or constitution generally: they are inbred, or the result of accident; and hence the disease exhibits the following varieties : a Organica. From organic deformity, oppres- Organic dyspnoea. sion, or accidental injury. (8 Extranea. From calcareous or other spicular Extraneous dyspnoea. materials inhaled while working on stones or metals. y Vaporosa. From the mischievous action of Mephitic dyspnoea. metallic or other poisonous ex- halations. } Phlegmatica. From a phlegmatic or cachetic Phlegmatic dyspncea. habit. s Pinguedinosa. Accompanied with oppressive fat- Corpulent dyspncea. ness. Pursiness. nica'orhr°- • ^nen tne cnest labours under an organic deformity, or oppres- i.ica.°rga" sion, or the effects of an accidental injury, its cavity is contracted, Sw£Co. an<*its motive Powers are usually enfeebled, or curtailed in their action. This is by far the most frequent variety under which the fromri idi disease makes its appearance. In some instances the lungs have ty°of "true- been found peculiarly small,* and shrivelled or dried up,| in persons ture. who have died of this complaint; in others, peculiarly hard, and cartilaginous in the duplicature of the pleura which surrounds them.j There has been adhesion between the folds of their mem- * Sandifort, Observat. Anat. Pathol. T Bonet. Sepulch. Lib. x. Sect. i. Obs. 45. I Sehreiber, Noy. Comment. Petropol. in. p. 395. cl. «.] RESPIRATORY FUNCTION. [ord. il 403 brane ; or adhesion, sometimes ossification* between the pleura and Gen. III. tiie ribs, sufficient to lay a foundation for difficulty of breathing. /"&£ The lungs have been found loaded with hydatids, which have *\<* <"sa- diminished their elasticity ;| and sometimes these animalcules have o^anic been thrown up by coughing ;J and still more frequently the lungs dHyy8d*S'. have been indurated by scirrhous, or oppressed with steatomatous or other tumours. In Bonet, and other writers, we have also examples of internal Excessive oppression, and a diminution of cavity, produced by an excessive "The"1 " magnitude in the substance of the lungs, offering a sort of parabysma lansa' of this organ, so as to leave little room, and allow little elasticity for their proper play.§ And still more generally the oppressive cause Cause? lies without, and the capacity of the chest is diminished by rickets, ?£ematins or a softness of the bones (parostia flexilis), or some accidental wilu°ut- injury by which the ribs or sternum have lost their proper form and are become incurvated, and without a power of elevation. In all these cases, the healing art can do little more than look on. Treatment It may, perhaps, occasionally palliate some of the distress to which the men!66'" patient is irrevocably doomed; but it cannot go. beyond. Perfect tranquillity of body and mind, gentle exercise, a light diet, with a total abstinence from flatulent vegetables and fermented liquors, and an undeviating habit of regular hours, comprises, perhaps, the whole that can be recommended by the physician, or attempted by the patient. Sawyers and hewers of free-stone or other fossil masses; glass- 0.o. cbro- .... , , ,. i • mca extra- CUtters, lapidaries, and workers upon metals, are often subject to aea. dyspncea, from having the lungs loaded with fine pulverulent from""^- particles detached from the materials on which they are employed, jar particles and floating in the atmosphere that surrounds them. And to these l maybe added, millers, starch-makers, horn and pearl-workers, needle, edge-tool, and gun-barrel grinders ; and, for a like reason, weavers, wool-carders, and feather-dressers. This affection is so nearly Nearly similar to the variety j8 of dry cough, on which we have treated p Tussis already, that it is only necessary to refer the reader to the remarks B10Ca' there laid down. The cause and mode of treatment are the same; and the symptoms chiefly differ from a difference of constitution. Where the lungs are peculiarly irritable, a troublesome cough will ensue from the first, before any considerable quantity of buoyant particles can have entered into the bronchiae; but where there is little irritability, no cough demanding particular attention has shown itself for years ; and the lungs, from a habit of exposure to the same influence, have betrayed no uneasiness till they have gradually been transformed into almost a mine or quarry, of the material worked upon.II Various contrivances have been devised for straining off the floating particles from the air inhaled, and thus producing a preventive. Dr. Johnstone, long ago, proposed a muzzle of * Schachier, Diss, de Ossificatione Prseternaturali, Lips. 1726. + Bonet. Sepnlch. Lib. u. Sect. I. Obs. 33. X Ephem. Nat. Cur. Dec. u. Ann. i. Obs. 80. 5 Sepulchr. Lib. n. Sect. i. Obs. 57, 58.—Ruysch, Obs. 19. 21. Eph. Nat. fur. Dec. i. Ann. i. Obs. 6.—Id. Dec. ii. Ann. x. Obs. 175. I] Hecquet, Maladies des Artisans, Tom. n. 404 cl. h.J PNEUMATICA. [ord. « Gen. HI Spec. I. 0 I), chro- nica extra nea. Dyspnoea from spicular particles inhaled. Magnetic device. y D chro- nica vapo- rosa. Dyspncea from mis- chievous exhala- tions. Causes- Remedial process. Galvanism. £ D. chro- nica phleg- matica Phlegmatic dyspncea. damp crape for this purpose, Dr. Gosse a sponge, and M. d'Arcet an apparatus which he calls a fourneau d'appel: but for workers in steel or iron, one of the most ingenious is a peculiar kind of magnet that concentrates the metallic spiculae, and thus prevents them from floating loose in the inspired air. It is an invention of Mr. Abrahams, of Sheffield, and has justly met with the approbation of the Society for the Encouragement of Arts. Exposure to the vapour of minek al acids, or of metallic or other mischievous exhalations, is also frequently found to produce a perma- nent difficulty of breathing. This affection is peculiarly" common to those wretched beings who are condemned by the laws of their country to work in metallic mines as an expiation of crimes proved against them ; a melancholy and interesting picture of whom is given by Diodorus Siculus, in his description of the mines of Arabia and Ethiopia. The air-cells of the lungs are often found constringed to half their proper capacity ; whilst, in many mines, the vapours are so irritable as to excite a perpetual cough. They are loaded accor- ding to the nature of the mine, with oxydes, sulphurets, or commi- nuted reguline particles of lead, copper, antimony, silver, arsenic. Metallurgists and the labourers in chemical laboratories are often severe sufferers from a like cause. Gold-refiners become dyspnetic from inhaling the vapour of aquafortis. Etmuller gives an account of his having been seriously injured in his breathing, while carefully superintending an antimonial preparation.* And Heurnius saw the lungs of a printer so changed by inhaling an atmosphere impregnated with lead as to resemble a shrivelled apple. The treatment of this variety must be regulated by the variety of the cause ; but a free inhalation of oxygene gas will be serviceable in perhaps all cases. An inhalation of moderately stimulant vapours, as of an infusion of lavender, marjoram, and indeed most of the ver- ticellate plants, or of diluted wiue-vinegar, has also proved frequently of use ; to which may be added a currqnt of the electric fluid passed two or three times a-day from the upper part of the spine to the dia- phragm. An atmosphere impregnated with tar heated over an oil or spirit lamp, has also in many instances been found essentially to invigorate the respiratory powers ; and to these, where there is much cough, should be added expectorants and the warmer demul- cents. After pursuing this plan for some weeks, pure air and the aerated mineral waters, where the case is not inveterate, will add a healthy degree of tone, and restore the respiratory organs to their natural action. Galvanism has also occasionally produced consi- derable, and in some instances, permanent relief after a few applica- tions, the opposite wires being applied, the one to the nape of the neck, and the other to the lower part of the epigastric region, and each fixed upon a thin plate of metal wetted with water, as recom- mended by Dr. Wilson Philip.| We sometimes find a permanent difficulty of breathing in persons labouring under great torpor or sluggishness of vascular ac- * Rammazini, de Morbis Artificum.—Ephem. Vratisl. t On IndigestioD, &c. p, 379. Fourth Edit. 8ro. Lond. 1824. <-l. n.] RESPIRATORY FUNCTION. [ord. n. 405 tion. The pulse is slow and unresisting; the muscles are soon fa- Gen. III. tigued ; the mind has little energy ; the face is pallid ; the skin cold *£*££ and soft; the urine scanty, and the extremities edematous, without mc<" phieg- any pathognomic symptoms of dropsy in the chest, or at least any phlegm, a tic sensible fluctuation in the thorax. It is the dyspnoea aquosa of dyspnea. sullen, and the dyspnea pituitosa of Sauvages. Whatever has a causes. , tendency to depress the living power, and particularly in flaccid and atonic habits, will readily lay a foundation for this variety of dyspncea ; and hence it is a frequent result of catching cold in the feet, and still more frequently of suppressed perspiration. It also occasion- ally follows upon chronic catarrhs, and pneumonitis. A tonic and gently stimulant plan, consisting of the warm gums, Medical camphor and other terebinthinates, the warmer bitters, the oxydes oftreatment zinc and iron, the compound squill pills, the warm-bath, moderate exercise, and a generous diet, will be the most successful mode of treatment; occasionally interposing antimonial emetics : which will relieve the lungs far more effectually than those of ipecacuan, as ope- rating longer on the moving powers of the chest. Of the terebin- thinate tribe, the best, perhaps, is the balsam of copaiba given in doses of a drachm or a drachm and a half three or four times a-day. Nothing succeeds so well in restoring the secretion of mucus where it has ceased or become deficient; or in producing a healthy dis- charge where its nature has been changed by a morbid action. On which account this medicine may also be regarded as a specific in morbid secretions of mucous membranes, whether of the lungs, the intestinal canal, or the urethra; as it has often proved highly ser- viceable in croup. The chief difficulty is in devising a convenient form for its exhibition, since it sometimes exOites nausea. The variety of least moment, perhaps, to the dyspnetic patient, is eD.chr©. that which proceeds from, or is accompanied with a short, stunted ^din'osa. figure, and considerable corpulence, or at least obesity of the PurBiness- chest. We see persons of this description, significantly described Description, by the colloquial term pursy, pant, and perspire, and grow fatigued, day after day upon very little exercise, and yet press on without any serious inconvenience to a late period of life ; or, if they sink sud- denly and sooner, they yield rather to apoplexy as a result of their general habit than to the idiopathic affection before us. Abstinence Treatment. from spirits, wines, and fermented beverages, a meagre allowance of animal food, a soluble state of the bowels, and exercise, rather per- severing than violent, will form the best plan for present ease, and the best guard against threatened mischief. Bleeding has often been Venesec- tried, but it affords only temporary relief, which is obtained by gain- lemporwy^ ing space in consequence of emptying the vessels. Sauvages gives RBeemarka, us the history of a female, who for two years had been so far suffo- biHn- a" cated, that it had often been judged necessary to bleed her three 8tance- times a-day at least, so that she had undergone not fewer than two thousand venesections when she applied to him at Montpelier. She was plunged into a warm-bath, the bath was frequently repeated, and friction at the same time made use of, so as to excite violent perspi- ration : by this mean she was convalescent in ten days. Obstructed perspiration, however, was the cause in this case. 406 cl. ii.] PNEUMATICA. [ord. u. Gen. III. Dyspncea has also sometimes been produced by causes somewhat iHtHtire?' more singular, as common respirablc air obtaining an entry into nica pin- cavities in the chest, or to which it does not naturally belong. Stoll f«reine?Ba' gives a singular case of dyspnoea, brought on by air-bladders, or ve- singuiar sjcles, seated on the surface of the lungs ;* and Gooch and various others tell of the same effect occasioned by air let loose between the lungs and the pleura, the action of which is far more obvious. In Ti- masus we have an example of a very extraordinary idiosyncrasy giving rise to a difficulty of breathing upon an inhalation of the smell of roses.f The morbid influence of metallic action is not always con- fined to vapour locally applied ; for in Schenck we have a case of dyspnoea produced by mercurial inunction ; j and, in other books, of a like effect on peculiar constitutions by a solution of the oxydes of lead taken internally, or even applied externally.^ Chronic Chronic dyspnoea appears also as a symptom or sequel in various other diseases, or affections of various other organs ; as aneurism, ossification, or other mischief in the 'heart, or aorta ; any morbid change in the diaphragm, ribs, or pleura, by which the cavity of the thorax is diminished, or the moving powers restrained in their action ; parabysmic enlargements of the liver, spleen, or omentum ; whence it is obvious that it must, in a greater or less degree, be an attendant on the latter period of pregnancy. It has also followed occasionally, not only upon suppressed perspiration, but on the suppression of va- rious cutaneous eruptions, and, in a few instances, upon suddenly closing an issue or seton of long standing.il SPECIES II. DYSPNCEA EXACERBANS. EXACERBATING ANHELATION. THE DISEASE SUBJECT TO SUDDEN AND IRREGULAR EXACERBATIONS; BREATHING DEEP, STERTOROUS, ACUTE, AND SUFFOCATIVE ; RE- LIEVED BY AN ERECT POSITION. Gen. III. This species admits of most of the varieties of the preceding HowC' H# wmcn "• *s hence unnecessary to repeat; and, like it, is often found produced, as a symptom in aneurisms, polypous concretions, and other affec- tions of the heart and larger vessels ; in parabysma, and other affec- tions of the abdominal viscera ; in empyema, dropsy of the chest, worms, peripneumony, bastard peripneumony, small-pox, and occa- sionally in severe accessions of intermitting fevers. I have already, indeed, stated that there is scarcely a function with which the action of the lungs is not connected, and consequently scarcely a disease of * Nat. Med. P. th. p. 135. § Eph. Nat. Cur. Dec. in. Ann. iv. Obs, 30. t Case, p. 216. || Riedlin, Lin. Med. 1695. p. 91. t Observat. Rar. Lib. ii. p. 63. il. ii.] RESPIRATORY FUNCTION. [ord. ii. 407 any importance in which it does not occasionally participate. Gen. HI. Whatever be the cause that produces anheiation, or permanent dif- D^f°,asaIL ficulty of breathing, in a patient, any accidental augmentation of it, exaTrbMs. or any sudden excitement of body or mind, or any diseased action of §J£iX any kind capable of uniting with the primary cause directly or re-tion- motely, will increase its power, and not unfrequently induce a spas- modic constriction in the muscles of respiration. And it is this ac- Present cidental exacerbation, produced irregularly by casual and often h™?ecu- occult causes, and especially in irritable or nervous temperaments, ii«iy.tHs- that peculiarly distinguishes this species from the preceding. In from'the3 asthma the returns are for the most part strictly periodical, and the £3^*' intervals perfectly free from difficulty of breathing. In exacerbating asthma, dyspnoea the constriction occurs with the utmost irregularity, in the day time, at night, in hot or cold weather, in a moist or dry atmos- phere ; and it is hence sufficiently distinguished from asthma. A catarrhal cough will sometimes prove an occasional cause ; several of the varieties of heartburn, and especially cardialgia syncopalis, still more frequently : other causes are, indigestible food, a fit of hysterics, or any violent commotion or agitation. While, as al- ready observed, the occasional cause is often beyond the power of detection. When the constrictive paroxysm makes its attack, it must be im- Therapia. mediately opposed by an erect position, without which suffocation would often instantly ensue ; and by the most powerful antispasmo- dics. Tincture of opium, ether, and volatile alkali, are what I have Sedatives chiefly trusted to, and have uniformly found far more to be depended spasmodics. upon than castor, or any other odorous antispasmodics in whatever quantity given. A large blister to the chest should also be immedi- Blisters. ately applied ; and, if the paroxysm do not yield soon, sinapisms to the feet. Upon its cessation, the gum-ammoniac mixture, or a solu- tion of assafcetida, with camphorated tincture of opium, will be found a convenient guard against fresh attacks, provided due atten- tion be paid to the state of the bowels, which ought indeed to form an early consideration. Issues have been recommended as a pre- issues. ventive of the paroxysm, where its approach has been expected, and I have sometimes thought them of efficacy. For this species, how- Voltaic ever, perhaps the most effectual means of relief are to be derived employed9 from the application of the voltaic battery, as already proposed for °y phi"P- anheiation from poisonous vapours ; and as has been successfully tried in numerous instances of the present species by Dr. Philip, who was first induced to apply this remedy from observing that ani- mals, whose eighth pair of nerves had been divided, exhibited the oppressed breathing and accumulation of phlegm that characterizes both species of dyspncea, and were relieved by having a stream of voltaic aura sent through the lungs. The accompanying cough, instead of being increased by the use of the voltaic power, is hereby diminished in consequence of its di- minishing the accumulation of phlegm in the lungs. In proper asth- ma, which is characterized by intervals of free and healthy breathing, little or no benefit has been derived from this process ; and hence Dr. Philip very ingeniously reasons that although in both diseases the 408 cl. il] PNEUMATICA. [ord. II. Gen. III. nerves of the respirable organ are alone in a morbid condition, apd Dyspncea not the brain or spinal marrow ; yet in the former, they are still ca- exacerbans. pable of being recalled to a state of healthy activity, or of becoming ting anhe- sufficiently cleared to form a passage for the supply of nervous in- Modeof Auence to the lungs, which effect he supposes to be obtained by the action. use of the voltaic machine. The American pathologists have found great benefit from various preparations of the lobelia inflata, or Indian tobacco, which is cer- tainly possest of powerful antispasmodic and expectorant virtues; and has hence a fair claim for a more extensive trial than it has yet received. The ordinary form is that of a saturated tincture of the leaves, prepared by digesting two ounces in a pint of proof spirit: the dose of which is from a tea-spoon to a table-spoonful, repeated every half hour or oftener till the paroxysm is conquered.* GENUS IV. ASTHMA. ASTHMA. DIFFICULTY OF BREATHING TEMPORARY, RECURRENT ; ACCOMPANIED WITH A WHEEZING SOUND AND SENSE OF CONSTRICTION IN THE CHEST ; WITH COUGH AND EXPECTORATION. Asthma, as already observed under dyspnoea, is closely connected with the latter, and particularly with its second species, characterized by what might be strictly called asthmatic exacerbations, and which I have hence denominated dyspncea exacerbans. The definition of the disease now offered, while it shows the prox- imity of the one to the other, is sufficient, if I mistake not, to form a marked and accurate distinction. The vulgar term for the com- plaint in our own language is hroken-wind; which as scientific pre- cision is seldom an object of popular language, is often, also, applied to some of the varieties noticed under dyspnoea, or short-breath. Asthma is more commonly a disease of the later than the earlier period of life ; for it does not often appear in infancy or youth, al- though occasional instances of this have occurred, particularly in infancy, that have been mistaken for cases of croup, which the asthma of infancy very much resembles, though admitting of a more easy cure. It soon becomes habitual, and seems sometimes to be here- ditary. It invades all temperaments, but more particularly the me- lancholic, or that which is a compound of the melancholic with the sanguineous. * * Tle„atise on the Materia Medica, &c/by John Eberle, M.D., 2 vols, 8ro. Phila- «.. il] RESPIRATORY FUNCTION. [orb. ii. 409 The paroxysms of asthma are universally preceded by languor, Gen. IV. flatulency, head-ache, heaviness over the eyes, sickness, pale urine, procursive disturbed rest, and a sense of straitness, fulness, and anxiety about symptoms. the praecordia. " When the evening approaches," says Dr. Bree, who unhappily describes from his own history, " the weight over the eyes becomes more oppressive, and the patient is very sleepy. Fre- quently at this period there is a tingling and heat in the ears, neck, and breast; and a motion to expel the contents of the bowels is at- tempted, with some violence and with great uneasiness of the abdo- minal muscles. When an asthmatic feels these warnings, he may be convinced that his enemy is at hand.* The accession is usually about the middle of the night and during Accession the first and deepest sleep : the cause of which has not been render- midnight ed very manifest, though I do not think it beyond the reach of ex- planation, and especially in constitutions predisposed to the disease by habit or hereditary affection. Respiration always takes place most easily in a raised or erect position, but in the night the body is - recumbent. Respiration is also so much of a voluntary action, that Why at although it continues during sleep, and when the will is not exerted, explained. it is considerably aided by the concurrence of the will. Now during sleep this concurrence is wanting ; and hence the most favourable period for the attack of this insidious complaint is that in which we actually find it makes its appearance—during a recumbent position of the body, when the muscles of respiration are destitute of the stimulus of volition. When the disease indeed has once established itself and become habitual, it will recur at other times also, but less frequently. For the most part, the patient wakes suddenly, and feels a most Description. distressing tightness about the chest, as if he were bound with cords : his anxiety is inexpressible, and he labours for breath as though every moment would be his last. He is obliged to sit erect, breathes distressfully with a wheezing sound, and cannot bear the weight of the bed-clothes. Cool fresh air is the object of his intense desire. At the same time the extremities are cold; the heart palpitates; the pulse is sometimes quickened, but usually weak, irregular, and often in- termitting ; the abdomen is distended with flatulence ; the stomach is faint, and often rejects with great violence a slimy and frothy ma- terial of a greenish or yellowish hue. The eyes stare prominently, and the face is sometimes pale, but more commonly bloated and livid ; and the alvine canal, though costive before, will now perhaps pass a loose stool.^ In many instances there is an ineffectual effort to excrete, with a harsh and dry cough that brings up nothing more than a little clam- my or frothy mucus through the whole of the struggle. And in these cases the fit usually subsides, or perhaps altogether leaves the patient in two or three hours. But, in other instances, the cough is far more violent and suffocative ; and when it has lasted for an hour or two, an expectoration of tough viscid mucus commences, and gradually becomes copious and affords relief. It is occasionally * Inquiry into Disordered Respiration. Sec. iv. p. 46. Vol. !.—?>? 410 cl. ii.] PNEUMATICA. [ord. if. Gen. IV. Asthma. Relieved hy a discharga of mucus or blood. Paroxysm often lasts many hours, and sometimes returns the ensuing night. Often lasts for a week or a fort- night. Has conti- nued for se- ven weeks. Not often fatal at the time of attack, but occa- sionally induces dangerous complaints. Exciting causes numerous, but all resolvable into irrita- tion of the chest. Sometimes symptoma- tic and dependent on a remote organ. The actual cause of importance to be dis- o»ered. mixed with blood from the severity of the struggle : but the larger the discharge of either, or of both, the more the bronchial vessels are made easy by being thus unloaded of part of their obstruction. It is often, however, many hours before a paroxysm of this kind very sensibly subsides ; and the patient generally feels some degree of constriction during the whole of the ensuing day ; and is fortu- nate if the next night be passed without the return of a like fit. The tendency to such returns usually continues for several nights : in severe cases, for a week or a fortnight. Sir John Floyer, who, from describing his own sufferings, has given us one of the best his- torical accounts of the disease that has ever been written, mentions a case in which the fits recurred for seven weeks together ; during the whole of which time the patient was obliged to sit erect in a chair. Yet, notwithstanding the violence of the assault, it is not often that asthma, under either of these forms, proves fatal at the time : for this " morbus maxime terribilis," as it is called by Willis, " may be carried on to old age, if supervening diseases do not destroy the patient, or disturb the operations of nature, by which a recovery from the paroxysm may be obtained."* But it rarely makes a first attack without subjecting the constitution to subsequent returns ; and frequently, by the debility which it hereby produces, lays a.foun- dation for tubercular phthisis, dropsies of the chest or abdomen, aneurisms of the heart, and various other fatal diseases. Whilst it occasionally happens, even where none of these take place, that the mucous glands of the bronchiae become relaxed, an habitual excess of secretion ensues, and a troublesome dyspnoea is the consequence, from the overloaded state of the air-cells and bronchial vessels ; a mischief, which in such cases, is felt most oppressively on first awa- king, and is only relieved by a long labour of severe coughing. This overloaded state of the bronchia? and air-cells, from too large a secretion of mucus, is, indeed, at the time, an original exciting cause of the disease ; and has by some writers, and especially in our own day by Dr. Bree, been supposed to be the chief cause. The exciting causes, however, are numerous, and it is difficult to say which is the chief: nor always easy, as we shall observe more at large by and by, to follow them up, and ascertain them satisfac- torily. Yet they may all be resolved into an irritation of some kind or other, existing within the cavity of the chest, and stimulating its moving powers to a convulsive constriction. I say existing within the cavity of the chest, because we are now considering asthma as an idiopathic disease. Yet it happens not unfrequently that it occurs as a mere symptom, or result of some other disease, or of a morbid state of some remote organ, as the stomach, liver, or spleen ; in which case it becomes a secondary affection, and is only to be re- moved by removing the primary disorder on which it is dependent. And hence it is of the utmost importance that we should trace out the actual cause, at least so far as to determine whether the asthma be an idiopathic affection originating in the chest, or a subsidiary affection catenated with some other part of the system. Bi»p's Inquiry, &i*. sect. vi. )>. 71. «l. n.J RESPIRATORY FUNCTION. [ord. ir. 411 Whether the suffocative tightness of the chest be the result of a Gen. IV. spasmodic stricture of the bronchial vessels, spreading thence to the whether muscles of respiration ; or produced by an infarction of these ves- g^^'0 sels from a superabundant effusion from their exhalants, is a ques- or mucous tion of a very different kind. Willis first started the former opinion, ^/the'com- which has flowed in a regular current, or with little opposition, m^ficrjtuse" through Floyer, Hoffman, and Cullen to the present day. Dr. Bree advanced has lately proposed the latter, and supported it with great ingenuity ^he^econd and learning ; illustrating and fortifying his views by numerous refer- by Dr. Dree. ences to unquestionable facts, and the opinions of earlier writers, and especially of the humoral pathologists to whose physiology he seems peculiarly to incline. The same principle, or at least a modi- fication of it, has been adopted by Dr. Parry, who places the vascular turgescence in the mucous membrane lining the bronchial cells. Admitting the former hypothesis, the thoracic convulsion is a dis- Under the eased action from the beginning, and under every degree and modi- thfe c0nvui- fication, and is so regarded by its advocates : while Dr. Bree only ?;vm^|°n allows it to be so when the convulsive action is violent; contending at ail times that in its commencement it is altogether a remedial effort, an in- ^x^esM stinctive attempt to expel the serum or mucus that clogs the bron- Under the chial vessels. And he hence accounts for the pathognomic whee- on,y w'hen zing, which he does not think the idea of a spasmodic stricture ofin«cess- these vessels is sufficient to explain ; as also for the general inef- ficacy of opium and antispasmodics to whatever extent they may be carried. I have already stated that an excessive secretion from the exhalants jjj£"jj of of the bronchiae may be an exciting cause, in many cases, and par- secretion as ticularly in a relaxed and debilitated condition of the bronchial ves- tchaeufee.neral sels in consequence of former attacks. But, notwithstanding the masterly manner in which Dr. Bree has argued this point, I cannot regard such a secretion as a common cause of asthma, since, in numerous instances, I have observed, in the words of Sir John Floy- er, that " the lungs do not appear to be much oppressed with phlegm before the fit; and at the end of the fit the straitness goes off before any considerable quantity is spit up :" while in what is commonly called the dry, nervous, or convulsive asthma there is Bq^atyr always very little, and sometimes no mucus whatever excreted from ZtvZuV the beginning to the end of the paroxysm. It may, indeed, be main- "«»ma. tained that the secretion is absorbed, but this is to beg the question, for we have no proofs of such an absorption. The existence of accumulated mucus in the bronchial vessels of those who have died of asthma, and whose bodies have been opened, does nothing more than establish the fact in those particular cases. And even here we are left in total darkness whether the serum or mucus anticipated the suffocative convulsion and was the cause of it, or whether the latter anticipated the serous or mucous effusion, and forced it into the vessels in which it has been found on dissection. How far the suf- *«* focative convulsion may originate in a spasm of the bronchia?, as thoj.ron- contended for by Dr. Cullen, we have no means of determining moBt ob_ manifestly. That it may exist, however, as well as a spasm of the n^™- 412 cl. h.j PNEUMATICA. [ord. il from suppi causes Gen. IV. alimentary canal, no one has been bold enough to deny; that il Asthma. mugt pr0(juce t}jat strangling constriction or straitness which is a pathognomic sign of asthma, where it does exist, can be as little doubted ; and I find it extremely difficult to ascribe the disease to any other state of the bronchiae, in all cases of dry or nervous asth- ma, in which, as there is little or no discharge from the lungs, we have full ground for inferring that there is little or no accumulation within them. " It is not, however, intended," says Dr. Bree, " to deny the possible existence of this spasm, but to object to it as a proximate cause ; and to state the imprudence of depending upon it Theprac- as an important indication in practice."* Yet it does not appear ^estedly to me that tne Practice suggested by the one opinion needs to be so the one much at variance with that suggested by the other, as this passage ne>ces°8ariiyt would seem to intimate. For if acids prove a beneficial mode of witTthat00 treatmem% and that benefit be ascribed by the upholder of the mucu- suggested lent hypothesis to the astringent power of the acid, by which the othw? A°w of mucus is restrained ; it may be ascribed by the upholder of the spasmodic hypothesis to the very same power, by which as a tonic, it takes off irritability, and allays all muscular irregularities. Subdivi- Dr. Bree's division of the disease is founded upon causes rather arranged by tnan uPon symptoms; and he has hence divided it into the four following i)r. Bree species :—Firstly, those cases, being most numerous and common, supposed which are produced by the irritation of effused serum in the lungs.— Secondly, those produced by the irritation of aerial acrimony in the lungs.—Thirdly, those dependent on irritation im the stomach, or some of the abdominal vicera—And, fourthly, those dependent upon habit. In treating further of this disease, I shall also have further to ex- press my deep sense of the value of Dr. Bree's learned and elabo- rate investigation : but, as the definitions under the present classifi- cation are founded upon a principle of symptomatology rather than of etiology, it will not be in my power to adopt his divisions in the exact terms and order in which he has given them ; though it will be found that his first two species run nearly parallel with the only two to which I propose tolimit the genus ; and which will be wide enough to embrace his fourth, or those cases of the disease, which, whatever be their symptoms, depend on an established habit; while the third species of Dr. Bree, comprising cases in which asthma is not an idiopathic affection, but a sign or result of morbid action in some organ remote from the lungs, cannot be correctly treated of in the present place ; the affection included under it being alone to be remedied by remedying the primary disease on which it is dependent. From the view, then, thus offered, and from other symptoms that we shall have presently to take notice of, it will, I think, be found convenient to contemplate the genus asthma, as comprising, and limited to, the two following species :— 1. ASTHMA SICCUM. DRY ASTHMA. NERVOUS ASTHMA. however, it seems to be the result of a plethora, or, as Dr. though Cullen expresses himself. " a turgescence of the blood, or any other "!>• n.\ RESPIRATORY FUNCTION. [ord. ii. 417 cause of any unusual fulness and distention of the vessels of the Gen. IV. lungs."* And sometimes, as in old age, or after long continued £££; IL and repeated catarrhs, it is produced by an excess of serum or mu- humidum. cus flowing inordinately from a weakened and relaxed state of the asthml bronchial exhalants or mucous glands : thus offering us three vari- ^Xma0" eties, as follow :— sometimes the con- x Simplex. Without any manifest cause or rary Simple humid asthma. combination with any other af- fection. 0 Plethoricum. From plethora, or the suppression From plethora. of some accustomed sanguine- ous evacuation. y Atonicum. From a debilitated and relaxed From local atony. condition of the excretories of the air-vessels, as a consequence of chronic and neglected ca- tarrhs, or of old age. We also meet with examples of the humid as well as of the dry occasiou- asthma, as a symptom or sequel of many other diseases ; as gout, fomatic^or hypochondrias, hysteria, parabysma, and syphilis. consequent. I have already observed that the attack of the present species is The more severe, as well as of longer duration, than the preceding ; as Secies though the patient were contending with two hostile forces instead ms0Jrglly of with one—a diminished diameter of the vessels, and infarction obstinate from a surplus of viscid mucus : and thus both the exciting causes preceding. co-operate, which have been contended for singly by the leaders of Reason of opposite principles. I am much disposed to think that this is fre- quently the case ; and that, to a certain extent, both hypotheses are correct. That asthma occurs, as in the preceding species, without any increased discharge of mucus, is unquestionable ; that it occurs with such increased discharge, is equally incontrovertible ; and that this overflow is often the result of a constrictive and irritant struggle, is only analogous to the increased secretion that takes place in the alimentary canal, from the torminal spasms of cholera in various cases in which we are equally incapable of ascertaining its imme- diate cause. In a relaxed and atonic state of the lungs and their air-vessels, constituting the third variety of the species before us, it is very probable that this overflow of mucus, and especially if it pos- sess any morbid acrimony, may itself be the stimulus, as an overflow of bile in a like state of morbid acrimony may occasionally be an exciting cause of cholera ; but as in spasmodic cholera, where we have no such overflow, we are compelled to admit the existence of some other, though an unknown cause, so in asthma, where there is no expuition, or the expuition does not appear till the paroxysm is sub- siding, we ought, I think, in fair reason, rather to acknowledge our inacquaintance with the actual cause, than to place our faith in one that has so little to support it. * Pract. of Phys. Part. n. Book in. Chap. vi. § mccclxxxiv. \rOL. 1—53 418 cl. ii.] PNEUMATICA. [ord.il Gen. IV. But whatever be the source of the aggravated distress endured in Arthrria.11' humid asthma, after some hours of suffering the patient feels less Diagnosis, anxiety, breathes more leisurely and with less labour ; and, with a growing freedom of expectoration, acquires general relief and tran- quillity. Yet such is the irritable state of the affected organs, that even on the second day " no change of posture is made with impu- nity, and particular distress affects him if he engage in the fatigue of dressing whilst the stomach is empty. During the day, if no particular hurry occur, the breathing becomes generally more free till the evening : an inexperienced asthmatic even flatters himself that his disease is leaving him; but he finds, at the approach of night, that he must sustain a new attack. The paroxysm recom- mences with the usual symptoms, and the night is passed nearly as the former, but the sleep is more perfect and productive of more relief. The third day the remission is more complete, there is some additional expectoration, and bodily motion is performed with less distress, but still with great inconvenience. After the paroxysm has been renewed in this manner for three nights, the expectoration generally becomes free, but there is no certain termination of the fit at a fixed period. However, except in particular cases, it goes off after a few days ; and as the daily remissions become more perfect, the urine is higher coloured, and in smaller quantities ; the expecto- rated mucus is more copious and digested ; strength of pulse and vigour of action increase ; and good humour again enlivens the mind."* General In treating asthma, our attention must be directed to the treatment, paroxysm itseif; an(j to the nature of the constitution after the paroxysm has ceased ; and, even during the paroxysm, to the character of the particular species under which the disease shows itself. Bleeding. Dr. Cullen, who, as we have already seen, regarded plethora and turgescence of the blood-vessels as the usual cause, recommends blood-letting in the first attack, and especially in young persons ; with the use of acids and neutral salts, as employed by Sir John Floyer, for the purpose of taking off the congestion of the blood. caution Nevertheless bleeding demands a nice discrimination, and is rarely Weeding.1" to De recommended in either species. The relief it affords, even in dry or convulsive asthma, is very temporary ; and Dr. Cullen allows that it cannot be persevered in without undermining the con- stitution and laying a foundation for dropsy. Dr. Bree regards it as a doubtful operation in the first species, or that, to adopt his own language, produced by aerial irritation, and as always imprudent in the second. In this last, " I have repeatedly," says he, " directed it; but I have never had reason to think that the paroxysm was shortened an hour by the loss of blood : and I have often been convinced that the expectoration was delayed, and that more dyspncea remained in the intermission than was com- mon after former paroxysms. In old people who have been long used to the disorder, it is certainly injurious."! * Bree-, Inquiry, &c* Sect. iv. p. 48. t Inquiry. &c. p. 24a. vA. u.] RESPIRATORY FUNCTION. [ord. u. 419 Purging, beyond the intention of keeping the bowels regularly Ge!K'JC* open, has seldom proved beneficial. When, indeed, the disease is A|"thma. secondary, and depends evidently upon an overloaded liver or ^en*malnt stomach, or some suppressed evacuation, active cathartics, and especially such as operate simply, will be of great use; and the increased action excited in the alvine canal will often take off the irregular action in the chest; but where the asthma is idiopathic, and especially where the constitution is infirm, as in old age, a powerful alvine irritation will exacerbate the spasm of the chest instead of diminishing it. In exciting nausea or vomiting, however, we may be less cau- Nauseating tious ; for each has often been found highly advantageous in both vomiting. species of idiopathic asthma. The first, by diminishing generally the living power, and hereby relaxing the convulsive action ; and the second, by changing the seat of the convulsive action, and at the same time determining to the surface. Riverius employed full vomiting.* Dr. Akenside was much attached to the practice of both; he vomited freely on the accession of the paroxysm, and often continued the same plan for a fortnight or three weeks, by giving from five to ten grains, or even a scruple of ipecacuan every other morning.! Sir John Floyer extended the time beyond this, though he did not repeat the dose so frequently. He advises the operation of vomiting once a-month. Blistering may also be made use of, but, like setons or issues, Blisters. can only be of ulterior advantage, for the fit must be of far more than ordinary length if it continue till the blister has produced vesi- cation. It may, however, go far to prevent or shorten a relapse on the ensuing night; and especially when the disease is connected with an asthmatic habit. Sir John Floyer is said, during his residence at Lichfield, to have Coffee. found great benefit in his own case by the use of very strong coffee. And the practice was afterwards followed up by Sir John Pringle, as he informs us, with equal success. " On reading the section on eoffee, in the second volume of your Essays,'' says he in a letter to Dr. Percival, " one quality occurred to me which I had observed of that liquor confirming what you had said of its sedative powers. It is the best abater of the periodic asthma that I have seen. The coffee ought to be of the best Mocha, newly burnt, and made very strong, immediately after grinding it. I have commonly ordered an Ounce for one dish, which is to be repeated fresh after the interval of a quarter or half an hour, and which I direct to be taken with- out milk or sugar."j. Sedatives and antispasmodics, given alone, have rarely been Sedaun. attended with any decisive advantage. They have occasionally gpagmodics. afforded relief in the first species, but have had little effect in the second • and, by heating the system unnecessarily, have often aug- mented and prolonged the paroxysm. Dr. Bree, in relating his own * Prax. Med. Lib. vn. cap. 1. t Transact, of the College of Phys, of Lond. Vol. i. Art. vii. . I pEopiical, Medici, and Experimental Essays; by Thomas Percival, M.D. Vol. HI. 420 cl. u.] PNEUMATICA. [ORD. II. Gen. IV. case, which was that of humoral asthma, tells us that in the access Asthma* U' °f a paroxysm he took four grains of solid opium, which produced General nearly an apoplectic stupor for two days. A few hours after trying treatment. ^ 0pmm^ a, most debilitating sickness supervened with incessant efforts to puke. The labour of the respiratory muscles abated, but the wheezing evidently increased, accompanied with an intense head-ache and a countenance more turgid than usual; the pulse being at first strong and quick, and afterwards sinking into great weakness. The paroxysm showed itself four hours earlier than usual the next day. He tried it in smaller doses during several sub- sequent fits, but in no instance without great general mischief, and with little or no local benefit. Much of this deleterious effect may have depended on idiosyn- Diapho- crasy. But in every instance sedatives and narcotics, if employed at all, should be combined with diaphoretics. In this form they often prove a very powerful remedy: and one of the best prepara- tions of this kind is the compound powder of ipecacuan. An uni- versal glow and diapnoe, as it has been called, or breathing moisture on the surface, are among the most favourable symptoms of the dis^ ease, under whatever form it makes its appearance. Antispasmodics and narcotics, as musk, castor, valerian, cardamine, camphor, and the fetid gums, may perhaps be employed successfully when the dis- ease is chiefly dependent upon a morbid habit; but even here they will derive a great advantage from an union with diaphoretics, as the neutral salts, and small doses of ipecacuan, or antimonial powder. Hyoseya- The hyoscyamus has often succeeded as a narcotic where opium mus- has failed : but, like the latter, it should not be trusted to by itself in either species of the complaint. Biuretics. Where the urine is small in quantity, and of a pale hue, and par- ticularly where the disease is connected with a pituitousor phlegmatic habit, diuretics have been found unquestionably serviceable. And it is apparently in reference to this variety of the disease, that Sir John Floyer asserts, that swelled legs and copious urine are bene- ficial changes in asthma. Dr. Percival indeed thought them of service generally : but if so, it can only be as co-operating with diaphoretics, or other medicines that prove revellent by exciting increased action in the excretories of remote organs. Dr. Ferriar combined them with opium, and thus unquestionably increased the power of both. Expecto- But as there is no discharge that promises such direct benefit as that from the excretories of the bronchial vessels themselves, so is there no tribe of medicines on which we can place so much de- pendence as the expectorants when judiciously selected and ad- ministered. In every kind of idiopathic affection these may be employed with advantage: for if there be a turgescence in the bloooVyessels, they will have a tendency to emulge them; if the bronchia! themselves be surcharged with serum or mucus, they will facilitate their exhaustion ; or if their interior tunic be dry and irri- table, by taking off the obstruction and restoring the deficient secre- tion, they will soften and lubricate the irritable membrane rants. cl. il] RESPIRATORY FUNCTION. [ord. il 421 Among the fetid gum* which have been employed for this pur- Gen. IV. pose, ammoniac has acquired the greatest degree of popularity : J^J11, but its power is inferior to that of assafcetida, the virtue of which is GenerV to be judged of by the degree of its offensive odour. Both these, TctT^L. however, are apt to be too heating, except in very flaccid and phlegmatic habits; and it will hence be often necessary to soften their pungency by a saline medium, taking care not to irritate the bowels unduly. And where there is a considerable degree of irritability Demui- and much quickness of pulse, we may prefer several of the olera- cents- ceous, and especially the mucilaginous demulcents : but oily demul- cents are always to be avoided. Dr. Paulet of Paris has lately employed the chenopodium Botrys, and speaks of its good effects in very high terms, especially in humoral asthma : but I am not aware that it has hitherto been introduced into our own country. He gives it in the form of an electuary, mixing the powder of the plant with honey. Of all the medicines, however, which act on fhe excernents of squills; the lungs, the squill is by far the most to be depended upon. It is indeed a stimulant of the excernent system generally ; for there is no part of this system capable of resisting its power: and it is hence necessary to watch its effects upon the kidneys and intestinal canal, and to attemper it with opium or some other guard, if it produce sometimes much influence in either of these ways ; except, indeed, in the case WIth°p,UD1: of asthma connected with the phlegmatic habit, which is the only modification of the disease in which this collateral influence is found to be of advantage. Squills have also a peculiar tendency to stimulate the stomach and produce nausea or vomiting ; and it rarely shows much of an expectorating power till it has occasioned the former. But as these are advantageous to the disease in both species, and especially in humoral asthma, we are not to discon- tinue it on this account, but only to moderate its use. There are many practitioners, indeed, who employ it directly as an emetic medicine, and prefer it to ipecacuan. In asthma it may, in some habits, be allowed to supersede it; but in no other disease that 1 recollect; for it is rougher in its action and more offensive in its taste. Where, however, the lungs seem to be affected only secondarily, Seneka. and the source of the disease lies in an infarcted and torpid state of the liver or some other abdominal organ, squills, and indeed expec- torants in general, will be found less serviceable than in idiopathic cases. And hence, we should prefer the seneka root, which has often been found of great success, after calomel, or whatever other cathartic may be judged most proper, has been previously.made use of. Seneka root, indeed, is in itself a sort of general evacuant; for while it increases very largely the discharge of mucus, it increases also the flow of perspiration and urine, and sometimes acts as an emetic and purgative. There is a tribe of medicines which are also found of essential Acids. benefit in many cases of both species of asthma, but whose mode of action we are so little acquainted with that it has been explained on very different principles by different pathologists; I mean, the 422 cl. n.J PNEUMATICA. [ord. ii. Gen. IV. acids both mineral and vegetable. These principles, we have not Asthma. * room to examine ; nor is it necessary ; since, if they be really bene General ficial, it is of little moment whether they act as sedatives in allaying irritation, or as tonics in invigorating the absorbents and restraining the loose and relaxed mouths of the bronchial exhalants. It may be sufficient to observe that the vegetable seem more efficacious than the mineral acids, probably because, in consequence of their being less corrosive, the patient can take them in larger quantity; and that, of the vegetable acids, those obtained by fermentation seem more useful than the native. Acida Yet it is rarely that these have been given alone ; for it has been with other found that by uniting them with diaphoretics, as small doses of medicines, ipecacuan, or with narcotics, the remedial power of each has been augmented ; and that the latter are not only rendered more effica- cious, but are borne with less mischief afterwards. Sir John Floyer was in the habit of uniting the acetous acid with squills, and hence, indeed, the popularity which the vinegar of squills has preserved to the present day. Dr. Bree has employed both the vegetable and the mineral acids, but always in union with some other preparation. Thus in humoral asthma, after puking, he advises a draught com- posed of an ounce of distilled vinegar, and from one to three grains of ipecacuan in a sufficient quantity of pure water, to be taken every four hours, as a mean of determining to the surface of the body, and of promoting absorption and exhalation. And as a mean of taking off irritation and exciting the secernents of the bronchiae, it may be also employed in nervous or dry asthma, and often with as good effect. In like manner, Dr. Bree has made use of the nitric acid in union with squills and extract of henbane ; giving three grains of the hen- bane with sis minims of the acid and ten of tincture of squills in the form of a draught, and repeating it every three or four hours during the paroxysm. And he tells us, that " Many patients, who had taken the most powerful antispasmodics, have assured me that none had been so useful; and two gentlemen now under my direction inform me that it is the only medicine that has ever given them relief in the paroxysms."* I cannot say, that I have found it thus pre-eminently serviceable ; but it has often been of decided benefit. And I know of no medicine that succeeds so well in preventing the mischievous effects of opium, and even in adding to its sedative power ; or that is so valuable an adjunct in almost all antispas- modic preparations, and especially where ether, camphor, and other terebinthinates are employed; or that tends so effectually to take off all excess of pungency from the more heating expectorants. andh'ofdhot 'A'S simPle relaxants are always hurtful in this disease, and only add to the debility, it is not to be wondered at that warm bathing should be also injurious. Cold bathing, as a tonic between the intervals, has much more to be said in its favour. Dr. Bree tried it in his own person, but did not obtain success. His was a case of humoral asthma. But in the first species, and particularly where * Inquiry, &c. p. 285. cl. n.] RESPIRATORY FUNCTION. [ord. ii. 423 habit has given inveteracy to the recurrence of the paroxysms, 2™*.^' and where the general constitution is vigorous, there is no single Afthraa. " remedy likely to be of more value. General We thus enter upon the prophylaxis of the disease, upon which it will not be necessary to dwell at any great length, after what has been observed under the two preceding genera. Wherever asthma may be supposed to be dependent upon a tur- f™£r gescent state of the blood, tonics can have no claim to be employed, treatment. till after such a condition has been removed ; and then, perhaps, the ToniC8, best medicine will be the mineral acids. But in all other cases of the idiopathic disease, tonics may be adverted to with great advan- tage during the interval of the fits : and if one do not seem to suc- ceed, it should only lead to exercise our ingenuity in the choice of another, and not to abandon the principle ; for we should never for- get that the fundamental evil we have to oppose, whether general or local, is a lax, mobile, and irritable state of the muscular fibres. Peruvian bark is often found to overload the stomach, and especially in dyspeptic patients ; and with these I have found columbo agree better, occasionally combined with carbonate of soda. But the besf; tonics are the metallic oxydes, and of these that of iron, where it is not found too heating. Inhalations cannot well be tried during the paroxysms, but they Gaseous have been very generally had recourse to in the intervals, and have ' consisted of very different vapours. When pneumatic medicine was at the height of its popularity, much benefit was supposed to be de- rived from the use of oxygene and hydrogene gases. Dr. Beddoes was peculiarly attached to the former, and thus describes its effects with his constitutional warmth of expression :—" No sooner does it touch the lungs, than the livid colour of the countenance disappears, the laborious respiration ceases, and the functions of all the thoracic organs go on easily and pleasantly again." Yet, with all this high recommendation, few patients choose to be cured in this man- ner in the present day ; oxygene gas is now rarely adverted to by asthmatics or their medical attendants ; and the remedy, from hav- ing been extolled beyond its proper level, has fallen back into an unmerited disesteem. Dr, Ferriar has spoken in soberer terms of the undoubted benefit of hydrogene in the first species ; and 1 am induced to believe that a long perseverance in the use of this gas may often produce the effects he has ascribed to it; but it is rarely that I have seen it so decidedly useful as to ascribe the patient's re- covery to this remedy, rather than to other means he had been in the course of employing at the same time. Warm aromatic fumes have been also tried ; as prophylactics, ob- Fumiga- tained from various substances. The smoking of tobacco has very tic extensively been recommended; the leaves of the scandix odorata were at one time in still higher repute ; but both have of late years given way to those of the datura stramonium or thorn-apple. Most of these contain anarcotic power, and whatever benefit they produce is hence, perhaps, chiefly derived : but either this narcotic power, or the stimulating power with which it is united so intimately, for all stimulants exhaust and promote a tendency to paresis or paralysis. 424 cl. 11.J PNEUMATICA. [ord. ii. Gen. IV. has at times been found to injure deglutition, and induce a difficulty Arthmt.IL °f swallowing. Tobacco is justly chargeable with this effect, and General the stramonium still more generally ; and hence if they produce any influence whatever upon the bronchiae, it must be ultimately of the same kind, and therefore highly injurious. impreg- There is another process, which has lately been adopted in France, aqueous but of the issue of which we have not yet received any satisfactory injections, information. It consists in a revival of the impregnated aqueous in- jections of Stephen Hales,* with a view of determining how far such impregnated materials may reach the lungs and be thrown off by the bronchial exhalants. MM. Magendie and Nysten have been chiefly engaged in these researches, and they have ascertained that alcohol, ether, camphor, and most of the other volatile antispasmodics, to- gether with the gases, are in this manner conveyed to the lungs, and transpire from the surface of their air cells.t issues and Issues, setons, and even cauteries, have been long in repute as useful drains or revellents ; and under this character, are highly suc- cessful in the cure of asthma. And where the disease has appeared upon a sudden check of a cutaneous eruption, or a sudden cessation of any habitual evacuation, I can unite in this recommendation of MacbrideJ and Reidlin.§ Issues to this end, and indeed for all others, are most conveniently kept open, and produce the most salutary irritations by small pieces of the bark of spurge-laurel or mezereon, both of which contain a very acrid matter ; and the latter of which, more especially, has for this purpose been very generally employed illustrated, in France, under the name of ecorce du Garou.W A lady, between fifty and sixty years of age, whom I have long been in the habit of attending, had several very severe fits of asthma, about three years ago, at the distance of ten days or a fortnight from each other. I discovered that she had been formerly subject, though at irregular periods, to slight bleedings from the hemorrhoidal vessels, which for some months had ceased to be renewed. With a view of exciting a vicarious action, I opened an issue in one of the arms, and irritated the rectum by small doses of aloetic cathartics. The issue discharged copiously for six weeks, during which time the patient continued free from all attack : I then suffered it to heal slowly, still continuing the aloes ; and about a month afterwards was informed that the habitual discharge had returned. She had no paroxysm after this for upwards of two years. cured by M. Bonifex, in like manner, relates a case in which a corpulent thTitih! asthmatic patient, whe suffered severely from frequent fits of this disease, was accidentally infected with the itch. As the eruption extended, his breathing became every day more easy ; and from the time that the contagion took place he had no return of a paroxysm whatever. He was then desirous of being cured of the itch, and for this purpose went for several days successively into a cold bath. The * Haemostatics, ii. 74, 75. t Precis Elementaire de Physiologic, Tom. u. p. 291. \ Med. Observ. and Inquir. Vol. vi. Art. n. § Lin. Med. 1695, p. 91. „ ».Es"aLSUr rUsase et les Effets de •'Ecorce de Garou, par M. Archaiwe le iNo, tans. 17r>7. " ■• "•] RESPIRATORY FUNCTION. [ord. ii. 425 eruption was hereby repelled; but he was immediately attacked with Gen. IV. an asthmatic fit, which returned twice within the space of a month. Shni?.11' M. Bonifex advised him to have recourse to his former cure, by using General" the bed-clothes of one infected with the itch. This advice he fol-t,eatmcnt lowed ; a few days after which the scabid eruption made its appear- ance, when he was again perfectly liberated from his asthma.* It is only necessary to add, that the diet should be light and cor- Diet. dial without being stimulant, the food of a solid rather than of a liquid kind ; and the meal never be suffered to overload the stomach : all flatulent fruits and other flatulent vegetables should be avoided ; but oranges, the alliaceous esculents, and the aromata may be allowed in moderation. Hot liquors should be sedulously ab- stained from ; and the beverage consist chiefly of coffee, ginger- tea, and acidulated waters. Where asthma is dependent upon some primary affection of another kind, 'it can only be effectually attended to by removing or palliating the original disorder. - GENUS Y. EPHIALTES. INCVBIS. SIGHING, SUFFOCATIVE ANHELATION, WITH INTERCEPTED UTTERANCE. AND A SENSE OF SOME EXTERNAL WEIGHT PRESSING HEAVILY ON THE CHEST : TRANSITORY. Ephialtes, incubus, night-mare, which are the common names Gen. V. in Greek, Latin, and English, for the present genus of diseases, jjJS"ofif0?ne though not exactly of the same meaning, import a sudden sense of generic an oppressive and suffocative weight on the chest, threatening stran- na gulation, and rendering the person attacked incapable of changing his position. Ephialtes, from tQxXXoputi, signifies " to leap upon ;" incubus, from incubo, " to lie upon ;" and the term mare, in our compound night-mare, embodies the looser idea contained in the Greek and Latin denominations, and signifies a hag, goblin, demon, or spectre ; as though the oppressive weight were occasioned by some such hideous monster's abruptly leaping or lying on the chest; whence our old Anglo-Saxon name for the disease Elf-sidenne, or elf-squatting ; which is as significant as any of them. The character of the genus will be found sufficiently expressed in the foregoing definition. ^ If the generic definition be correct, as I trust it is, there can be no doubt that ephialtes belongs to, or should be ranged in close con- nexion with the family of anhelations, under which it was usually classed by the earlier writers ; and indeed continued to be so till the * Recueil d'Observations de Medicine des Hopitaux Militaires par M. Richard de Hautesierck, &c. Tom. n. 4to. Paris, 1774. Vol. I.—54 426 IL] PNEUMATICA. [ord. ir. Gen. V. Ephialtes Incubus. Incorrectly classed by Dr. Cullen. Appears most frequently in irritable tempera- ments. Usually in the night- time after mental or corporeal fatigue; or adisoidered stomach. Why such causes should produce such an effect. Respiration often by the will. Digestion often assisted by the remedial power of instinct. The addition of sensorial power thus bestowed upon the stomach, taken from She system at large; time of Dr. Cullen, who has strangely removed it to that of vesanice, or mental derangements, putting it immediately after mania; reducing it from a generic to a specific station ; and as singularly uniting it with sleep-walking, with which it has little or no connexion in cause or symptoms, as will be sufficiently obvious from comparing the account about to be given of the one disease with that of the other. The history of the affection will easily lead us to the nature of its production. It appears most frequently in persons of an irritable or nervous temperament, and of a weakly constitution; particularly among those who are predisposed to hypochondrias or low spirits. Others, indeed, are occasionally affected by it, but more rarely, and perhaps in a less degree. It usually, though not always, occurs in the night, during a reclined position, and after great fatigue of body or mind, or a stomach disordered by indigestible food, or food taken in excess. Although, therefore, the symptoms of this complaint are to be taken from the actual state of the muscles and other organs of respiration, the exciting cause i3 to be ascribed, for the most part, to the actual state of the stomach, or the sensorium, or both :—more generally indeed to both, as the brain and the stomach are so much in the habit of associating'in the same action. Yet how comes it that the organs of respiration should be thus singularly affected by the state of the stomach and the sensorium, and chiefly so in the night rather ^than in the day ? The solution of the question may be found in the reasons we have already offered why the paroxysms of asthma, or of exacerbating dyspncea, should mostly recur under similar circumstances, and at the same period. Respiration is a semi-voluntary action. In firm health, the will, indeed, is seldom applied to for its aid : but the moment the moving powers of the chest labour under any degree of debility, the will in- stantly interferes, and by its stimulus compensates for the deficient energy. Something like this applies to the state of the stomach during the process of digestion. In a period of what may be called eupepsy, or firm and healthful digestion, the ordinary action of the stomach is equal to its own demand: but the moment it labours under any de- gree of debility, or, in consequence of its being overloaded, or loaded with indigestible materials, its ordinary action is not sufficient, it be- comes necessary that it should be supplied, not indeed by the will, but instinctively, or by the remedial aid of the living principle, with an additional flow of nervous energy to enable it to meet the excess of duty hereby imposed upon it. Now it would be easy to prove, if we had time, that the surplus of sensorial power, under such circumstances bestowed upon the stomach, is taken from the general supply to the system at large, as from a common stock; and that every organ contributes its proportion: the chill that during digestion in a weakly stomach takes place in the extremities, the tendency to sleep, or in other words the torpitude of the brain that occurs at the same time and the stertorous sound that so often accompanies or follows such «t. ii.] RESPIRATORY FUNCTION. [ord. ir. 427 tendency, are sufficient proofs that all the organs which are impli- Gen. v. cated in these phenomena, are simultaneously exhausted by the Kb™.'" proportion of sensorial power they have conjointly contributed to assist the enfeebled stomach in the discharge of its" duty. On such occasions, therefore, the lungs are as much called upon And hence for their contribution as any other organ, or in other words they fin^*6 make as large an advance as any other organ to the proportion of sensorial power which is thus deducted from the general stock, and sent, as a temporary accommodation, to the stomach. And if this which, in demand, on the part of a feeble or overloaded stomach, should Sfare occur in a system in which the general weakness of the respiratory 5tib,Tfuit,dei: organ is so considerable as to render il necessary for them to be perpetually drawing upon the will for its collateral -stimulus ; if it should take place in a recumbent position, in which they have, at all times, less power of action than in an upright posture ; and if, moreover, it should be exhibited during sleep, in which the will and especi- itself, and most, sometimes indeed all, the faculties of the mind sieeP^ur"lg are in a state of suspension, from a cause I shall hereafter have occasion to explain ; almost every fact will co-operate that can Whence tend to impede respiration, to lower the tone of the respiratory r™Spiration: muscles, and consequently to excite in them irregular and spasmo- dic action ; in one word, that can lay a foundation for all the symp- toms which characterize ephialtes: the mind sympathetically dis-and, from turbed and hurried in the midst of sleep, imagining to itself, at the fitful*' moment, from the terrible sensation induced; as terrible a cause dreams, and for its production, and giving full credulity to the presence of a huge ' and hideous spectre, tyrannically squatted upon the chest, and striving to take away the breath. In ephialtes, however, the respiratory organs, though thus sud- denly and violently affected, have seldom any other disease than that of debility, and may not perhaps in every instance even have this, but be affected by sympathy alone; and hence, as soon as the mind is thoroughly roused, and the will recalled by the emer- gency of the case to the exercise of its duty, the respiratory organs are re-invigorated, and all the distressful symptoms fly away as a dream. Now in revery, the will, as indeed all the faculties of the mind, From may be as abstracted during the day as they are suspended in sleep IT/dthTr during the night: and from the peculiar strength and vivacity of a*j£cfi™ the train of ideas or mental emotions that constitute the revery, it. may the same sudden exhaustion may take place, and the same inordi- -Xj. nate demand upon the common stock of sensorial power, distri- buted throughout the system at large, may be made upon every organ acting under a common bond of sympathy, as we have just contemplated during the influence of sleep. And the respiratory organs being thus, in the same manner, mulcted of a part of their ordinary influx of nervous power, the same complaint may take place in the one period as in the other ; though, the body not being- recumbent in the day, the lungs will not sustain so violent a struggle; and the intellect, from its being less passive than in sleep, not so strongly imposed upon. And hence we may expect to meet, and ~42S cl. ii.] PNEUMATICA. [ord. il Gen. V. do in fact meet, with the two following distinct species of the Ephialtes „. . ■ incubus, affection:— 1. EPHIALTES VIGILANTIUM. DAY-MARE. 2.---------NOCTURNTJS. NIGHT-MARE. SPECIES I. EPHIALTES VIGILANTIUM. DAY-MARE. PRODUCED DURING WAKEFULNESS : THE PRESSURE SEVERE, AND EXTENDING OVER THE ABDOMEN : RESPIRATION FREQUENT, LABO- RIOUS, CONSTRICTED : EYES FIXED : SIGHING DEEP AND VIOLENT : INTELLECT UNDISTURBED. Gen. V. This species is less frequently described by pathological writers Spec. I. tnan tjje ephialtes of the night season. Rhodius,* however, Fo- frequent restus,t and Sauvages,| have distinctly marked it; and a striking mare.mght" example of it occurred some years ago in my own practice. illustrated. Forestus gives a case that returned periodically every third day like an intermittent fever. The patient was a girl nine years of age, and at these times was suddenly attacked with great terror, a constriction of both the upper and lower belly, with urgent diffi- culty of breathing. Her eyes continued, open, and were perma- nently turned to one spot; with her hands she forcibly grasped hold of things that she might breathe the more easily. When spoken to, she returned no answer. In the mean time the mind seemed to be collected ; she was without sleep ; sighed repeatedly, the abdomen was elevated, the thorax still violently constricted and oppressed with laborious respiration and heavy panting; she was incapable of utterance. Makes an This case seems to be founded upon a highly irritable orspastic towards*1 diathesis, and makes some approach towards ecstasis and catalepsy ; ecstasis and but with that intolerable weight on the chest which peculiarly taepsy. markg ephialtes. No exciting cause is stated. A predisposed cause 1 have already hinted at; and shall briefly advert to the treat- ment under the ensuing species. * Cent. i. Observ. 54. t Lab. x. Obs. 52. t Class v. Ord. i. Anhelationes Spasmodic;?. Gen. i. «r-n.] RESPIRATORY FUNCTION. (ord. ii. 429 SPECIES II. EPHIALTES NOCTURNUS. NIGHT-MARE. PRODUCED DURING SLEEP AND INTERRUPTING IT WITH VIOLENT STRUGGLE AND TREMOR : THE PRESSURE ON THE CHEST SEEMING TO BE THAT OF SOME HIDEOUS MONSTER OR PHANTOM. The sensation is said to be frequently preceded by some fearful Gen. V. dream, as that of an implacable enemy, known or unknown, in ^E such a state of body. If, however, the first attacks do not prove fatal, the disease is often Apt to apt to become chronic ; and to exhibit the symptoms that characterize chronic. the present species. The attack is now not only more easily brought in which on, but requires a longer period of time for its removal. Rest, even if it removed commence during exercise, has little or no effect, and the paroxysm Acuity!** has at times been protracted not only for some hours, but even for several days, without remission, and occasionally with a considera- ble degree of danger through the whole period. Yet it has occa- sionally continued to harass and weaken the constitution, without actually destroying it, for twenty years; and, in a few instances, has been known to cease spontaneously. In this species of the disease, Morbid we meet with far more instances of palpitation of the heart and ^lpuat"^ irregular pulse than in the preceding : and not unfrequently these more^ catenating symptoms become more manifest and distressing as the in chronic disease becomes more inveterate ; as though the morbid state of the cascs- heart or its appendages were a result of sternalgia, instead of sternalgia being a result of the former. In Sir Gilbert Blane's valuable Table Illustrated. of Medical Cases occurring in his private practice, as contradistin- guished from the diary of his public duty as physician to St. Tho- mas's Hospital, under the head of " Palpitation of the Heart and Angina Pectoris," we have the following remark : " In one of these cases there was an extreme distress of breathing for five years, and the pulse fluctuated from twenty to thirty-two, never falling below the former, nor exceeding the latter. Nothing gave material relief. Leave was not obtained to open the body after death."* Dr. Fo- thergill in like manner asserts, not only that the pulse in his practice ha* been irregular and intermitting during the exacerbations, but * Mcd.-Chir. Trans. Vol. iv. p. 136. 438 cl. ii.] PNEUMATICA. [ord. ii. that it has continued irregular and even intermittent when the patient has been free from pain and at rest. Of the medical treatment and regimen I have already spoken under the preceding species. GENUS VII. PLEURALGIA. PAIN IN THE SIDE. PUNGENT PAIN IN THE SIDE ; DIFFICULTY OF BREATHING ; WITHOUT FEVER OR INFLAMMATION. Gen. VII. The last genus of diseases which occurs under the present order, Synonym jg ^j. wnich has been usually denominated pleurodyne, for which pleuralgia is here adopted in its stead for the sake of simplicity. Both terms import pain or ache in the side ; but as algia is a more common medical termination than odyne, and one alone is sufficient, a preference ha3 been given to the former. On a nice and critical examination it would not be difficult to point out a shade of differ- ence between xXyet and e}w», but no such critical distinction has been ever attended to by professional writers, and, as terminations to medical compounds, they are used convertibly, or as direct syno- nyms.* Difficulty of The difficulty of breathing noticed in the generic definition de- brewhantg Pends altogether upon the acute ache produced by every attempt to dependent, inflate the lungs ; and though negative characters ought to be avoid- ed as much as possible, both in generic and specific definitions, it is necessary in the present instance to add, " without fever or inflam- mation ;" since this is the chief feature by which pleuralgia, or " stitch in the pleura," is distinguished from " pleuritis, or inflam- mation of the pleura." Pleuralgia, or pleurodyne, is no more to be found in Dr. Cullen's Nosology than sternalgia. Pain in the side is, in his opinion, never any thing more than a mere symptom of some other complaint, most commonly rheumatism ; and the example which Dr. Cullen has thus set has been followed by most of the later writers of our own coun- try. There are two species, however, that have a fair claim to be regarded as strictly idiopathic. They do not often indeed consti- tute alarming diseases, but, so long as they continue, are peculiarly distressing; while the latter is often of long duration, and demands a considerable range of medical treatment. Sauvages, therefore, is fully justified in forming a distinct genus of the complaints before us ; and Macbride is more to be commended * See the Author's Preliminary Dissertation to bis Nosology, p. lix. cl. il] RESPIRATORY FUNCTION. [oe». n. 439 in following his example than Cullen in departing from it. The two Gen. VII. species are as follow • Pleuralgia. Pain in the side. 1. PLEURALGIA ACUTA. STITCH 9 ________ ' CHRONICA. CHRONIC PAIN IN THE SIDE. SPECIES I. PLEURALGIA ACUTA. STITCH. PAIN SUDDEN AND TEMPORARY : SUPERVENING ON MUSCULAR EXER- CISE : RELIEVED BY PRESSURE. This species is found most frequent among boys who are engaged Gen. VIL in any violent exertion, and particularly in hard running. It is pro- Spec- *• duced by too great and sudden a distention of the fine blood-vessels of the pleura from undue propulsion of the blood, at an age in which these delicate vessels readily give way, and become overloaded. It is hence relieved by a handkerchief, or any other tight bandage, How which has the double advantage of supporting the vessels, and ofteheved" diminishing the current of blood by its pressure. In like manner it gradually subsides on rest or even slackening the pace ; for the overstretched vessels, no longer urged by an inordinate propulsion, soon return to their proper diameter by their proper elasticity. Where this is not the case, bleeding and other evacuants are instantly ne- cessary ; together with warm relaxing liniments and anodyne fomen- tations. It is from this forcible distention of the minute vessels of the pleura that Van Swieten, Sauvages, and Macbride distinguish this species by the name of pleurodyne a spasmate ; thus making a distinction spasma between spasma and spasmus ; and understanding, by the former, gushed'81"1, that voluntary stretching or straining which takes place in any ve- from hement exertion, contraction, or extension of a muscle, as in striving,spasraus' bearing heavy burdens, or running. In the language of M. de Sau- vages, " Spasma non est spasmus, sed distractio, divulsio, qualis ac- cidere solet a vehementi musculi nisu, contractione, extensione ; ut inter luctandum, onera gestanda, currendum."* This species is occasionally met with as a symptom in flatulence, Found as a hysteria, and hypochondrias : in all these cases, however, though Mother"1 the disease or symptoms are the same, the exciting cause is very gj^^ different. There is here, evidently, a nervous or irritable tempera- however,' ment, and a tendency to spastic action ; and the pleura, and conse- c^se™ting quently the delicate vessels of the pleura, are spastically and invo- different. luntarily contracted ; so that the blood-vessels are forcibly diminished instead of being forcibly enlarged in their diameter ; and the * Nosol. Method. Cl. v. Ord. u. Gen. xi. 440 cl.il] PNEUMATICA. [ord. n. Gen. VII. acute pain proceeds from an urgent pressure of the ordinary current p?ePurakia of blood through a contracted channel, instead of from an urgent Pleuralgia acuta. Stitch. acuta. pressure of an accumulated current of blood through a channel dis- tended to its utmost stretch. SPECIES II. PLEURALGIA CHRONICA. CHRONIC PAIN IN THE SIDE. PAIN PERMANENT : AUCMENTK1) BY PRESSURE : INABILITY OF LYINS ON THE SIDE AFFECTED. Gen. VII. This species is more diffused than the first, and accompanied with Prcfsure11' a considerable degree of irritation ; whence pressure, instead of dimi- augments nishing, augments the pain. The cause is therefore of a different this specie's kind from any of those already noticed, and is perhaps, most fre- common quently, to be found in adhesions of the folds of the pleura to each other, or to the intercostal muscles, or, a thickening in some part of its extent, whereby the play of the respiratory organs is impeded, and a state of perpetual irritation, or a perpetual tendency to irritation, is kept up. Produced fhjg species has also often been produced by a fractured rib, or some tai injury, other lesion of the chest; or by some internal malformation, or other structured structural disease in the organs of the same cavity. Dr. Perceval, in a note upon this species appended to the volume of Nosology, refers to a case which once occurred to him, of pain in the left side acute and obstinate, that baffled all remedies, local and general ; and which was at length found to have originated from an aneurism of the aorta. inflamma- Chronic pleuralgia may also follow from an inflammation of the pleura,or8 pleura; or from transferred gout or rheumatism. It is peculiarly transferred gout: apt to take place under every disease, which, by lowering the tone of the system, renders it generally irritable and subject to irregu- wormg, larity of action ; as is the case in worms, syphilis, and phthisis. The pjfthis'js':"' opposite extreme of plethora has, moreover, not unfrequently been p°eThora.es wun(^to produce it by the permanent stimulus of an access in the circulating fluid ; in consequence of which the minute blood-vessels of the pleura are kept constantly upon the stretch, in the same man- ner as we have already seen they are transiently distended under the former species. when Most of these, however, may be regarded as mere symptomatic Idiopathic. . affections. Among the genuine idiopathic cases may be mentioned, in the first place, those produced by external pressure, as habitually forcing the chest, in writing against the hard edge of a desk • or Tightstays, which still more frequently occurs, and is productive of far severer cMevous effects, by the absurd though fashionable use of tight stays, which. effects. «i»"] RESPIRATORY FUNCTION. [ord. it. 411 while they undermine the health, generally coop up and distort the Gen. VII. chest into a shape equally ungraceful and unnatural. This barba- K^"' rous custom cannot be too strongly inveighed against: for though chronica. the imprisoned young female may, by dint of habit, and where little SSLT exercise or exertion is required, be able to obtain a sort of triumph ,he s,de over the primary mischief of adhesions hereby produced ; yet may she pave the way for an obstinate cough, phthisis and lateral curva- ture of the spine ; and should she escape these, she will still have other inconveniences to suffer as soon as she reaches a state of pregnancy. That adhesions may take place without inflammation, and conse- instances 0f quently the cause we are now contemplating occur without pleu- witbouT9 ritis, is clear from what is every day occurring in other organs. tio^in™14 If a boy, subject to an inguinal rupture, wear a truss that sits with other tolerable force and precision, a radical cure, the result of adhesion, inguinal is often obtained in a few years. And hence pressure, in the present jupture. day, has become a powerful and extensive engine in the hands of pressure the surgeon ; and bids fair, like many other powers in nature which mir^ed,et0 are highly mischievous when misdirected or left to themselves, to be a good of great value and importance under a skilful control. purpose. In attempting either to cure ox to palliate the present species of Treatment. pleuralgia, we must direct our eyes as nearly as possible to its cause. If the affection be symptomatic, we must combat the original dis- ease. If idiopathic, bleeding from the arm will generally be found Bleeding requisite, and freely, if we suspect plethora ; but locally by cupping fequisue^ or leeches, if it be from the mischievous habit of dress we have just ^ ^J}"" reprobated, and the constitution, as is mostly the case, be relaxed and delicate. Here also dry cupping has been frequently found ser- Dry . viceable. Under all circumstances, a loose dress should be insisted Loose upon. Blistering will often afford relief, and the discharge should BhsuJring. be rendered permanent; but a seton or an issue will generally sue- setons and ceed better than a blister. Electricity by drawing sparks has also Electricity proved frequently of use. Quiet rather than exercise is demanded, inirntant and the ablest course of internal medicines will be that which is best med]Cines- calculated to take off irritating and irregular action, as bark, valerian, snake-root, conium, and the various preparations of the hop. The Has been pain has occasionally yielded to the sudden appearance of some cu- „retastaL. taneous eruption,* a remote abscess,! a critical evacuation from the bowels, the skin,| or the sanguiferous system,§ or a smart fit of the gout.ll * Huxtaam, I. p. 200. t De Haen, Rat. Med. Contin. ii- 1 Krebs, Medic. Beobachtungen, Band. n. p. 82. § Horst. Opp. Vol. hi. p. 51.—Schenck, Obs. Lib. II. N. 100. fl Eph. Nat. Cur. Dec. in. Ann. in. Obs. 16. END OF VOL. I. Vor. |.—5fe- it rr 2101 § LIBRARY OF MEDICINE NLM 03277^3H 2 NLM032779342